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NEW JERSEY REGISTER
VOLUME 39, ISSUE 11
ISSUE DATE: JUNE 4, 2007
RULE PROPOSALS
LAW AND PUBLIC SAFETY
DIVISION OF CONSUMER AFFAIRS
STATE BOARD OF MEDICAL EXAMINERS

39 N.J.R. 2202(a)

Proposed New Rule: N.J.A.C. 13:35-6.25

Cultural Competency Training

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

Authority: N.J.S.A. 45:9-7.2, 7.3 and 7.4; 45:1-15.1 and 45:9-2.

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

Proposal Number: PRN 2007-179.

Submit written comments by August 3, 2007 to:

William Roeder, Executive Director
State Board of Medical Examiners
P.O. Box 183
Trenton, New Jersey 08625-0183

The agency proposal follows:

Summary

The State Board of Medical Examiners (the Board) is proposing new rule N.J.A.C. 13:35-6.25 to implement the legislative mandate of P.L. 2005, c. 53, which requires physicians to be trained in cultural competency. P.L. 2005, c. 53, now codified at N.J.S.A. 45:9-7.2 through 7.4, became effective on March 24, 2005. The legislative findings set forth at N.J.S.A. 45:9-7.2 embody a recognition that there are "race and gender-based disparities in the provision of health care" and that "cultural awareness and cultural competence are essential skills for providing quality heath care to a diverse patient population." This regulatory initiative advances the legislative goal and extends a similar requirement to other licensees under the Board's jurisdiction, not expressly included in the statutory reach, who would benefit from cultural competency training.

Proposed new N.J.A.C. 13:35-6.25(a) defines terms as used in the section. For purposes of this regulation the Board defines "physician" as an individual holding an M.D. or D.O. degree licensed pursuant to N.J.S.A. 45:9-1 et seq.; "podiatrist" as an individual holding a D.P.M. degree licensed pursuant to N.J.S.A. 45:5-1 et seq.; and "practitioner" as a physician or a podiatrist. N.J.A.C. 13:35-6.25(a) also provides definitions for "college of medicine," to include only those educational institutions accredited by nationally recognized accrediting bodies -- specifically the Liaison Committee on Medical Education.

The term "continuing medical education" (CME) is defined to mean a post-secondary educational activity, which is designated Category 1, as that term is defined by the American Medical Association (AMA) in its' Physician Recognition Award booklet, or as Category la, lb or 2A, as those terms are defined by the American Osteopathic Association in its' continuing medical education guide. Educational activity in the number of hours prescribed by the American Association of Family Practitioners (AAFP) Commission on Continuing Professional Development and the Council on Podiatric Medical Education (CPME) will also be considered CME for purposes of the new rule. The Board notes that it has incorporated by reference the AMA Physician Recognition Award booklet and the AOA continuing medical education guide, which outline the standards utilized by those entities in determining whether an educational activity rises to the level of Category 1 (for AMA purposes) and Category 1a, 1b or 2A (for AOA purposes). Licensees may obtain copies of the AMA Physician Recognition Award booklet and the AOA continuing medical education guide by accessing the AMA's Internet website at www.ama-assn.org or the AOA's Internet website at www.do-online.org, respectively.

The term "post secondary education," a term used in the statute and pertinent to the evaluation of courses that are substantially equivalent to those offered at New Jersey medical schools, is defined to be education obtained after college, at professional school or in graduate medical education.

In its effort to comprehensively track the statutory language of N.J.S.A. 45:9-7.3(a), the Board is proposing N.J.A.C. 13:35-6.25(b), which directs that each college of medicine in this State must provide cultural competency training, completion of which is required as a condition of receiving a diploma from a college of medicine in this State. This inclusion is not intended to reflect any effort on the part of the Board to assert jurisdiction over the development of the cultural competency curriculum at any accredited medical school in New Jersey, but rather to apprise the regulated community of the legislative determination that cultural competency training is now a mandated part of every New Jersey medical student's preparation.

In addition, the Board is proposing at N.J.A.C. 13:35-6.25(c), that cultural competency training for CME training be offered by each college of medicine in this State. Such training must satisfy the criteria for cultural competency training established by the Board. Again, this provision is included in an effort to make clear the shared responsibilities of the Board and medical schools. At this time, the only medical schools accredited by a nationally recognized accrediting body in the State are those within the University of Medicine and Dentistry of New Jersey (UMDNJ). The Board has worked collaboratively with representatives of UMDNJ and with the Commission on Higher Education to develop the criteria, against which cultural competency training programs must be measured when determining whether the experience offered will achieve the desired goals.

