51 N.J.R. 1597(a)

VOLUME 51, ISSUE 21, NOVEMBER 4, 2019
RULE PROPOSALS

Reporter
51 N.J.R. 1597(a)
NJ - New Jersey Register  >  2019  >  NOVEMBER  >  NOVEMBER 4, 2019  >  RULE PROPOSALS  >  LAW AND PUBLIC SAFETY -- DIVISION OF CONSUMER AFFAIRS

Interested Persons Statement

INTERESTED PERSONS
Interested persons may submit comments, information or arguments concerning any of the rule proposals in this issue until the date indicated in the proposal. Submissions and any inquiries about submissions should be addressed to the agency officer specified for a particular proposal.

The required minimum period for comment concerning a proposal is 30 days. A proposing agency may extend the 30-day comment period to accommodate public hearings or to elicit greater public response to a proposed new rule or amendment. Most notices of proposal include a 60-day comment period, in order to qualify the notice for an exception to the rulemaking calendar requirements of N.J.S.A. 52:14B-3. An extended comment deadline will be noted in the heading of a proposal or appear in a subsequent notice in the Register. 
At the close of the period for comments, the proposing agency may thereafter adopt a proposal, without change, or with changes not in violation of the rulemaking procedures at N.J.A.C. 1:30-6.3. The adoption becomes effective upon publication in the Register of a notice of adoption, unless otherwise indicated in the adoption notice. Promulgation in the New Jersey Register establishes a new or amended rule as an official part of the New Jersey Administrative Code.

Agency


LAW AND PUBLIC SAFETY > DIVISION OF CONSUMER AFFAIRS > STATE BOARD OF MEDICAL EXAMINERS

Administrative Code Citation


Proposed Amendments: N.J.A.C. 13:35-1.5, 3.11, and 3.11A
Text

  Registration and Permit Requirements for Graduate Medical Education Programs in Medicine or Podiatry

Authorized By: Board of Medical Examiners, William V. Roeder, Executive Director.

Authority: N.J.S.A. 45:9-1 et seq.

Calendar Reference: See Summary below for explanation of exception to calendar requirement.

Proposal Number: PRN 2019-141.
Submit written comments by January 3, 2020, to:
William Roeder, Executive Director
Board of Medical Examiners
140 East Front Street, 2nd Floor
PO Box 183
Trenton, New Jersey 08625
or electronically at:   http://www.njconsumeraffairs.gov/Proposals/Pages/default.aspx.  

The agency proposal follows:  

Summary  
The State Board of Medical Examiners (Board) is proposing amendments to its existing rules concerning graduate medical education programs in order to update the eligibility requirements for graduates of international medical schools who seek licensure or authorization to engage in the practice of medicine as residents. The proposed amendments would replace outdated restrictions on graduates of international medical schools pursuing licensure or authorization in New Jersey and allow the Board to rely on recognized accrediting bodies for international medical schools that adhere to standards substantially similar to the bodies that accredit domestic medical schools. By expanding eligibility, the proposed amendments may positively affect the supply of physicians practicing in the State.  

Under the Board's existing rules, a medical school graduate seeking authorization to engage in the practice of medicine as a resident in a graduate medical education program must complete full basic sciences studies in the jurisdiction where the graduate's medical school is authorized to confer medical degrees, unless the graduate's medical school was accredited by the Liaison Committee on Medical Education (LCME) or the American Osteopathic Association (AOA). N.J.A.C. 13:35-3.11 extends that same requirement to applicants for licensure. A variant of the existing rules had its roots in an initiative applicable to those seeking licensure that was originally adopted 35 years ago, in 1984. The prefatory language accompanying the notice of proposal, at 16 N.J.R. 505(a), provides the Board's original rationale for the rule:  

[page=1598] The proposed new rule would specify for graduates of foreign medical schools prerequisites to establish comparability of their medical education with the education licensing agencies such as the Liaison Committee on Medical Education (LCME) and the American Osteopathic Association (AOA). The new rule is designed to assure that graduates of foreign medical schools comply with all of the pertinent requirements which would satisfy the host country of the medical school as to the fitness of the graduate for practice within that country. The rule appears to be necessary because the New Jersey Medical Board has observed a substantial variability in the educational experiences received by foreign medical graduates, both as to those who complete the entirety of their medical training in the foreign host country and those who take merely the first two years of medical studies in the foreign country and then seek clinical training somewhere within the United States.

