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NEW JERSEY REGISTER
VOLUME 39, ISSUE 18
ISSUE DATE: SEPTEMBER 17, 2007
RULE PROPOSALS
LAW AND PUBLIC SAFETY
DIVISION OF CONSUMER AFFAIRS
STATE BOARD OF MEDICAL EXAMINERS

 

Proposed Amendments: N.J.A.C. 13:35-1.5 and 3.11
Proposed New Rule: N.J.A.C. 13:35-3.11A
Proposed Recodification with Amendments: N.J.A.C. 13:35-1.3 as 3.14

Click here to view Interested Persons Statement

Postgraduate Training; Registration and Permit Requirements for Graduate Medical Education Programs in Medicine or Podiatry; Standards for Licensure of Physicians Graduated from Medical Schools Not Approved by American National Accrediting Agencies; Standards for Licensure of Physicians Graduated from Medical Schools Approved by American National Accrediting Agencies

Authorized By: State Board of Medical Examiners, William Roeder, Executive Director.
Authority: N.J.S.A. 45:9-8 and 45:9-19.12.
Calendar Reference: See Summary below for explanation of exception to calendar requirement.

Proposal Number: PRN 2007-293.
Submit written comments by November 16, 2007 to:

William Roeder, Executive Director
State Board of Medical Examiners
Post Office Box 183
Trenton, New Jersey 08625-0183

The agency proposal follows:

Summary

By P.L. 2001, c. 307, the Legislature enacted a number of measures designed to strengthen the credentialing process for physicians and podiatrists, to facilitate enforcement and provide for educational remedies for those found to have skills deficiencies and to require continuing medical education of current licensees. This rulemaking focuses on implementation of those reforms directed at enhancing the educational prerequisites for licensure by increasing -- prospectively -- the number of years of post-graduate training required of applicants for licensure. It also codifies the standards applicable to those physicians in training who seek additional remuneration by practicing while holding a permit. As a result of the legislation, now codified at N.J.S.A. 45:9-8 and 45:9-19.12, the Board is proposing to amend N.J.A.C. 13:35-1.5, concerning registration and permit requirements for graduate medical education programs in medicine or podiatry, and N.J.A.C. 13:35-3.11, concerning the standards for licensure of physicians graduated from medical schools not approved by recognized national accrediting agencies, more specifically the Liaison Committee on Graduate Medical Education (LCGME) and the American Osteopathic Association (AOA). In addition, the Board is proposing a new section, N.J.A.C. 13:35-3.11A, to establish standards for licensure of physicians who have graduated from medical schools approved by a recognized national accrediting agencies.

Prior to the 2001 legislative enactment, N.J.S.A. 45:9-8 required graduates of nationally-accredited medical schools to complete one year of post graduate training (known as PGY training). By operation of current N.J.A.C. 13:35-3.11, graduates of schools not eligible for accreditation through nationally-recognized entities are required to complete three years of post graduate training, as a means to assure that any disparity in medical school education would be addressed by an extended period of "on-the-job" training. Thus, graduates of American and Canadian medical schools had been eligible for licensure, and outside employment, after just one year even though the vast majority remained in residency training for two or more years; graduates of all other schools needed to obtain licensure and complete three years of PGY training before being eligible to "moonlight."

The 2001 statute, and now this proposal, are intended to accomplish several goals. Most importantly, they require all applicants graduating after July 1, 2003 to complete two years of PGY training and have a contract for the third year of a residency program. Given the volume and complexity of what must be learned by those embarking on medical practice in the 21st century, one year of PGY training is not sufficient. The statute, at N.J.S.A. 45:9-8(b) strikes the balance requiring completion of two years of post graduate training, and assuring that applicants are on a track towards the completion of the third year. In addition, the statute and now these rules "even the playing field" in the future by ending the disparity of treatment based on the location of the medical school attended. As noted above, the current regulation, at N.J.A.C. 13:35-3.11(j), adopted on May 9, 1984, had required applicants who graduated from foreign schools after July 1, 1985 to complete three years of PGY training. By this initiative, N.J.A.C. 13:35-3.11 will be amended to bring the post graduate training requirements for those graduating from schools outside of the United States and Canada into alignment with those graduating from schools subject to national accreditation standards. Finally, this rule initiative establishes the parameters for acceptable "moonlighting" opportunities for permit holders in post-graduate training programs to provide assurance of adequate supervision and that the residency program director approves of such endeavors. Thus, the protocols allow for approved "moonlighting" for extra remuneration, making all PGY participants eligible, regardless of the medical school attended. Preservation of this opportunity allows New Jersey PGY training programs to remain competitive with their counterparts in other states.

