AAMC Reporter: June 2008
Controversy, Innovation Shake Up Field of Continuing Medical Education
These are challenging and even tumultuous times for
the continuing medical education (CME) community.
With persistent questions swirling around the funding,
the format, and even the very purpose of CME, it is no
wonder that many CME experts and providers share
mixed feelings on the future of their field.
Perhaps the most prominent criticism facing many CME
programs—which generally serve to maintain or develop
an established physician's knowledge base with the goal of
improving professional performance—is that they invite
conflicts of interest by accepting commercial support as
one of their principle revenue streams.
In January, a report from the Josiah Macy, Jr. Foundation
stated, among other things, that the CME field
was "in disarray" and needed to completely eliminate
commercial support over the next five years. CME
experts have responded vigorously, claiming that such
a move is easier said than done given the profession's
current funding environment.
"CME is a huge and important business," said David
Davis, M.D., AAMC's vice president for continuing
health care education and improvement. "In general,
CME is seen as a cost-recovery unit for medical schools.
Deans, CEOs, and others who might support physician
learning are strapped financially, for all kinds of reasons,
and commercial support has stepped in to fill the vacuum.
To many companies, CME appears to be an
appropriate vehicle for their messages. But for many
others, there is a perception of bias."
If profitability is the only factor, CME programs are
an unbridled success. According to an article published
in the March 5 Journal of the American Medical
Association, in 2006 the nation's 729 accredited CME
programs generated $2.38 billion. About 34 percent of
this was earned by publishing and education companies,
while physician member organizations received
about 33 percent and medical schools took in about
18 percent. The profit margins from CME activities
for these three communities were 46.3 percent, 34.7
percent, and 20.7 percent, respectively. Pharmaceutical
industry grants generated $1.2 billion for the field
in 2006, according to the Accreditation Council for
Continuing Medical Education (ACCME).
The scrutiny and criticism that have accompanied this
profitability have left many medical school CME officials
feeling caught in the middle—looking for ways to
keep programs profitable in an environment that has
come to rely on CME for revenue, while responding to
the conflict of interest concerns. In the words of Michigan
Medical School CME Director R.Van Harrison, Ph.D.,
the controversy has left the community feeling "politically
used" and "defensive."
For now, it is anybody's guess how the issue of commercial
support in CME will play out. Fortunately, however,
there are signs of progress. In January 2007, Memorial
Sloan-Kettering Cancer Center in New York City stopped
accepting commercial support for CME. A report to the
AAMC Executive Council from the AAMC Task Force
on Industry Funding of Medical Education has recommended
that academic medical centers offering CME
programs should establish a central CME office to
receive and dispense industry funds for CME and
"develop audit mechanisms to assure compliance with
the standards of the ACCME, including those with
respect to content validation and meals" for all educational
programs that are provided to CME participants.
CME directors are capitalizing on their increased visibility
to discuss and encourage changes that reach down to
the bedrock of their field. To make programs more effective
and their lessons more lasting, CME officials are
rethinking the traditional CME format, which revolves
around a lecture or similar didactic exercise—often commercially
backed, often in an attractive locale, and frequently
coupled with leisure activities such as golf outings.
Moving away from this format, experts say,may
have the side benefit of limiting industry support and
potential conflicts of interest.
"The CME community is in a time of very active
change," said Ellen M. Cosgrove, M.D., CME director
at the University of New Mexico School of Medicine.
"CME is not like putting on a course for medical students,
where attendance is obligatory. We have to do this
in a marketplace, where we have to give people not only
what they need, but also what they want. But people are
stepping up to face this challenge. They are trying to
move their programs forward into more interactive
and hands-on formats. And they're doing this at a
time of shrinking resources."
As in many other fields, technology is proving to be a
useful resource for CME. The University of Pittsburgh
Medical Center's Peter M. Winter Institute for Simulation,
Education, and Research employs computer
simulators for CME instruction on topics like airway
management and advanced cardiac life support.
"We want to take the mystique of the simulator off the
table," said center director Paul Phrampus, M.D., "and
bring learners up to snuff from a functional standpoint.