On adoption, the Board explained the initiative as being responsive to "recent revelations of large scale bogus and/or deficient credentials being disseminated in the name of certain foreign medical schools." (16 N.J.R. 1806(a)). At the time of the promulgation of the rule, there was no accrediting body that would undertake a thorough review of international schools that was comparable to the review conducted by the LCME or the AOA. Schools at that time were listed in the World Health Directory, without any substantive review of the education provided.  

When the Board promulgated a rule regarding eligibility to participate in residency training in 1999, it extended this approach. To make up for the absence of a reliable accrediting agency, the rule required applicants seeking to participate in residency training programs in New Jersey hospitals to present evidence that all of the didactic training was obtained in the country in which the medical school was domiciled. (31 N.J.R. 1742(a) at 1752).  

Thus, under existing N.J.A.C. 13:35-1.5(c)1ii, a graduate of an international medical school can only obtain a permit or register as a resident if he or she certifies that "the didactic training was completed in the jurisdiction where the school is authorized to confer a medical degree." In addition, existing N.J.A.C. 13:35-3.11(c) provides that applicants for licensure shall demonstrate:  

successful completion of the full medical curriculum, didactic elements and clinical training prescribed by the medical school and by the country in which the medical school is located and   within which the training took place, and successful completion of all of the educational requirements to practice medicine in that country. (Emphasis added.)

Subsection (e), reiterates and reinforces that construct in the context of the requirement that undergraduate clinical training be done at hospitals with approved residency programs by engrafting onto this provision that the licensure applicant is required to have "successfully completed the full basic science studies (or the equivalent of the first two years of an American medical school) at the foreign medical school located in the country of domicile authorized to confer the degree or certificate." In practice, the Board has not foreclosed applicants who received part of their didactic training in a country other than the domicile of the international school, but rather reviews such applications on a case-by-case basis.  
While at the time of the original rulemaking there was no reliable accrediting body to review international schools, there have been major developments on this front in the last 35 years.  

The World Federation for Medical Education (WFME) conducts reviews of regional accrediting bodies to determine if the standards are comparable to those utilized by the LCME. In addition, countries that evaluate schools based on standards comparable to LCME standards are now recognized by the U.S. Department of Education, National Committee on Foreign Medical Education and Accreditation (NCFMEA). These entities are specifically charged with determining if the standards of an accrediting body (in the case of WFME) or the country (in the case of NCFMEA) are comparable to those of the LCME.  

This rulemaking moves to a model that would allow the Board to rely on recognized accrediting bodies for international medical schools that adhere to standards substantially similar to the LCME or AOA. Proposed amendments to N.J.A.C. 13:35-1.5 would allow graduates of schools accredited by regionally recognized bodies that have standards comparable to those of LCME to participate in residency training programs, regardless of the site of the didactic training. As to graduates from schools that are not accredited by these recognized agencies, the current requirements would be preserved.  

With respect to N.J.A.C. 13:35-3.11, in an effort to clarify current language and in recognition of the 2003 legislative determination to move jurisdiction over clinical clerkships offered by alternatively accredited medical schools to the Advisory Graduate Medical Education Committee (AGMEC), the proposed amendments delete existing subsections (a) through (i) and substitute a more modernized, streamlined approach as proposed new subsections (a) and (b). Existing subsections (j), (k), and (l), which are proposed to be recodified as (c), (d), (e), respectively, lay out the requirements for those who graduated after 1916 but before 1985, after 1985 but before 2003, and after 2003, respectively. These provisions are retained to address applicants who come to New Jersey years after graduation. Amendments are proposed to recodified subsection (e) to incorporate the proposed amendments to N.J.A.C. 13:35-1.5, as discussed above. Similarly, amendments to N.J.A.C. 13:35-3.11A are proposed in order to reflect the recognition of acceptable accrediting processes.  

The Board has determined that the comment period for this notice of proposal shall be 60 days; therefore, pursuant to N.J.A.C. 1:30-3.3(a)5, this notice is excepted from the rulemaking calendar requirement.  

Social Impact  

The proposed amendments will permit graduates of international medical schools, many of whom may be residents of this State, to compete for residency training programs in New Jersey. Those who complete residency training are more likely to settle in the State where the training occurred and, thus, the rulemaking may have a positive impact on the availability of physicians in the State. Given that there are accreditation processes now in place that determine the comparability of medical education offered at international schools to that offered at schools evaluated by the LCME, the proposed amendments streamline and modernize the process, reducing the burden of reviewing individual applications on a case-by-case basis and allowing for a speedier process for those seeking to begin their medical careers in New Jersey.  