The specific regulatory changes are outlined, sequentially, below. The Board is proposing to recodify N.J.A.C. 13:35-1.3 as 3.14. This rule deals with post-graduate training and should appear in Subchapter 3, which now contains provisions concerning post-graduate training. The Board proposes to delete the last sentence of this rule, which requires a program to be acceptable to the Board, based upon Advisory Graduate Medical Education Council (AGMEC) standards. Any post-graduate training that meets the other requirements of this rule will be acceptable to the Board and requiring Board approval of the post-graduate training is therefore redundant.

The Board is proposing to amend N.J.A.C. 13:35-1.5(r) to reflect the statutory changes to N.J.S.A. 45:9-19.12 by deleting the limitation on permit holders restricting their practice of medicine or podiatry to the confines of a hospital affiliated with the graduate medical education program and outpatient facilities integrated into the curriculum of the program. N.J.A.C. 13:35-1.5(r), as amended will make clear that not only may a permit holder engage in the practice of medicine or podiatry within the context of an accredited graduate medical education program at a licensed hospital, but in addition, a permit holder may engage in practice outside the context of a graduate medical education program for additional remuneration if that practice is approved, in writing, by the residency program director and supervised by a plenary licensee. The level of supervision required is to be determined based on whether the practice is occurring in a health care facility or elsewhere. If the practices occur outside of the licensed facility, the supervising physician must remain on the premises.

New provisions N.J.A.C. 13:35-1.5(s) and (t) will establish the responsibilities of the residency program director and the supervising physician. More specifically, N.J.A.C. 13:35-1.5(s) provides that the residency director must require that each permit holder complete and submit a verification of supervision/employment form prior to approving practice outside of the approved graduate medical education program. A verification of supervision/employment form is required for each place of employment in which a permit holder practices outside the context of a graduate residency training program. The form shall include the name of the permit holder, field of practice, New Jersey physician license number of the supervisory physician, type of facility, telephone number and street address of the facility. The verification form must be retained for seven years and may be subject to review by the Board.

N.J.A.C. 13:35-1.5(t) will require the supervising physician to complete an affidavit accepting responsibility for reading and implementing the Board's statutes and rules that pertain to employment of permit holders outside of their approved graduate medical education programs. In addition, the supervising physician must provide evidence to the program director that arrangements have been made for professional liability coverage of the permit holder that are consistent with the rules of the Board, specifically N.J.A.C. 13:35-6.18.

Proposed new subsection N.J.A.C. 13:35-1.5(u) includes the content originally included in N.J.A.C. 13:35-1.5(r), setting forth the requirements relating to the prescriptive authorities for permit holders.

Current N.J.A.C. 13:35-1.5(s) and (r) are being recodified as subsections (v) and (w). The Board is also proposing to delete current N.J.A.C. 13:35-1.5(u) because it simply repeats the content of N.J.A.C. 13:35-1.5(k).

N.J.A.C. 13:35-1.5(v) through (x) are being recodified as subsections (x) through (z). In addition, the Board is proposing to delete N.J.A.C. 13:35-1.5(y) because it is obsolete and no longer applicable.

Amendments to N.J.A.C. 13:35-3.11(a), (e) and (h) substitute abbreviations for the names of organizations, after they have been defined once, for ease of reading. The Board is also proposing new and revised rule subsections to appear at N.J.A.C. 13:35-3.11, to integrate the statutory amendments set forth in N.J.S.A. 45:9-8, as they apply to graduates of medical schools not accredited by nationally recognized entities. As before, through new subsection (j), those who graduated before July 1, 1985, are required to have successfully completed at least one year of post-graduate training in a program accredited by the American Council on Graduate Medical Education (ACGME), the AOA, or any other equivalent group or agency, which the Board approves. The new rule at N.J.A.C. 13:35-3.11(k) will continue the prior requirement (presently found at N.J.A.C. 13:35-3.11(j) and in effect since July 2, 1984), that any applicant who has graduated from a medical school not subject to nationally recognized accrediting body, on or after July 1, 1985 (but before July 1, 2003), must complete three-years of approved post-graduate training.

