CME Crossroads: Adult Learning Principles Leading to Better Outcomes

As we noted last week, Global Education Group published a report entitled “CME Crossroads: A Survey of Continuing Medical Education Analysis, Criticism, Research and Policy Proposals,” which looked at four recent trends in continuing medical education (CME). Before specifically discussing these trends, the report first looked at conflicts of interest and the confusion between certified CME and non-CME.

Conflicts of Interest: CME, Non-Certified “Education” and promotion

In reviewing more than 100 studies, proposals, and reports on CME between 2005 and 2010, the authors asserted that one of the complicating factors to identify trends in CME was that papers and reports did not consistently define CME or separate it from other forms of “education.” The Crossroads report found that this phenomenon particularly occurs in studies and articles addressing either real or potential conflicts of interest.

One cause of this problem is that although federal government reports in the past have noted the significant differences between certified CME and industry programs for marketing and promotional purposes, less than 6% of the reports and policy papers examined during the past five years identified the distinction between certified and promotional activities. Most published reports on “medical education” comingle discus­sion of CME, GME, and promotional programs designed to combine promotion with educational data. As a result, the authors found that criticism and policy papers addressing, for example, industry support of medical schools and teaching hospitals, have little connection to those addressing industry grants to ACCME-accredited providers of certified CME.

In addition, the authors pointed out how the AMA Council on Ethical and Judicial Affairs (CEJA) identified conflicts of interest that occurred when industry financially supported “professional education” such as promotional activities or speakers bureaus. However, the authors clarified that “the real and potential conflicts associated with these industry-funded promotional programs are worthy of consideration but are outside the realm and guidelines governing certified CME.”

Another problem the authors found was that the Association of American Medical Colleges (AAMC), in their report addressing “Industry Funding of Medical Education,” developed guidelines that were not directly connected to a discussion of CME. However, AAMC included CME in the same report, causing confusion. The report did not acknowledge that collaboration with industry has proven benefits for medical centers, students, practicing faculty, and patients. The problem is that medical schools, as well as professional societies, have varied interests and missions, whereas CME units typically focus exclusively on CME. Accordingly, the CME Crossroads report recognized that “confusion between certified CME and non-CME activities seems partially to result from the fact that many organizations have not managed CME separately from other activities.”

Additionally, the authors recognize that confusion over critical non-CME and CME issues also stems from the fact that institutions man­age broad conflicts much differently from how the ACCME requires accredited providers to man­age financial conflicts of interest related to CME activities. One reason is that each academic medical center has its own rules and guidelines governing conflicts of interests. Moreover, management of conflicts for medical societies and universities is generally decentralized; each organization decides for itself. In contrast, all ACCME accredited providers of CME – be they medical societies, hospitals, education compa­nies, or academic institutions – must demonstrate compliance with a unified set of ACCME, Food and Drug Administration (FDA), and other rules governing CME practices

With more than 81% of the reviewed reports, policy proposals, and consensus documents comingling analysis or discussion of CME with non-CME activities, the Crossroads report addresses how the CME enterprise has responded to this confusion.

Trend 1: Incorporate adult learning principles/expertise into CME

Over the past few years, several national organi­zations have called for greater incorporation of adult learning principles and professional expertise in the CME field, and reports have called for greater adult learning expertise from various types of accredited providers. The AMA stated that CME should advance to “im­part clinical knowledge and skills” to the profession and “advance the science of adult learning in medicine.” The authors noted that Trend 1 was readily identified and appears to be borne out of a need to demonstrate professional­ism and specific expertise within the CME enterprise.

Following the implementation of the 2003 Department of Health and Human Services Office of Inspector General Compliance Guidance and ACCME policies and definitions that no longer allowed those working on behalf of commercial interests to have any control over certified CME content, the push for CME-specific professional roles and expertise seems to have increased. Early calls for increased expertise and better incorporation of “adult learning theory in CME culminated in a chorus of voices for improvement in this area of practice.”

CME Enterprise Response to Trend 1: Incorporate adult learning principles/expertise into CME

According to the Crossroads Report analysis, “CME stakeholders appear to have embraced the call for greater incorporation of adult learning ex­pertise.” The NC-CME developed a Certified CME Professional (CCMEP) exam and designation in 2008; within two years, more than 250 individuals earned the credential for expertise across five core competency areas.