Economic Impact  

The proposed amendments may allow for more efficient, and, thus, less costly processing of applications for permits, registrations, and licensure. There may also be savings for those who ultimately seek residencies and practice opportunities in New Jersey as they will relocate once, from medical school to New Jersey to complete a residency and then to practice, rather than twice, from medical school to another state to complete residency and then to New Jersey to practice.

  
Federal Standards Statement

  
A Federal standards analysis is not required because the proposed amendments are governed by N.J.S.A. 45:9-1 et seq., and no Federal laws or standards are applicable to the proposed amendments.  

Jobs Impact  

The proposed amendments will potentially increase the number of jobs in New Jersey by lifting barriers that precluded some graduates of international medical schools from participating in residency programs in New Jersey, increasing the likelihood of their remaining in New Jersey to establish medical practices, thus, providing greater opportunities for other individuals who will work in those practices.  

Agriculture Industry Impact  

The Board does not expect the proposed amendments to have any impact on the agriculture industry in the State of New Jersey.  

Regulatory Flexibility Analysis  

If physician applicants for residency training and ultimate licensure are considered "small businesses" for purposes of the Regulatory Flexibility Act (the Act), N.J.S.A. 52:14B-16 et seq., then the following analysis applies. The proposed amendments do not impose any additional or new reporting or recordkeeping requirements upon such applicants. The proposed amendments impose new compliance requirements upon such applicants, which are discussed in the Summary above. There are no costs [page=1599] associated with compliance and the Board believes the proposed amendments may reduce the burden on applicants who otherwise must submit proofs and instead would be allowed to rely on the accreditation status of international medical schools. The Board believes that the proposed amendments should be uniformly applied to all such applicants in order to ensure that they are held to the same standard. Therefore, no differing compliance requirements for such applicants are provided based upon the size of the business. 

 
Housing Affordability Impact Analysis  

The proposed amendments will have an insignificant impact on the affordability of housing in New Jersey and there is an extreme unlikelihood that the proposed amendments would evoke a change in the average costs associated with housing because the proposed amendments concern physician applications for residency training and licensure.  

Smart Growth Development Impact Analysis  

The proposed amendments will have an insignificant impact on smart growth, and there is an extreme unlikelihood that proposed amendments would evoke a change in housing production in Planning Areas 1 or 2, or within designated centers, under the State Development and Redevelopment Plan in New Jersey because the proposed amendments concern physician applications for residency training and licensure.  

Racial and Ethnic Community Criminal Justice and Public Safety Impact  

The Board has evaluated this rulemaking and determined that it will not have an impact on pre-trial detention, sentencing, probation, or parole policies concerning adults and juveniles in the State. Accordingly, no further analysis is required.

  
Full text of the proposal follows (additions indicated in boldface   thus; deletions indicated in brackets [thus]):

  
SUBCHAPTER 1.   MEDICAL SCHOOLS, COLLEGES, EXTERNSHIPS  , AND CLERKSHIPS  

13:35-1.5   Registration and permit requirements for graduate medical education programs in medicine or podiatry  

(a)-(b) (No change.)  

(c) A registration applicant shall certify that he or she:  

1. Has attained the preliminary educational prerequisites for licensure, including:  

i. (No change.) 

 
ii. With respect to medical residents, graduation from a medical school [which]   that, during each year of attendance, was [either] accredited by the Liaison Committee on Medical Education (LCME) or the American Osteopathic Association (AOA)  ; [or] was accredited by an entity recognized by the World Federation of Medical Education (WFME), having accreditation standards comparable to the LCME or the AOA; or was authorized to confer a medical degree in a country that has an accrediting process recognized by the National Committee on Foreign Medical Education and Accreditation (NCFMEA) to be a reliable process for the evaluation of medical education leading to an M.D. or D.O. degree and having accreditation standards comparable to the LCME or the AOA. A registration applicant who cannot demonstrate graduation from a medical school meeting such standards, but whose school is listed in either the World Directory of Medical Schools published by the World Health Organization or the International Medical Education Directory (IMED) published by the Educational Commission for Foreign Medical Graduates (ECFMG), [and that the]  shall be deemed eligible to participate in a residency training program only if all of the graduate's didactic training was completed in the jurisdiction where the school is authorized to confer a medical degree. If the applicant has attended more than one medical school, he or she shall certify that each school attended was accredited through a process identified above or listed in either the World Directory of Medical Schools published by the World Health Organization or the International Medical Education Directory (IMED)  , published by the Educational Commission for Foreign Medical Graduates (ECFMG) during the same time he or she was matriculated.  

iii.-v. (No change.)  