The Board is also proposing amendments to N.J.A.C. 13:35-3.11(j) (recodified as (l)), to reflect the statutory amendment set forth in N.J.S.A. 45:9-8(b)2. N.J.A.C. 13:35-3.11(l) provides that an applicant who has graduated from a medical school not accredited by the nationally recognized entities on or after July 1, 2003 must complete at least two years of approved PGY training, with a signed contract for a third year of PGY training. At least two of the three years of PGY training must be in the same field or would, when considered together, be credited toward the criteria for certification by a single specialty board recognized by the American Board of Medical Specialties (ABMS), the AOA or any other equivalent group with comparable standards. New section N.J.A.C. 13:35-3.11A sets forth standards for licensure of physicians graduated from medical schools approved by nationally recognized accrediting agencies. Consistent with N.J.S.A. 45:9-8, N.J.A.C. 13:35-3.11A(a), requires an applicant from an accredited medical school, who has graduated before July 1, 2003 to successfully complete at least one year of approved PGY training. Subsection (b) establishes the standard for those who have graduated from an accredited medical school on or after July 1, 2003, to be the same as that applicable to those governed by N.J.A.C. 13:35-3.11(l): at least two years of approved postgraduate training and a signed contract for a third year of PGY training in the same field or in different fields if taken together would be credited for certification by a single recognized specialty board.

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

The proposed amendments to N.J.A.C. 13:35-1.5(r) will have a positive social impact upon permit holders since the amended rule allows permit holders, while in training, to engage in the practice of medicine or podiatry outside the context of a graduate medical education program for additional remuneration, so long as that practice is supervised in accordance with N.J.A.C. 13:35-1.5(r)1 through 3. Proposed new rules N.J.A.C. 13:35-1.5(s) and (t) provide assurance to patients being treated by those in PGY training, who are not yet licensed, that their residency program directors approve of such practice and that they will be appropriately supervised, at a level tailored to the setting. Proposed amendments to N.J.A.C. 13:35-3.11 and new rule N.J.A.C. 13:35-3.11A codify legislative changes designed to ensure that all those embarking on licensed practice in this State will have a sufficient educational foundation to practice medicine. Together these sections will require all plenary license (M.D.s and D.O.s) applicants graduating after July 1, 2003, to complete two years of PGY training and have a contract for the third year. The requirement that at least two of the three PGY training years be in the same field, or in different fields, which would be recognized by a single recognized specialty board, ensures that the applicant has received comprehensive preparation, rather than a disjointed experience. In addition, these rules will result in equal treatment for plenary license applicants regardless of the location of the medical school attended.

Economic Impact

The new provisions of N.J.A.C. 13:35-1.5(t) may have an economic impact upon those physicians who elect to supervise permit holders who practice outside of their approved graduate medical education programs. Physicians may choose to supplement the services they offer to their patients, so long as they assure that appropriate oversight is provided. N.J.A.C. 13:35-1.5(t)2 requires the supervising physician to provide the program director with evidence that arrangements have been made for professional liability coverage of the permit holder that is consistent with the regulations of the Board. In addition, permit holders who seek employment opportunities outside of the residency training program will be able to derive an additional source of income. Some permit holders who in earlier years would have been eligible to engage in unfettered practice as licensees after only one year of PGY training, may be foreclosed from these opportunities if the residency program director believes that the activity would impinge on the educational goals of the residency program. The rule provisions establishing -- prospectively -- a single standard for licensure, regardless of the medical school attended may make those medical schools not accredited by nationally recognized entities more competitive, since graduates will no longer have to complete three years of residency training before becoming licensed.

Federal Standards Statement

A Federal standards analysis is not required because the proposed amendments, recodification and new rule are proposed pursuant to State statute and are not subject to any Federal requirements or standards.

Jobs Impact

The Board does not anticipate that the proposed amendments, recodification and new rule will result in the creation or loss of any jobs. There may be some impact on the pool of medical personnel eligible to accept "moonlighting" positions. Physicians in post-graduate programs who are graduates of medical schools subject to nationally recognized accreditation agencies will not be eligible for licensure -- an unsupervised practice -- as early in their training. Those graduating from medical schools not subject to accreditation standards will no longer have to wait until completion of the third year of residency training to accept moonlighting opportunities available to plenary licensed physicians. In addition, permit holders will be able to accept positions for remuneration, so long as they obtain approval from the residency program director and the setting-specific oversight is provided.

Agriculture Industry Impact

The Board believes the proposed amendments, recodification and new rule will have no impact upon the agricultural industry in New Jersey.

Regulatory Flexibility Statement

Since physicians (M.D., D.O. and Podiatrists) are individually licensed by the Board, they may be considered "small businesses" under the Regulatory Flexibility Act (the Act), N.J.S.A. 52:14B-16 et seq.

