JAMA: Reform of Continuing Medical Education – Still Living in 1910

A recent commentary published in the Journal of American Medicine (JAMA) begins its call for reforming continuing medical education (CME) by citing The 1910 Flexner Report, as if Abraham Flexner is alive and well today.  

 

Flexner an unemployed school principle had never physically been in a medical school prior to embarking on his research.  He claimed to have investigated 69 medical schools during a 90 day period.  At that time meant train travel throughout the country.

 

Abraham Flexner in his research to his own admission failed to utilize standardized research criteria.  His goal was to reduce the number of physicians, close all non-allopathic medical schools, and abolished proprietary medical schools (medical schools run as businesses).  In addition he failed to take into account any of the advances that these private institutions had contributed to medicine.

 

The report was full of utopian altruism, less known is Flexner’s recommendation that medical schools appoint full-time clinical professors. Holders of these appointments would become “true university teachers, barred from all but charity practice, in the interest of teaching.”

 

Compliance to the Flexner report which was embraced by the American Medical Association and state regulatory boards drastically reduced the supply of physicians in the US, and significantly increased the cost of medicine.  Rural and areas with poorer patients were especially hard hit by the lack of physicians that resulted from shutting down most of the countries medical schools. 

 

The report was particularly discriminatory towards women and African American physicians resulting in the closing of all women only medical schools and reducing the number of African American schools to 2 and in 1964 fifty years later largely as result of his report subsequent regulation less than 3% of students entering medical school were African American’s and we still see extremely low numbers today.

 

The commentary, titled “Reform of Continuing Medical Education: Investments in Physician Human Capital,” was written by Eric G. Campbell, PhD who by his own words lasts December received $150,000 for this “research” from the Josiah Macy Foundation that would more than likely get published in JAMA (such confidence in his connections). 

His “research” is part of a full scale initiative by the Macy Foundation which hired Campbell, IOM and AAMC to write complementary reports on CME.   Eric outlined at the IOM hearing in December how he was going to find a new system of funding for CME.   In his own words “CME was expendable”(Audio Files of his talk).

Moreover, JAMA editor Katherine De Angelis, MD is an active participant in several Macy Foundation fully funded initiatives including the IOM committee on a Planning a Healthcare Continuing Medical Education Institute, and was a participant in the Macy Conference held in Bermuda and subsequent Monograph on Continuing Education in the Health professions.  The Director of the JAMA oversight committee Jordan Cohen, MD is a member of the Macy Foundation Board of Directors.

The results of Eric’s “study” are less than impressive and his subsequent commentary requires a strong response.

Accordingly, his editorial on CME, which cites only 8 references, (2 news stories, 2 editorials, 1 report based on editorial, 1 survey, 1 review, 1 research paper on GME) is nothing more then a clearly unsubstantiated “opinion paper,” that should be properly disclosed or retracted.

Regardless of this error, Mr. Campbell goes on to make the claim that “CME should apply new knowledge and skills that directly benefit patient and societal outcomes (e.g. providing high-quality, efficient, and cost-effective care).” Completely disregarding the breakthroughs CME programs have provided to physicians and patients over the past few decades (e.g. how to use new medical devices, instruction on new treatments and medicines), he claims that traditional CME does not focus on these outcomes. One wonders in all of his paid research whether Mr. Campbell even attended a CME program.

 

Instead, Mr. Campbell would rather focus on a century old report that could not have predicted the impact that medical device and pharmaceutical companies would play in creating life saving treatments and breakthroughs. He tries to downplay such breakthroughs so that he can call for “sweeping reform” in CME that provides a “productive means of investing in physician human capital.” What exactly does human capital refer to? He calls this capital, “knowledge and skills.”

 

Such knowledge and skills are inherent throughout all CME because these programs are created by medical professionals, for medical practitioners to educate doctors on ways to better serve society by making people healthier through new research and ways to practice medicine. 

 

The only human capital Mr. Campbell is referring to is an attempt to remove industry investment, which he believes may be potentially biased. To make such a claim using a century old report and no evidence, is clearly more biased than any industry involvement in CME.  

 

Excessive Commercialization

 

He cites numbers which show that CME has high profit margins (23.5%) which can be attributed to the fact that most CME providers are hospitals, universities and medical societies which attribute all income from CME for accreditation as (profit) and do not include their overhead and staff time in their reports as expenses.  But in fairness to Eric he would not know this unless he worked in CME which he does not.

 

He attributes the profit  to commercial support, which the ACCME annual report does not, which accounts for 58% of income of accredited CME provider organizations.   Of course he uses the 2007 data and not the most current data, which shows a precipitous $200 million drop in CME funding.

 

If industry did not provide such support then who would? How much would physicians and patients suffer with only 42% support of CME from other non-profit sources?

 

The reality of commercialization is that today, for a new drug or device to become useful to help treat patients is a multi-stage, multi-million dollar, multi-year process that few investors are willing to take the risk of, even when it means saving lives. So then why criticize those companies that take on all the risk, when their sole purpose is to save lives and make people healthier?

 

Unstandardized Curricula

 

As is the case for all highly trained professionals, physicians must fulfill a designated number of accredited CME credits to maintain their licenses in most states. Mr. Campbell’s criticism that “physicians have broad autonomy in selecting course topics types of learning experience, and activity locations” sounds like government controlled medicine.  His ethical dilemma is Eric’s and JAMA’s editors firmly held belief that physicians should not have broad autonomy that they are unable to think for themselves, that medical practice should be restricted by academia and the government.

