Orientation

Available online at: http://cmefuture.blogspot.com/

Abstract

Typical continuing medical education (CME), as delivered via AMA PRA Category 1 Credit ™, is still obtained almost exclusively via passive experience (whether that means listening in lecture, clicking through pages of an online course, watching an online video, or reading a journal/PDF). And funding of CME (and thus the topic priorities) is still 50% related to support from pharmaceutical and device manufacturers. The slow changes in health professional development over the past decade have thus far yielded little in terms of changing the actual experience.

Yet perception of calm or stagnation in the CME field is unwarranted. The foundation for change has been laid by:
Change to continuing health professional development (CHPD) is upon us and will proceed rapidly. The new CHPD/CME experience will:
  • Be based on user demand and available via multiple devices when the user wants it,
  • Focus more on topics based on medical needs (practice gaps) rather than topics related to pharmaceutical and device manufacturer interests (good for addiction professionals),
  • Move topic control away from learner choice and more toward public policy requirements set by states, the federal government, and institutions,
  • Require effort and attention on the part of the learner,
  • Collect outcomes, especially patient outcomes, to determine effectiveness - and thus accelerate change toward highlighting more effective solutions and downgrading less effective solutions,
  • Experiment with the potential of technology via use of simulations (deliberate practice) to deliver a more clinically relevant and challenging experiences.
Key References
  1. Accreditation Council for Continuing Medical Education. CME as a bridge to quality: Leadership, learning, and change within the ACCME System [monograph on the Internet]. Chicago, IL; 2008 Jan. Available at: http://www.accme.org/dir_docs/doc_upload/e2843247-7cae-40fe-a0eb-27a982b8fcc0_uploaddocument.pdf
  2. Institute of Medicine. Redesigning Continuing Education in the Health Professions. Washington, DC: National Academies Press; 2009. Available at: http://www.nap.edu/openbook.php?record_id=12704
  3. Davis D, Galbraith R; Continuing medical education effect on practice performance: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines. American College of Chest Physicians Health and Science Policy Committee. Chest. 2009 Mar;135(3 Suppl):42S-48S. PMID 19265074. Available at: http://chestjournal.chestpubs.org/content/135/3_suppl/42S.long
  4. John W. McMahon, Sr., MD, Chair, Financial Relationships with Industry in Continuing Medical Education, REPORT OF THE COUNCIL ON ETHICAL AND JUDICIAL AFFAIRS, CEJA Report 1-A-11, 2011. Available at: http://www.acme-assn.org/imis15/aCME/PDFs/Advocacy/2011_AMA_CEJA_Report_1-A-11.pdf

Disclosure

Bradley Tanner is President and 100% owner of Clinical Tools. Inc, which is a small business that creates and delivers online CME. He and Clinical Tools receive no money or support in any form (educational or non-educational) from pharmaceutical or medical device manufacturers.

Clinical Tools is not the focus of this talk and Dr. Tanner will not highlight the products of Clinical Tools. He is speaking for himself and not for the company.

Objectives

The learner will know, be aware of, describe, recognize, be familiar with, understand, appreciate... NO!
The learner will be able to:
  1. Discuss with colleagues the trends in CME and describe what changes have occurred, and are likely to occur in the future, as we move toward CHPD - Continuing Health Professional Development
  2. Explain to other educators the rationale for pursuing a different approach to providing CME and help them in the process of developing CME/CHPD that is more focused on improving competence, performance, and health outcomes
  3. Champion the cause of increasing the frequency, acceptability, interest in, and effectiveness of CHPD in the field of addiction in their conversations with others in the medical field

Why a blog?

When asked to give a talk on where CME is going, I was struck by the irony of delivering a standard talk using Powerpoint to highlight the future of CME. After struggling with creating "slides" to explain something as dynamic as the recent evolution of CME and huge changes ahead, I eventually settled on a blog as a more appropriate venue to "present" the idea. This format can support ongoing revision and improvement, as well as participation by others.

Why CME?