The Act requires the Board to set forth reporting, recordkeeping and other compliance requirements of the amendments and new rule, including the kinds of professional services likely to be needed to comply with the requirements. The Act further requires the Board to estimate the initial and annual compliance costs of the amendments and new rule, to outline the manner in which it has designed the rules proposed to minimize any adverse economic impact upon small businesses, and to set forth whether the amendments and new rules establish differing compliance requirements for small businesses. Licensees will not need to employ professional services in order to comply with the requirements of the proposed amendments and new rule.

Proposed amendments to N.J.A.C. 13:35-1.5(r) impose compliance requirements upon 1) permit holders who wish to engage in practice outside the context of a graduate medical education program for additional remuneration; 2) their residency program directors; and 3) the plenary licensed physicians who take on supervisory responsibilities. Practice outside the context of the residency training program must be approved by the residency program director of the graduate medical education program and supervised by a plenary licensee who shall either remain on the premises or be available through electronic communication if that practice is at or through a health care facility licensed by the DHSS. If the practice is outside of a health care facility licensed by the DHSS, then the permit holder must be supervised by a plenary licensee who shall remain on the premises.

Proposed new rule N.J.A.C. 13:35-1.5(s) imposes compliance and recordkeeping requirements upon residency program directors since the new regulation establishes that the program director must require each permit holder to complete and submit a verification of supervision/employment form prior to approving practice outside the approved graduate medical education program. This procedure must be completed for each place of employment a permit holder practices outside the context of a graduate residency training program. The verification of supervision/employment forms must be kept for seven years.

Proposed new rule N.J.A.C. 13:35-1.5(t) imposes compliance requirements upon the supervising physician. The supervising physician must complete an affidavit accepting responsibility for reading and implementing the Board's statutes and regulations that pertain to employment of permit holders outside of their approved graduate medical education programs. In addition, N.J.A.C. 13:35-1.5(t)2 imposes reporting requirements upon the supervising physician since he or she must provide evidence to the program director that the arrangements have been made for professional liability coverage of the permit holder that is consistent with the regulations of the Board.

The proposed amendments and new rules to Subchapter 3 do not impact on small businesses as the term is defined in the Regulatory Flexibility Act, N.J.S.A. 52:14B-16 et seq. The rules provide the standards for licensure of physicians graduated from medical schools not approved by a recognized national accrediting agency as well as standards for licensure of physicians graduated from medical schools approved by a recognized national accrediting agency. Consequently, a regulatory flexibility analysis is unnecessary. The costs of the reporting, recordkeeping and compliance requirements are discussed in the Economic Impact above.

As the proposed amendments to N.J.A.C. 13:35-1.5 provide for the safe and effective practice of permit holders who work outside the context of a graduate medical education program, and ensure that permit holders are properly supervised by residency program directors and supervising physicians, the rules should be applied to all permit holders, program directors and physicians.

Smart Growth Impact Statement

The Board does not anticipate that the proposed amendments, recodification or 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 proposal follows (additions indicated in boldface thus; deletions indicated in brackets [thus]):

SUBCHAPTER 1. MEDICAL SCHOOLS, COLLEGES, EXTERNSHIPS[,] AND CLERKSHIPS [AND POST-GRADUATE WORK]

(Agency Note: N.J.A.C. 13:35-1.3 is proposed for recodification with amendments as N.J.A.C. 13:35-3.14.)

13:35-1.3 (Reserved)

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

(a)-(q) (No change.)

(r) A permit holder may engage in the practice of medicine or podiatry provided that such practice shall be [confined to a hospital affiliated with the graduate medical education program and outpatient facilities integrated into the curriculum of the program, under the supervision of licensed plenary physicians or licensed podiatric physicians, as appropriate.] within the context of an accredited graduate medical education program conducted at a hospital licensed by the Department of Health and Senior Services (DHSS). A permit holder may engage in practice outside the context of a graduate medical education program for additional remuneration only if that practice is approved, in writing, by the residency program director of the graduate medical education program in which the permit holder is participating and the practice is supervised by a plenary licensee who shall:

1. Either remain on the premises of the health care facility or be available through electronic communication if that practice is at or through a health care facility licensed by the DHSS; or

2. Remain on the premises if that practice is outside of a health care facility licensed by the DHSS.

(s) The residency program director shall:

1. Require each permit holder to complete and submit a verification of supervision/employment form prior to approving practice outside of the approved graduate medical education program. A verification of supervision/employment form is required for each place of employment a permit holder practices outside the context of a graduate residency training program. The form shall include, but not be limited to, the following information:

i. Name of the permit holder;

ii. Field of practice;

iii. New Jersey physician license number of the supervising physician;

iv. Type of facility;

v. Telephone number; and

vi. Street address of the facility; and

2. Retain the verification of supervision/employment forms for seven years, which may be subject to review by the Board.

(t) The supervising physician shall:

1. Complete an affidavit accepting responsibility for reading and implementing the Board's statutes, N.J.S.A. 45:9-1 et seq., and rules, N.J.A.C. 13:35, that pertain to employment of permit holders outside the context of their approved graduate medical education programs; and

2. Provide evidence to the program director that arrangements have been made for professional liability coverage of the permit holder that is consistent with the rules of the Board, specifically N.J.A.C. 13:35-6.18.

(u) Prescriptions and orders may be issued by permit holders in the inpatient setting without countersignature. All prescriptions issued by permit holders in the outpatient setting, which are to be filled in a pharmacy outside a licensed health care facility shall be signed by a licensed physician or licensed podiatric physician, as appropriate.

Recodify existing (s) and (t) as (v) and (w) (No change in text.)

[(u) Upon a duly verified application of the Attorney General alleging a violation of any act or regulation administered by the Board which palpably demonstrates that the resident's continued practice would constitute a clear and imminent danger to the public health, safety and welfare, the Board may enter an order temporarily suspending the resident's permit to engage in the practice of medicine or podiatry pending a plenary hearing on the charge.]

Recodify existing (v)-(x) as (x)-(z) (No change in text.)

[(y) This rule shall be effective upon publication as an adopted rule in the New Jersey Register. With respect to the first year during which this rule is in effect, Directors shall be required to submit a master list. Registration application forms and permit application forms will be made available after the publication of the rule. Unlicensed residents intending to participate in a graduate medical education program on or after July 1, 1988 may, if they so choose, seek registration or a permit, as may be applicable for the year beginning on July 1, 1988. Registration and permits will be required, as applicable, for participants in the second year (or beyond) of a residency training program which begins on or after July 1, 1989.]

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 accrediting agencies

(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)-(d) (No change.)

(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 American Council on Graduate Medical Education (ACGME) and the [American Osteopathic Association] 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)-(g) (No change.)

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

(i) (No change.)

(j) 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 not eligible for and not accredited by the LCME or the AOA, 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 the Board, upon review, has determined has comparable standards.

(k) 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 not eligible for and not accredited by the LCME or the AOA, 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 the Board, upon review, has determined has comparable standards.

[(j)] (l) [Any applicant having] 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 not eligible for and not accredited by the [Liaison Committee on Medical Education] LCME or the [American Osteopathic Association] AOA [on or after July 1, 1985] shall [also demonstrate successful completion of a three-year post-graduate training program accredited by the American Council on Graduate Medical Education, the American Osteopathic Association, or any other equivalent group or agency recognized by the Board of Medical Examiners.] 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 the Board, upon review has determined has comparable standards. At least two of the three years of post-graduate training shall be:

1. In the same field; or

2. In different fields, if when considered together, the post-graduate training fields would be credited toward the criteria for certification by a single specialty board recognized by the American Board of Medical Specialties (ABMS), the AOA or any other equivalent group or agency which the Board, upon review, has determined has comparable standards.

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

(a) An applicant, who has graduated from a medical school on or after July 1, 1916 and before July 1, 2003 and has received a medical degree from a medical school approved by the Liaison Committee on Graduate Medical Education (LCGME) or American Osteopathic Association (AOA) or other recognized national accrediting agency, 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 American Council on Graduate Medical Education (ACGME), the AOA, or any other equivalent group or agency which the Board, upon review, has determined has comparable standards.

(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 LCGME or AOA or other recognized national accrediting agency, 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 the Board, upon review, has determined has comparable standards. At least two of the three years of post-graduate training shall be:

1. In the same field; or

2. In different fields, if when considered together, the post-graduate training fields would be credited toward the criteria for certification by a single specialty board recognized by the American Board of Medical Specialties (ABMS), the AOA or another certification entity which the Board, upon review, has determined has comparable standards.

13:35-[1.3]3.14 Postgraduate training

Postgraduate training shall be taken under the auspices of a hospital or hospitals accredited for such training by the Accreditation Council for Graduate Medical Education (ACGME) or by the American Osteopathic Association (AOA) or by the American Podiatric Medical Association (APMA), as applicable to the profession. [The program shall further be acceptable to the Board, which shall take into account the standards adopted by the Advisory Graduate Medical Council (AGMEC).]



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