2.-5. (No change.)  

(d)-(z) (No change.)  

SUBCHAPTER 3.   LICENSING EXAMINATIONS AND ENDORSEMENTS, LIMITED EXEMPTIONS FROM LICENSURE REQUIREMENTS; POST-GRADUATE TRAINING  

13:35-3.11 Standards for licensure of physicians graduated from medical schools not approved by [American national]   Board-recognized accrediting [agencies]   processes  
[(a) An applicant for a license to practice medicine and surgery in this State, who is a graduate of a medical school not eligible for and not accredited by the Liaison Committee on Medical Education (LCME) or the American Osteopathic Association (AOA), shall satisfy the conditions in this section to be deemed eligible for New Jersey licensure by examination or to be licensed by endorsement of a sister-state license. 

 
(b) During the course of the applicant's medical training, and at the time of graduation, the medical school(s) was listed (or notified of eligibility for listing) in either the World Directory of Medical Schools published by the World Health Organization or the International Medical Education Directory (IMED) published by the Educational Commission for Foreign Medical Graduates (ECFMG), or the medical school(s) was approved and authorized by the country of domicile to confer the degree or certificate evidencing completion of a medical curriculum for the plenary practice of medicine and surgery.  

(c) The applicant shall demonstrate successful completion of the full medical curriculum, didactic elements and clinical training prescribed by the medical school and by the country in which the medical school is located and within which the training took place, and successful completion of all of the educational requirements to practice medicine in that country.  
(d) If the applicant is a national of the country in which the medical training was received, the applicant shall have obtained an unrestricted license or certificate of registration to practice medicine and surgery in that country.  

(e) An applicant who has successfully completed the full basic science studies (or the equivalent of the first two years of an American medical school) in the foreign medical school located in the country of domicile authorized to confer the degree or certificate and has been given academic credit for successful completion of clinical training programs in United States hospitals, with residency programs approved by the Accreditation Council on Graduate Medical Education (ACGME) and the AOA in that field, shall demonstrate that the medical school was approved by the New Jersey State Board of Medical Examiners (Board) to conduct such a program in this State, or that the program was performed in a sister-state and recognized as acceptable by the Board.  

(f) A graduate of a foreign medical school shall demonstrate to the satisfaction of the Board that he or she holds certification issued by the Educational Commission for Foreign Medical Graduates (ECFMG) which was granted following the attainment of a passing score on an acceptable examination and verification of his or her credentials by ECFMG. The Board shall accept certification of successful completion of an approved Fifth Pathway program in lieu of issuance of the ECFMG Certificate.  

(g) The applicant shall demonstrate satisfaction of all other requirements of law. 

 
(h) The applicant shall demonstrate attainment of a passing grade on an examination approved by the Board for purposes of medical licensure in this State.  

(i) An applicant who has successfully completed the full basic science studies, or the equivalent of the first two years of an American medical school, in the foreign medical school located in the country of domicile authorized to confer the degree or certificate, but who has completed clinical training in the United States in a program not specifically approved by the Board, shall demonstrate prior licensure in another state and compliance with all other provisions of this section and of law, and may then be eligible to be considered for licensure in this State by endorsement. An applicant from a program specifically disapproved by [page=1600] the Board or conducted outside of an available approved program procedure shall not be eligible under this subsection.]  