At N.J.A.C. 13:35-6.25(d), the Board is proposing that the cultural competency training for CME must be a program of instruction of at least six hours duration. Consistent with the statute, such instruction can be offered in the classroom and through workshops. The Board is expressly recognizing that cultural competency training may also be offered over the Internet or through other venues. The Board, with input from UMDNJ and from the Commission on Higher Education, has identified six facets of content that should be present in acceptable cultural competency training. Five of these facets are based on the Association of American Medical College's (AAMC's) Tool for Assessing Cultural Competence Training (TACCT). TACCT was developed by a cadre of nationally recognized experts and is intended to assist medical schools in meeting the standard set by accreditation bodies and to provide a framework "for building an effective educational program."

Proposed N.J.A.C. 13:35-6.25(e), (f), (g) and (h) make clear the time periods within which licensees are to fulfill the cultural competency training requirement. N.J.A.C. 13:6.25(e) establishes that a physician who was licensed prior to March 24, 2005, and who did not receive instruction in cultural competency training as part of the curriculum of a college of medicine must, as a condition of the next renewal after March 24, 2008, document completion of CME or equivalent post-secondary education in cultural competency training. Thus, these physicians will have until June 30, 2009 (the next renewal date after March 24, 2008), to complete the CME. Consistent with the statute, the six credits for this training is in addition to the 100 CME credits already required by the Board by N.J.S.A. 45:9-7.1.

Proposed N.J.A.C. 13:35-6.25(f) establishes that a podiatrist who was licensed to practice podiatry prior to March 24, 2005, and who did not receive instruction in cultural competency training as part of the curriculum of a college of medicine (defined to include colleges of podiatric medicine) must, as a condition of the next renewal after March 24, 2008, document completion of CME or equivalent post-secondary education in cultural competency training before being granted licensure renewal by the Board. Credits for this training may be included within the number of CME credits required by the Board pursuant to N.J.S.A. 45:9-7.1.

Proposed N.J.A.C. 13:35-6.25(g) provides that a practitioner (both physicians and podiatrists) licensed to practice after March 24, 2005, the effective date of the law, but on or before the last day before the beginning of a new renewal cycle (June 29, 2007 for physicians and October 31, 2007 for podiatrists), and who did not receive instruction in cultural competency training as part of the curriculum of a college of medicine, as a condition of the next renewal after March 24, 2008, must document completion of CME or equivalent post-secondary education in cultural competency training. Because N.J.S.A. 45:9-7.3 does not expressly dictate that this group of physicians obtain the training, the Board, by this rule, will be exercising its authority to require it as part of the already-mandated CME, required by N.J.S.A. 45:9-7.1. The legislative goal of assuring that physicians develop the skills needed to address a culturally-diverse patient population and reduce disparities in the delivery of health care will only be furthered if the mandate is applied to all physicians, regardless of the date of licensure or school of origin. Accordingly the Board has determined to make the requirement applicable to those physicians who did not fall within the specific reach of the statutory mandate because they were not licensed on the date that the statute became effective. The credits received for training by these practitioners may be included in the 100 CME credits already required by the Board under N.J.S.A. 45:9-7.1.

Proposed N.J.A.C. 13:35-6.25(h) establishes that a physician licensed to practice on or after June 30, 2007, or a podiatrist licensed to practice on or after October 31, 2007, and who did not receive instruction in cultural competency training, as part of the curriculum of a college of medicine, must document completion of CME or equivalent post-secondary education in cultural competency training by the end of the next complete renewal cycle in which he or she was licensed. This training may be included in the CME required by the Board.

Proposed N.J.A.C. 13:35-6.25(i) establishes that the Board may waive the cultural competency training CME requirement for an applicant who is applying for relicensure and who can demonstrate to the satisfaction of the Board that he or she has attained the substantial equivalent of the cultural competency training CME requirement through completion of a similar course in his or her post-secondary education. As the Board has provided a 60-day comment period on this notice of proposal, this notice is excepted from the rulemaking calendar requirement pursuant to N.J.A.C. 1:30-3.3(a)5.