We need the health care workforce to ...
  • Evaluate their current practice
  • Obtain new skills in reaction to evolving science
  • Stop practices based on old evidence when new evidence shows that what was working is no longer 
  • Apply new practices when new approaches eclipse old solutions
  • [given today's realities] Provide higher quality medical care for less $
Other than CME and related work in MOC (Maintenance of Certification) and MOL (Maintenance of Licensure) ...
  • Is there any other way we can ensure the health care workforce is adapting to a scientific field with constant change and that their practice is up to date and effective? 
  • How else can we ensure that our physician and health professional workforce is giving us the most ROI for our health care dollars?
Let's consider:
  • What we see now 
  • Calls for change in CME
  • Changes that are currently happening 
  • Changes that will likely happen
  • How can CME utilize and adapt to technology
May we live in interesting times! For those of us in the CME/CHPD field - We Do! 
References
  1. Chaudhry HJ, Rhyne J, Cain FE et al. Maintenance of Licensure: Protecting the Public, Promoting Quality Health Care. Journal of Medical Regulation. 96(1). 2010. Available at: http://www.fsmb.org/pdf/mol-bg.pdf
  2. ABMS Maintenance of Certification [Web page on the Internet]. Chicago, IL: American Board of Medical Specialties; 2006-2011 [cited 2011 Jul 24]. Available at: http://www.abms.org/Maintenance_of_Certification/ABMS_MOC.aspx
  3. White Paper: CME for MOC ABMS/ACCME Joint Working Group on MOC CME January 2011, Available at: http://policymed.typepad.com/files/moc-cme-abms-white-paper-11-10-2-1.pdf

Current CME

CME is extremely expensive. The CME market that ACCME is aware of is worth $2.242 billion. This likely does not include indirect costs, direct payments to speakers by pharma, or travel compensation to speakers (currently not disclosed publicly). By comparison, here are some other costs:
This CME financial support paid for:
  • 81,000 activities
  • 660,000 hours of available instruction
  • Over 19 million participants (11.5 million physicians, 7.8 million non physicians)
In 2010, for the first time, < 50% of funding came from industry [commercial support + exhibits/advertising]. This breaks down as:
  • $831,000,000 (37%) in commercial support [a decrease of 25 million and 2.9%]
  • $277,000,000 (12%) in advertising and exhibit revenue

In terms of total activities the breakdown is as follows:

Type of CME
Courses
Internet (enduring materials)
Regularly scheduled series
Enduring materials (other)
Journal CME
Internet (live)
Performance improvement
Internet searching
 and learning
Total		Activities
36,374
23,310
9,740
6,230
3,329
1,767
168
143

81,543		%
44.61%
28.59%
11.94%
7.64%
4.08%
2.17%
0.21%
0.18%

100.00%
CME experience in terms of physician participation include
Type of CME Physicians %
Internet (enduring materials)
Regularly scheduled
 series
Courses
Enduring materials (other)
Journal CME
Internet searching
 and learning
Internet (live)
Performance
 improvement
Total		 4,589,342
3,147,545

1,474,725
1,089,537
1,053,741
75,844

46,909
29,371

11,507,014		 39.88%
27.35%

12.82%
9.47%
9.16%
0.66%

0.41%
0.26%

100.00%
References
  1. ACCME 2010 Annual Report Data. http://www.accme.org/dir_docs/doc_upload/e7520312-92c3-4969-acf0-bdf4c5b8d289_uploaddocument.pdf
  2. PolicyMed. ACCME Releases 2010 Annual Report Data: The CME Economy increased by 2.7% Slowing a Three Year Downturn. August 12, 2011  http://www.policymed.com/2011/08/accme-releases-2010-annual-report-data-the-cme-economy-increased-by-27-slowing-a-three-year-downturn.html