 

CME is voluntary, and no doctor would choose to lose the income from his practice, or the risk of losing a patient if such a program or educational opportunity was not of great importance. Furthermore, there is no way to standardize the practice of each program because every patient is different, and each person requires different sorts of medical attention and treatments. Since this is the case, CME delivered only as a standardized curricula would prevent doctors from the necessary experience to identify complex problems and provide critical decisions for pressing issues that are increasingly a matter of life or death.   It also limits the

 

Additionally, his call for CME to represent a “mastery of an essential core set of knowledge and competencies” is precisely what CME does. There are numerous professional organizations, associations and medical journals that provide endless scholarship in every area of medicine. CME simply represents another facet for physicians to use to help them master their core set of knowledge and skills. The fact that there are a “diversity of CME offerings that provide benefits to physicians” should reassure patients that physicians are carefully choosing programs that will truly benefit them the most, not because the doctors have a paid trip to a nice hotel.

 

Lack of Effect on Patient Care

 

The idea that CME today is analogous to a century old report is laughable. Programs that discuss the outcomes of clinical studies, show physicians how to use medical devices, and discuss the future and present needs in medicine in an open and experienced forum is nothing like lectures and note memorization in medical school. Perhaps the reason why such programs are held at various locations is for that exact reason: to remove doctors from the classroom experience and provide more practical experiences.

 

Still, Mr. Campbell’s claim that “traditional CME is not adequately focused on improving patient outcomes” is a blatant distortion of the truth. In fact, he uses a source an AHRQ study that says exactly the opposite of his claim that “there is scant evidence that CME actually improves patient outcomes.” Specifically, researchers in the AHRQ study concluded that:

 

    “CME appears to be effective at the acquisition and retention of knowledge,     attitudes, skills, behaviors and clinical outcomes.”

 

Contrary to this case of academic misrepresentation, Mr. Campbell calls for a new model of CME, one with a purpose to “maintain and improve the quality and efficiency of the US health care system.” What evidence states at present that CME has a different purpose than this? The problems of quality and efficiency in the US health care system are not caused by CME, they are alleviated. Without CME, health care would be in much worse shape. So what changes are needed to give physicians more skills and knowledge (human capital)?

 

First, Mr. Campbell thinks there should be “financial incentives for more meaningful CME. “ He notes that “currently, most physicians are not paid based on the quality or efficiency of their practice.” This is a problem of the health care system (e.g. reimbursement rates, fee for service, insurance company practices). While the idea of incentivizing CME is important, has assisted in incentivizing CME by providing grants for higher quality education than non funded education.  The only thing that providers of CME need to refocus is how to avoid burdensome regulations and policies that make it almost impossible to continue staying in the business of educating doctors on how to save more lives.

 

Second, Mr. Campbell asserts that “making maintenance of certification a mandatory requirement for licensure should be strongly considered.” This point is already accomplished by CME programs which do “embody continual engagement with the process of professional improvement through accredited programs. Interestingly, the editorial calls for more CME credits, calling the current minimum of 20-50 CME credits per year “too low.” More CME is exactly what will provide patients with better care and physicians more knowledge and skills. Since Mr. Campbell, as do most critics, offer no way in which the additional programs and courses will be offered and funded, surely industry and providers will gladly foot the bill, not because of the profits but for the lives they will change.

 

Campbell’s third idea to use health information technology (HIT) has already been discredited numerous times. Enhancing physician learning from their routine clinical duties means having more meaningful interactions with patients, and attending more programs where physicians can interact with researchers and scientists to share experience. Using electronic health records will reduce the amount of time doctors have to see patients, and will result in no cost savings. Furthermore, the training of staff, potential for error, and privacy issues all outweigh any potential gains. Finally, “CME activities that include clinical problems encountered in day-to-day practice” already exist.

 

Financing the New CME

 

While claims like CME are “too reliant on industry funding” and “tend to promote a narrow focus on products,” once again, what is the alternative source for money? To create a broader “education on alternative strategies for managing health conditions and other important issues” without industry is highly unlikely. If Mr. Campbell wants to reorient CME away from “marketing drugs,” what system of funding will he use?

 

His idea that physicians should personally invest in their own CME is already the case: although required by most states to maintain their license, doctors choose which programs to attend often giving up large amounts of personal time and traveling great distances to meetings and conferences at their own personal expense. How would we reward physicians for “practicing high-quality, efficient medicine” or “performance-based incentives?” Who would determine such rewards?

 

How is the use of specialty boards, also accredited organizations, any different than accredited CME providers? Having a large infrastructure to operate and enforce large-scale maintenance-of-certification programs guarantees nothing (e.g. AMA’s CEJA Report is on round three).

 

The use of funded and provided by medical schools and teaching hospitals should be highly valued and increased in use but, where is the money coming from?  Will this shift the current focus from therapy and treatment to diagnostics and referral from local physicians for high end procedures?  How many physicians in Montana have access to a program only offered in one place, as is the case for many rural states? Physicians need CME to come to them, and medical schools cannot provide such a service.

 

Conclusion

 

There is only one problem with CME today: there are not enough programs to address the growing needs of patients and physicians. The continued use of commercial support to fill in this gap is necessary to help physicians treat patients. The suggestions outlined by Mr. Campbell suggest a complete misunderstanding of the significance of CME today.   

 

Mr. Campbell and other “reformers” pride themselves on repeating Abraham Flexner’s accomplishments; proposing to limit the choices of physicians.  Perhaps they should also consider theirs and Flexner’s shortcomings at the same time.

 

Perhaps he should focus less on 1910 and more on 2010 and read some of our stories here on the success of CME.