Social Impact

Proposed new rule N.J.A.C. 13:35-6.25 will have a positive social impact upon patients since the new rule establishes training requirements for practitioners in cultural competency in an attempt to eliminate racial and sexual biases. As the law states at N.J.S.A. 45:9-7.2(l)(g), "the public interest in providing quality health care to all segments of society dictates the need for a formal requirement that medical professionals be trained in the provision of culturally competent health care as a condition of licensure to practice medicine in New Jersey." By broadening the reach of the statutory mandate to include physicians not included and podiatrists, the Board is assuring the public that all practitioners will gain the necessary training.

Economic Impact

Proposed new rule N.J.A.C. 13:35-6.25 may have an economic impact upon those physicians who were licensed to practice medicine in New Jersey prior to March 24, 2005, and who did not receive instruction in cultural competency training as part of the curriculum of a college of medicine, since these physicians will be required to complete six hours of CME in cultural competency training, in addition to the already required 100 hours of CME. Completing an additional six hours of CME in cultural competency training will have an economic impact upon these physicians, since they must pay for the program and possibly take time off of work to participate in the program. However, since the proposed new rule furthers the health, welfare and safety of the public by ensuring that licensees are properly trained in cultural competency, any costs that may be incurred as a result of the proposed new rule are greatly outweighed by the benefit of having physicians trained in cultural competency. The Board expects that the training will be offered in a variety of venues, including over the Internet, and thus there may be no or low-cost options available to practitioners.

The remaining subsections should have no significant adverse economic impact upon practitioners since the completion of CME in cultural competency training may be included in the 100 CME hours required by the Board.

Federal Standards Statement

A Federal standards analysis is not required because the proposed new rule is being proposed pursuant to N.J.S.A. 45:9-7.2 through 7.4, and is not subject to any Federal requirements or standards.

Jobs Impact

The Board does not anticipate that the proposed new rule will result in the loss of any jobs. There may be jobs created in connection with the provision of this training.

Agriculture Industry Impact

The Board believes the proposed new rule will have no impact upon the agriculture industry in New Jersey.

Regulatory Flexibility Analysis

Currently, the Board licenses approximately 34,775 physicians (M.D., D.O. and Podiatrists). If Board licensees are considered "small businesses," within the meaning of the Regulatory Flexibility Act, N.J.S.A. 52:14B-16 et seq., then the following analysis applies.

Proposed new rule N.J.A.C.13:35-6.25 imposes compliance requirements upon Board licensees since they must be trained in cultural competency to practice medicine in this State. The proposed new rule also imposes compliance requirements upon licensees since the required training must conform to the criteria set forth in the rule. The proposed rule will also impose recordkeeping requirements upon Board licensees to the extent that licensees will be required to maintain documentation concerning the completion of cultural competency training as required by the Board pursuant to N.J.A.C. 13:35-6.15. The proposed new rule will not impose any reporting requirements upon Board licensees.

No additional professional services will be needed to comply with the proposed new rule. Moreover, the Board does not believe that there will be any significant, additional economic impact upon licensees as a result of the proposed new rule. The costs associated with the proposed new rule are discussed in the Economic Impact statement above. The Board also believes that the proposed new rule should be uniformly applied to all licensees in order to ensure the health, welfare and safety of the general public in the practice of medicine.

Smart Growth Impact

The Board does not anticipate that the proposed new rule will have any impact on the achievement of smart growth and implementation of the State Development and Redevelopment Plan, otherwise known as the State Plan.

Full text of the proposed new rule follows:

13:35-6.25 Cultural competency training

(a) When used in this section, the following terms shall have the following meanings. unless the context clearly indicates otherwise:

"College of medicine" means a college accredited by the Liaison Committee on Medical Education, the American Osteopathic Association (AOA), or other accrediting agency with comparable accrediting standards as recognized by the New Jersey Board of Medical Examiners. Schools accredited by the Council of Podiatric Medical Education (CPME) to confer the degree D.P.M. in New Jersey shall be considered colleges of medicine for purposes of this section.

"Continuing medical education" or "CME" means post-secondary educational activity, which must be: 1. designated Category 1, as defined in the American Medical Association (AMA) Physicians Recognition Award booklet, incorporated herein by reference, as amended and supplemented and available at www.ama-assn.org; 2. designated Category 1a, 1b or 2A in the AOA CME Guide for Osteopathic Physicians, incorporated herein by reference, as amended and supplemented, and available at www.do-online.org; 3. prescribed hours, as designated by the American Association of Family Practitioners (AAFP) Commission on Continuing Professional Development; or 4. approved contact hours, as designated by the Council on Podiatric Medical Education (CPME); and which must be provided by sponsors accredited, recognized or approved at the time of the educational activity by the Accreditation Council on Continuing Medical Education (ACCME), the AOA, the AAFP, or as to podiatrists, the CPME.