The Society for Academic CME (SACME) and Alliance for CME developed and produced a na­tional CME faculty training initiative to improve CME faculty management/expertise, especially in recognizing the differences between independent and promotional education. Additional quality improvement indicators related to Trend 1:

• Updated ACCME Accreditation Criteria (2006)
• ACCME published the “CME as a Bridge to Quality” document and associated live work­shops
• AMA published a handbook identifying performance improvement and internet point of care learning as eligible for AMA credit
• New, experiential educational formats incorporated a blend of self-directed and hands-on as­sessment/mentoring
• NC-CME developed the CCMEP exam addressing adult learning fundamentals
• Several new training programs and online tools were launched to support growth in perfor­mance improvement (PI) CME
• Increased standards for and improved practices related to CME grant evaluators were devel­oped within pharmaceutical and medical device manufacturers
• The development of the Pharmaceutical Alliance for CME within the Alliance for CME and its efforts to share best practices and improve CME outcomes and professionalism
• 2010 updates to the AMA Physician’s Recognition Award credit system requiring assessment of learner performance and new format requirements
• Accredited providers moved beyond participant satisfaction to measure, at a minimum, im­proved physician competence resulting from CME

Trend 2: Produce Better CME Outcomes

The authors recognized that “the call for more adult learning expertise coincided in the literature with demand for better out­comes design, analysis, and reporting.” The Conjoint Commit­tee on CME made several recommendations focused on improving outcomes analysis and reporting. Recom­mendation 5 sought to develop performance and continuous improvement by documenting evi­dence of changes in physician knowledge, competence, and practice performance along with out­comes in patient care.

Recommendation 6 focused on the metrics used to measure and recognize physician learning and practice changes: the evolution of CME programs should identify innova­tive ways for implementing education and measuring learning and change in physicians. Some called for higher-level outcomes based on analysis showing that didactic CME sessions in some therapeutic areas were less effective at producing behavior change than interactive sessions.

Acting on these recommendations, stakeholders called for improvements to CME outcomes meth­odologies and results. The AMA and the Alliance for CME published documents outlining edu­cational formats and measurement approaches to achieve higher outcomes levels.

CME Enterprise Response to Trend 2: Produce Better CME Outcomes

The CME Enterprise responded to the need to produce better CME outcomes in a number of ways. The ACCME, the AMA and CME/adult learning professionals have taken a stand to im­prove the knowledge, competence and performance behaviors of the learners. The ACCME’s 2006 updated accreditation criteria requires accredited providers to set forth outcomes in their mission statements and measure effectiveness in achieving these goals. More than half of the 22 ACCME accreditation criteria either directly or indirectly address CME outcomes-related issues/results.

Additionally, the American Board of Medical Specialties (ABMS) and the Federation of State Medical Boards (FSMB) have recognized the importance of continued education that strives to improve physician competence and practice behaviors and have implemented both the Maintenance of Certification (MoC) and Maintenance of Licensure (MoL) programs respectively. These programs were both developed to establish physician life-long learning that leads to improved practice behaviors and patient outcomes. Many hospital systems are also utilizing competency-based credentialing that physicians will need to complete to obtain hospital privileges.

The interest in CME outcomes led to the development of several outcomes-focused companies and new methodologies to assess outcomes based on adult learning theories, such as Prochaska’s stages of change, and the incorporation of knowledge, attitude, and case-based competency testing. In 2006, the first issue of the journal CE Measure was published.

According to the Crossroads report, “the CME enterprise has taken significant steps toward the development of reliable practices and systems to accurately measure the effectiveness of the interventions.” In fact, all accredited CME providers are now required to plan for and demonstrate their role in improving knowledge, competence, physician practice behaviors and/or patient health both at the activity level and more broadly. Additional quality improvement indicators related to Trend 2 include:

• 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

Despite the overwhelming confusion that the Crossroads report identified among papers and proposals regarding CME, it is clear that the CME Enterprise is addressing these criticisms in a superior manner through consistent and comprehensive efforts. Not only has the CME Enterprise incorporated adult learning and expertise into CME, but they have done so in an effective and efficient manner. Finally, given the new tools that CME providers have to measure and produce better outcomes, evidence is already showing that CME programs are improving patient and clinical outcomes. As a result, Global Education’s analysis of these two trends demonstrates the positive changes and steps the CME Enterprise has taken over the past five years to answer concerns.