The Institute of Medicine (IOM) issued a report titled Redesigning Continuing Education in the Health Profession. This is the outcome of the IOM Planning a Continuing Health Professional Education Institute which was funded by the Josiah Macy Foundation.
The report consisted of a 12 month study, 3 face-to-face meetings, 2 public workshops with 17 speakers, an “extensive literature review,” and 16 external reviewers.
Overall the report is ambitious, involving research and regulation for a diverse group of professions including physicians, nurses, pharmacists, physical therapist, social workers, dieticians, dentist and all other health professionals.
It is a top down driven report calling for a central system for research and regulation of all continuing education in the health professions (CE). It somewhat falls into a belief that a small group of 13 people should decide what is best for educators and clinicians, potentially missing the marketplace and innovation.
The report states that the purpose of CE is to enable health professionals to keep their knowledge and skills up to date, with the ultimate goal of improving performance and patient outcomes. Consequently, the report suggests that there are major flaws in the way CE is conducted, financed, regulated, and evaluated.
They report flaws that exist in the current CE system include:
· Meeting regulatory requirements rather than identifying personal knowledge gaps
· Concerns about conflicts of interest in CE activities
· Regulations that vary widely by profession, specialty, and state, leading to inconsistent learning
The report also claims that the science underpinning CE is fragmented and underdeveloped, which leads to “didactic learning methods (e.g., lectures) in traditional settings (e.g., auditoriums); little specific information about how to best support learning; and health professionals lacking a dependable basis for choosing among CE programs.
Such a claim is somewhat overstated as any heart surgeon, oncologist, or other specialist would contest to, as CE programs have helped keep these specialists up to date on the newest treatments and breakthroughs.
From these claims, the report calls for a new, comprehensive vision for CE that prepares all health professionals to perform to their highest potential, which they call Continuing Professional Development (CPD). In CPD, learning opportunities:
· Stretch from the classroom to the point of care
· Shift control of learning to individual practitioners
· Adapt to individuals’ learning needs
The CPD system offers promise to:
· Advance evidence-based, inter-professional, team-based learning
· Strengthen the research workforce, particularly through academic institutions
· Engender coordination and collaboration among the profession
· Provide higher quality for a given amount of resources
· Lead to improvements in patient health and safety
To achieve this CPD system, the report recommends that the Secretary of the Department of Health and Human Services should commission a planning committee to develop a public-private institute for continuing health professional development. The role of this institute would be to coordinate and guide efforts in content and knowledge of CPD; regulation across states and professions; financing of CPD; and strengthening of a scientific basis. What this boils down to is simple: government controlled continuing education. One obvious problem is: where are the resources (money and staff) to support such a drastic change?
Financing CE
The report rightly asserts that CE will need the necessary resources (money) because of the innovations in learning, specifically about treatments, drugs and devices created by academic-industry-government collaboration. The report notes that at present, 58% of CE funding comes from industry, and out-of-pocket cost to physicians is 42%, or $1,200 per physician per year.
In addition, IOM notes how medical schools provide the most hours of continuing medical education (45 percent of the total). Almost another quarter of all CME hours comes from professional societies and organizations, who are also important providers outside of medicine (ACCME, 2008). Other sources of CME hours include employers of health care professionals, such as the Department of Veterans Affairs (VA), and health care institutions, such as hospitals and insurers.
Other providers of CME, who are crucial for medicine and physician include medical education and communication companies (MECCs). These companies which are accredited by the ACCME, provide tremendous service to physicians and health care providers, even though the report believes their motivations to sometimes have the potential for bias.
This potential however is minimal, because as the report states, “CE funding comes from numerous sources, including health professionals themselves, employers, commercial entities, and the government.” Bias can easily be avoided by the fact that because many physicians have to pay for CE “they are likely to choose an activity based on its perceived value.” In other words, they know who is funding the program, and as highly trained professionals will be able to judge the content and clinical benefit accordingly.
Ideas for new ways to fund CE are obviously important but, as the report notes, “the federal government provides little direct financing for CE for health professionals.” Although some federal money is spent on CE for professionals in the VA or DOD, “no consistent investment for a large majority of non-government related health professionals exists.”
The lack of government funding, and thus the increased reliance on private industry funding, causes critics to believe conflicts may arise. Such claims are also contradictory considering the report itself states that “MECCs can be significant resources, for example, by supplying well-trained staff who provide high quality CE.” Moreover, the potential for bias has also been significantly reduced over the past five years by ACCME and PhRMA, who have ensured that commercial interests are kept separate from learning activities and course content. For example, the ACCME requires CME providers to give a balanced view of therapeutic options and encourages the use of generic names of therapies, rather than promoting specific proprietary names (ACCME, 2006).
With organizations already regulating CE payments, it is hard to see what is wrong with the current system. Today, CE does “directly align with the goals of driving improved quality of care and patient safety and it does support a mix of activities that are effective both in terms of performance and cost.” To safeguard CE from making a profit goes against the very nature of freedom of enterprise and numerous American principles. Investing in CE requires a significant risk and investment, and profits do not reflect the impact such programs have on saving lives and training physicians.
IOM notes that if all industry funding were removed, the average physician could fund his own CME and continue attending the same types of CME activities by investing about $3,500 annually. But the report states that this is an “estimate and does not take into account the nuances of the various sources of CME funding.” The report also states that ‘it is not even clear how the content would change in the event” that industry funding is removed.
Another reason why removing industry funding of CME is problematic is because physicians want to learn and be motivated in a network of their peers to be updated on new practices. In fact the report states that “a mix of cost-effective CE could be achievable in the current financing environment.”
In the absence of evidence, the committee assumes that physicians could maintain participation in activities similar to the ones in which they currently participate (e.g., a hybrid of low-cost, journal-based CME with occasional participation in higher quality, higher cost activities) without paying more out of pocket.
Since IOM clearly states that “no evidence exists to predict how physicians would respond to changes in CE financing, and a determination cannot be made of whether the costs of an ideal system would be greater than the costs of the current system,” why make any changes?
Summary
Overall there are lots of interesting recommendations dealing with continuing education in this report. They have truly identified a problem in the system that the focus of CE is often on meeting regulatory requirements rather than identifying personal knowledge gaps.
There is a tread of national control throughout the report, and one of the presenters on the conference call stated that they realize the next committee to report on this (always more committees) will temper their recommendations. Also requiring more regulations may not necessarily help the problem of over regulation.
The report which would like to set up some type of national system for all CE in the health professions is ambitious project but not a current national priority given the expenses that will go into healthcare reform. To accomplish great things one must think big thoughts, this report is not lacking in any big thoughts. It will be interesting to see if any of those thoughts are implementable.
For details on the recommendations the report and slide set are available online. The report provides details on the nature of the recommendations, the data and science the members of the committee hope to collect from this effort.
Institute of Medicine: Redesigning Continuing Education in the Health Professions 12/04/09