"Cultural competency training" means a curriculum developed in consultation with the Association of American Medical Colleges (AAMC) or another nationally recognized organization, which reviews medical school curricula, designed to address the problem of race and gender-based disparities in medical treatment decisions and to improve the sensitivity to and awareness of values in diverse communities that may affect the delivery of health care.

"Physician" means an individual holding an M.D. or D.O. degree licensed pursuant to N.J.S.A. 45:9-1 et seq.

"Podiatrist" means an individual holding a D.P.M. degree licensed pursuant to N.J.S.A. 45:5-1 et seq.

"Post-secondary education" means education obtained in a professional school, graduate medical education or continuing medical education consisting of courses with content deemed, by the Board, to be substantially equivalent to cultural competency curriculum criteria established by the Board.

"Practitioner" means a physician or a podiatrist.

(b) Each college of medicine in this State shall provide cultural competency training, as identified in (d) below, completion of which shall be required as a condition of receiving a diploma from a college of medicine in this State.

(c) Cultural competency training for CME credit shall be offered by each college of medicine in this State. The training shall satisfy the criteria for cultural competency training established by the Board.

(d) To be recognized in satisfaction of the cultural competency training requirement applicable to licensees, any CME program of instruction shall be of at least six hours duration, offered in the classroom, or through workshops, over the internet or through other venues, that provides:

1. A context for the training, common definitions of cultural competence, race, ethnicity and culture and tools for self-assessment;

2. An appreciation for the traditions and beliefs of diverse patient populations, at multiple levels -- as individuals, in families and as part of a larger community;

3. An understanding of the impact that stereotyping can have on medical decision-making;

4. Strategies for recognizing patterns of health care disparities and eliminating factors influencing them;

5. Approaches to enhance cross-cultural clinical skills, such as those relating to history-taking, problem solving and promoting patient compliance; and

6. Techniques to deal with language barriers and other communication needs, including working with interpreters.

(e) A physician who was licensed to practice medicine prior to March 24, 2005, and who did not receive instruction in cultural competency training as part of the curriculum of a college of medicine shall, as a condition of the next renewal after March 24, 2008, document completion of CME or equivalent post-secondary education in cultural competency training pursuant to (d) above before being granted licensure renewal by the Board. Cultural competency training shall be in addition to the CME required by the Board at N.J.A.C. 13:35-6.15.

(f) A podiatrist who was licensed to practice podiatry prior to March 24, 2005, and who did not receive instruction in cultural competency training as part of the curriculum of a college of medicine shall, as a condition of the next renewal after March 24, 2008, document completion of CME or equivalent post-secondary education in cultural competency training pursuant to (d) above before being granted licensure renewal by the Board. Cultural competency training may be included in the CME required by the Board at N.J.A.C. 13:35-6.15.

(g) A practitioner licensed to practice after March 24, 2005, but on or before June 29, 2007, who did not receive instruction in cultural competency training as part of the curriculum of a college of medicine, as a condition of the next renewal after March 24, 2008, shall document completion of CME or equivalent post-secondary education in cultural competency training pursuant to (d) above before being granted licensure renewal by the Board. Cultural competency training may be included in the CME required by the Board at N.J.A.C. 13:35-6.15.

(h) A practitioner licensed to practice on or after the date of the expiration of the next licensure cycle (June 30, 2007 for physicians and October 31, 2007 for podiatrists) who did not receive instruction in cultural competency training as part of the curriculum of a college of medicine, shall document completion of CME or equivalent post-secondary education in cultural competency training pursuant to (d) above by the end of the next complete renewal cycle after he or she was licensed. Cultural competency training may be included in the CME required by the Board at N.J.A.C. 13:35-6.15.

(i) The Board, or its designee, may waive the cultural competency training CME requirement for an applicant who is applying for relicensure and who can demonstrate to the satisfaction of the Board that he or she has attained the substantial equivalent of the cultural competency training CME requirement through completion of a similar course in his or her post-secondary education.



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