CME Critics Ignore Updates in Educational Design and Methods

The United States has long been the world leader in advancing medicine and science. American companies, universities, and institutions are rapidly discovering new medicines and innovation in treatments. The face of health care changes in revolutionary ways almost every day.

Doctors however, do not have the time or the means to keep up with such changes. Physicians in America in all settings, private practice or academia, institution or corporation, are too busy seeing patients to read the latest clinical studies or journal articles about breakthroughs in new treatments. This is not new either. Since the early twentieth century, when the Flexner report was published, America has known that physicians have inadequate medical training.

While much has evolved over the past century in medical education to address issues in medical training, continuing medical education (CME) has significantly helped close the gap in medical education and training. Despite the enormous success CME has enjoyed over the past several decades by improving patient outcomes and physician training in numerous practice areas and specialties, critics still maintain that the “CME System is Obsolete,” according to a recent article in Minnesota Medicine.

The article explores historical perspectives on CME, outlines its shortcomings, and presents an idea for a new system based on the recommendations of the Institute of Medicine (IOM) and Macy Foundation reports that would make continuous learning more relevant to today’s medical practice.

History of CME

In tracing the evolution of CME, the article notes that “historically, medical schools took the lead in creating a CME system to update physicians on both clinical advances as well as breakthroughs in basic science.” Eventually, the American Medical Association (AMA) incorporated CME into medical practice in the 1950s. In addition, “large-scale post-war investments in scientific research caused an explosion of new information relevant to medical practice,” leading to a growth in CME. One of the reasons for this growth was because so much new information caused concerns “about physicians’ knowledge becoming obsolete and the “half-life of professional knowledge,” which at the time was considered to be five years.⁶ Eventually, in the early 1970s, CME became a requirement for relicensure, specialty recertification, and credentialing by health care organizations.

Today, 44 states have some form of mandatory CME relicensure requirements for physicians.⁷ As a result, the demand for CME has grown exponentially, leading to the development of the CME regulatory and accreditation system, which allows for professional societies, for-profit organizations, pharmaceutical companies, health care corporations, and medical schools to provide CME. Given such a large enterprise and high demand for CME, and the complexity involved, CME companies, for-profit and non-profit emerged to address this need for a common purpose: improve patient outcomes through physician education and training.

Despite the genuine and patient-centered focus CME providers have demonstrated over the past several decades, the authors of this article seek to discredit all the work that has been accomplished over the years. They assert that there is still debate about whether the present CME system is effective, and suggest that current forms of continuing education may not be what is needed in 21st century medicine.

It is certainly important to recognize that CME is still evolving and that certain methods of education have shown greater impacts on patient outcomes and clinician performance. Medicine, science, and education are always evolving. Based on recommendations from various stakeholders in the CME enterprise, the Accreditation Council of Continuing Medical Education (ACCME) has firmly responded to the changes called for by groups such as IOM and the Macy Foundation. However, the authors of this article only acknowledge some of the weaknesses in the present CME system.

For example, the ACCME has recognized the need for other methods to teach practitioners and in 2009, ACCME issued a statement to the IOM referencing ACCME Content Valida­tion Value Statements requiring CME content to:

–       include evidence-based clinical recom­mendations,

–       rely on research that conforms to generally accepted standards of experimental design, data collection and analysis, and

–       meet the definition of CME and avoid patient care recommendations in which risks outweigh the benefits

Additionally, 2010 updates to the AMA Physician’s Recognition Award credit system require assessment of learner performance and new format requirements. Also, accredited providers have begun to move beyond participant satisfaction to measure, at a minimum, im­proved physician competence resulting from CME

Moreover, in 2006, ACCME Accreditation Criteria 1 through 22 were implemented, setting forth requirements to ensure edu­cational rigor and independence. At the same time, ACCME adopted elements addressing appropriate educational Purpose/Mission, Planning, and Evaluation/Improvement. Essentially, the authors of this article missed an entire list of changes ACCME and CME stakeholders have implemented or are presently in the process of updating, that we previously outlined. For example, a number of measures have been put in place to address outcomes, including

• Formation of the peer-reviewed journal, CE Measure, focusing on outcomes measurements of continuing healthcare education
• Incorporation of performance improvement and internet point of care CME programs by the AMA
• Donald Moore’s reevaluation and update of the levels of outcomes measurements, which was supported in part by industry
• The number of performance measurement posters and presentations at the Alliance for CME annual meetings doubled between 2005 and 2010
• Outcomes-specific organizations and service offerings led by biostatisticians were introduced and have grown in number in the CME field
• Outcomes measurements are now routine components of CME grant applications

With respect to commercial support of CME, the authors are completely misguided. The authors suggest that commercial support of CME does not result in need-based programs, without offering any evidence. In doing so, they completely ignore a large number of measures ACCME and CME stakeholders have put into place to ensure the quality of CME when commercial support is present. These measures provide the independence and control of content that allows CME providers to create programs that are based on demonstrated needs and gaps in care gathered from scientific research and surveys of health care providers.

Discussion

Despite all of the above changes in CME, the authors assert that the recommendations from IOM and Macy Foundation should be adopted. They suggest redesigning the CME system to include lifelong learning as a set of core competencies and place emphasis on demonstrating continuing professional development rather than simply accumulating continuing education units. The main thrust of their argument stems from the claim that “the continuing education system for health care professionals in the United States has been described as being in “disarray” and having a “dismal record” in terms of its effect on learning and patient outcomes.” However, they offer no hard evidence to support such a broad claim.

No one doubts that CME must continue to improve and enhance the outcomes of patients and training of physicians. However, this process does not happen overnight. While ACCME and other accrediting agencies are requiring new sets of core competencies and methodologies for education and outcomes, CME providers are busy adapting to these demands as well.

Ultimately, there is no question that CME today is different from several years ago, and will be different several years from now. CME providers are in fact moving beyond that of a meeting planner, despite what the authors suggest. The CME enterprise has responded adequately to the changes and challenges in medical education over the past several years, as noted above. Presently, CME providers do assist in and provide external validation of and feedback about physicians’ self-assessment, and help physicians design, adapt, and assess their lifelong learning experiences.

Accordingly, the CME enterprise needs to work together and collaborate with all players involved in aspects of medical education. As was evident from this one sided article, the authors failed to acknowledge any benefit from the CME system in place now, and any of the measures the CME enterprise has taken to improve CME. Before supporting the arguments of IOM and Macy, the authors should refer back to the changes in existence and other proposals from CME providers that address these issues.