Simulation is a richer environment than a simple
lecture, and it allows for experiential learning."
The simulator exercises happen in a tightly controlled
environment,with observers watching and videotaping
learners through a one-way mirror and then comparing
each performance against established benchmarks
for efficiency, technique, and other variables. Tests given
before and after each course gauge the program's effects.
"It is a very objective review, and we try to make it relevant,"
Phrampus said. "For example, we know exactly
how long it takes each learner to deliver supplemental
oxygen. In the traditional formats, you have no idea if
anyone got anything out of it. With this, we're getting a
real flavor of whether the learners are getting it or not."
Some are going even further in an attempt to redefine
the concept of CME. Michigan's Harrison, whose background
is in organizational performance, argued that
the practice of CME should no longer be self-contained,
but rather should be integrated across an entire
institution. Working with Michigan's faculty group
practice as well as its CME program, Harrison said he
regularly finds mutual benefits in weaving CME into
the fabric of everyday practice.
"There has to be an emphasis not only on individual
knowledge but also on the application of that knowledge,"
Harrison said. "It's all about alignment. We have
to align [CME] so that it feeds into other systems. Most
of the actual education that we receive does not come
through a formal education structure. You have to link
the CME people to those who control the physician
feedback systems. Most feedback happens not during
grand rounds but during individual performance."
At the University of Wisconsin School of Medicine and
Public Health, the Office of Continuing Professional
Development (CPD) trains about 80,000 learners each
year—half of whom are not physicians but health team
members like nurse practitioners or physician assistants.
The office's performance improvement program is
designed to help entire practices operate better. Health
teams can earn CME credits by comparing their practice's
performance in a specific area to established standards
of care, closing the gap between the two, and then
re-evaluating down the road. The CPD office's Internet
Point of Care program allows physicians to earn half a
CME credit each time they find the answer to a medical
question through a widely recognized online resource
such as PubMed or Micromedics.
"Time is no longer what is important," said George C.
Mejicano, M.D., M.S., Wisconsin's associate dean of
CPD. "Doing one stage of performance improvement
can take two minutes, or it can take 100 hours. Either
way, you get five credits. Docs get nervous about this,
but it's all about finding those areas where an entire
practice can improve."
Mejicano likens CME and CPD to enforcing a teenager's
curfew: He or she usually knows when curfew
is, and how to get home in time. The hard part lies
in following through to meet expectations.
"Docs know what to do and how to do it," he said. "We
help them overcome system obstacles. We're moving
away from sheer knowledge and more toward competence
and performance."
At New Mexico's school of medicine, a "bridge committee"
comprised of the school's associate deans in
CME, graduate medical education (GME), and clinical
affairs meets regularly to discuss ways of synchronizing
these mission areas.
"This helps us emphasize team learning," Cosgrove said.
"Faculty physicians and residents are working together,
and that can really be energizing for both sides."
Although the ACCME ensures that CME programs
adhere to specific benchmarks, there is no such safeguard
for individual CME instructors, who have expertise
in fields as disparate as event planning and basic
sciences but are not required to have any specific knowledge
base. That is about to change. As early as late summer,
the National Commission for Certification of CME
Professionals (NC-CME) will aim to bring more consistency
to this field by offering accreditation to those who
pass a Web-based exam.
"A lot of CME providers have been openly questioning
whether they have the skills to do their own job," said
Jack Kues, Ph.D., NC-CME president and assistant dean
for CME at the University of Cincinnati College of
Medicine. "Nobody offers a degree in CME, so people
are coming from a variety of backgrounds and learning
on their own. So there has been an evolving educational
imperative. Accreditation is an important piece, because
this field is complicated by issues related to conflicts of
interest, various rules and regulations, and specialty
societies doing things around maintaining certification."
Problems exist, but CME experts said they are heartened
by the wave of change already in motion, and
which seems unlikely to subside any time soon.
"CME is a wonderful service," said the AAMC's Davis.
"But the current gestalt of CME is getting 300 people in
a conference room at a 5 percent profit, and with little
ultimate impact on patients. We intend to change that."
—By Scott Harris
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