(a)   To be eligible for a New Jersey license by examination, an applicant who has graduated from an international medical school that is not accredited by an entity recognized by the World Federation of Medical Education (WFME), having accreditation standards comparable to the LCME or the AOA; or authorized to confer a medical degree in a country that has an accrediting process recognized by the National Committee on Foreign Medical Education and Accreditation (NCFMEA) to be a reliable process for the evaluation of medical education leading to an M.D. or D.O. degree and having accreditation standards comparable to the LCME or the AOA, shall demonstrate:  

1. That the medical school was listed in either the World Directory of Medical Schools, published by the World Health Organization or the International Medical Education Directory (IMED), published by the Educational Commission for Foreign Medical Graduates (ECFMG), during the entire period that the applicant was in attendance; 

 
2. Successful completion of the full medical school curriculum, including:  

i. Didactic or basic science training obtained in the country in which the medical school is located and authorized to confer a degree required to practice medicine in that country; and  

ii. Clinical training obtained in the country in which the medical school is located or, if in the United States, at a hospital with residency programs approved by the Accreditation Council on Graduate Medical Education (ACGME) or the AOA in that specialty field of the clinical training;  

3. Certification issued by the Educational Commission for Foreign Medical Graduates (ECFMG) following the attainment of a passing score on an acceptable examination and a verification of his or her credentials; and  

4. Attainment of a passing score on an examination approved by the Board.  

(b) To be eligible for a New Jersey license by endorsement, in addition to satisfying the requirements in (a) above, an applicant shall demonstrate licensure in another state that is active and in good standing for a minimum of two years.  

[(j)]  (c) An applicant, who has graduated from a medical school on or after July 1, 1916 and before July 1, 1985  , and has received a medical degree from a medical school [which is] that was not eligible for, and not accredited by, the LCME or the AOA   during the applicant's attendance, shall demonstrate to the Board, through submission of documentation, that after receiving a medical degree the applicant has successfully completed at least one year of post-graduate training in a program accredited by the ACGME, the AOA, or any other equivalent group or agency [which] that the Board, upon review, has determined has comparable standards.  

[(k)]   (d) An applicant, who has graduated from a medical school on or after July 1, 1985 and before July 1, 2003, and has received a medical degree from a medical school [which is] that was not eligible for, and not accredited by, the LCME or the AOA during the applicant's attendance, shall demonstrate to the Board, through the submission of documentation, that, after receiving a medical degree, the applicant has successfully completed a three-year post-graduate training program accredited by the ACGME, the AOA, or any other equivalent group or agency [which] that the Board, upon review, has determined has comparable standards. 

 
[(l)]   (e) An applicant, who has graduated from a medical school on or after July 1, 2003, and has received a medical degree from a medical school [which is] that was not [eligible for and not] accredited by the LCME or the AOA   or an accrediting body recognized by the WFME having accreditation standards comparable to the LCME or the AOA or authorized to confer a medical degree in a country that has an accrediting process recognized by the NCFMEA as a reliable authority for the accreditation of medical education leading to an M.D. or D.O. degree and having accreditation standards comparable to the LCME or the AOA, during the period of attendance,shall demonstrate to the Board, through the submission of documentation, that after receiving a medical degree, the applicant has completed, and received academic credit for, at least two years for post-graduate training in a program accredited by the ACGME, the AOA, or any other equivalent group or agency which the Board, upon review, has determined has comparable standards, and has a signed contract for a third year of post-graduate training in a program accredited by the ACGME, the AOA, or any other equivalent group or agency [which] that the Board, upon review has determined has comparable standards. At least two of the three years of post-graduate training shall be:  

1.-2. (No change.)  

13:35-3.11A Standards for licensure of physicians graduated from medical schools approved by recognized [national] accrediting agencies  

(a) (No change.)  

(b) An applicant, who has graduated from a medical school on or after July 1, 2003, and has received a medical degree from a medical school approved by the LCME or AOA or [other recognized national accrediting agency,]   with respect to medical residents, graduation from a medical school that, during each year of attendance, was either accredited by the LCME, the AOA, or   an accrediting body recognized by the WFME having accreditation standards comparable to the LCME or the AOA, or authorized to confer a medical degree in a country that has an accrediting process recognized by the NCFMEA as a reliable authority for the accreditation of medical education leading to an M.D. or D.O. degree and having accreditation standards comparable to the LCME or the AOA shall demonstrate to the Board, through the submission of documentation, that after receiving a medical degree, the applicant has completed and received academic credit for at least two years for post-graduate training in a program accredited by the ACGME, the AOA, or any other equivalent group or agency, [which]   that the Board, upon review, has determined has comparable standards, and has a signed contract for a third year of post-graduate training in a program accredited by the ACGME, the AOA, or any other equivalent group or agency[, which] that the Board, upon review, has determined has comparable standards. At least two of the three years of post-graduate training shall be:

1.-2. (No change.)