Limitations of CME concept

CME is a popular and familiar term and typically means AMA PRA Category 1 Credit ™, but like other terms it is limited and being eclipsed by changes outside of CME.
  • It only applies to physicians. Other professionals receive/require a different type of credit for education/training.
  • It is a legal term that almost always refers to an educational experience in compliance with the ACCME's rules that qualify for AMA PRA Category 1 Credit ™ (AMA, 2010)
  • Credits are seen as equivalent even if one prioritizes practice improvement and improved outcomes
  • CME has become a requirement if one wishes to maintain their license, certificate and thus has a strong motivation component). (ACCME, 2008). Most states simply require a certain amount of credits be earned, not that specific outcomes be achieved. 
  • Content, delivery and time are controlled by the particular accreditation agency and is not in sync with local needs of health provider organizations.
  • Typically not coordinated with other provider training/education.
  • Structure provides consistency but it limits innovation and thus hinders potential benefit. Call for change (such as McMahon, 2011) are often met with resistance.
Perhaps we need a new organization principal outside of CME to support more rapid changes and rid the field more quickly or practices which are less effective (Institute of Medicine, 2009, ABMS White Paper, 2011).
References
  1. The Physician’s Recognition Award and credit system: Information for accredited providers and physicians [monograph on the Internet]. Chicago, IL: American Medical Association; 2010. Available from: http://www.ama-assn.org/resources/doc/cme/pra-booklet.pdf.
  2. CME as a bridge to quality: Leadership, learning, and change within the ACCME System [monograph on the Internet]. Chicago, IL: Accreditation Council for Continuing Medical Education; 2008 Jan. Available from: http://www.accme.org/dir_docs/doc_upload/e2843247-7cae-40fe-a0eb-27a982b8fcc0_uploaddocument.pdf
  3. John W. McMahon, Sr., MD, Chair, Financial Relationships with Industry in Continuing Medical Education, REPORT OF THE COUNCIL ON ETHICAL AND JUDICIAL AFFAIRS, CEJA Report 1-A-11, 2011 (http://www.acme-assn.org/imis15/aCME/PDFs/Advocacy/2011_AMA_CEJA_Report_1-A-11.pdf)
  4. Institute of Medicine. Redesigning Continuing Education in the Health Professions. Washington, DC: National Academies Press; 2009. Chapter 5. Pages 93-114 Available at: http://www.nap.edu/openbook.php?record_id=12704&page=93
  5. White Paper: CME for MOC ABMS/ACCME Joint Working Group on MOC CME January 2011, Available at: http://policymed.typepad.com/files/moc-cme-abms-white-paper-11-10-2-1.pdf
  6. Carol Havens, MD; Jeffrey Mallin, MD, Climate Change: It’s Not About the Weather—Continuing Medical Education and Maintenance of Certification and Licensure. The Permanente Journal, Summer 2011 - Volume 15 Number 3. Available at: http://www.thepermanentejournal.org/issues/2011/summer/4157-cme-editorial.html

CHPD or Continuing Health Professional Development

Are terms important?


As an example review the terms used for substance use and addiction:
A New Term: CHPD or Continuing Health Professional Development
  • Interdisciplinary, not just "medical" (which to most other health professionals means physicians). Coordinated care is the future of health care - we need coordinated health professional development.
  • Focused on professional development (skills) not education.
  • More typically an activity that usually provided by the place of employment to keep their staff up to date in the activities they perform as health care providers. Direct measurement of benefit/impact is thus more possible.
  • It is a term that is evolving and flexible and not tied to specific solutions.
Reference
  1. Institute of Medicine. Redesigning Continuing Education in the Health Professions. Washington, DC: National Academies Press; 2009. Chapter 5. Pages 93-114 Available at: http://www.nap.edu/openbook.php?record_id=12704&page=93

Changes in CME are an opportunity for addiction professionals

See this discussion from the public health perspective!

View changes in CME from the perspective of a professional interested in a skilled and effective population of health care providers to prevent addiction and assist treatment of addiction.

Why? Health professional addiction education has received little attention in terms of CME, despite the large ROI on addiction interventions and the prominent practice gaps that exist in health care related to the identification and treatment of addiction disorders.

In terms of improving the effectiveness of the health care workforce's ability to screen for, adjust practice for and treat addictive disease we have a lot to gain from improvements in the system!

CME Funding: Do we need to change how we fund CME?

Imagine we are deciding where to go for dinner and we ask the cab driver where we should go. Here are 5 scenarios:
  1. The restaurants pay the cab driver's salary.
  2. The cab driver receives funds from restaurants, but we don't know about it.
  3. We know the cab driver receives funds from restaurants, but we don't know how much or
    We know that the cab driver doesn't receive money from restaurants.
  4. We know that the cab driver receives money and we can go to the Internet to figure out exactly how much in money or other gifts the cab driver receives from restaurants.
Here is how it matches up the CME equivalent:
  1. Remote past: Speakers who are employees of pharma companies have an obvious conflict of interest. This is no longer allowed for CME.
  2. Pre-disclosure rules: Speakers who are paid by pharma companies, but don't tell us, is no longer acceptable for CME credit.
  3. Current state of CME: Speakers are grouped into those who receive an unknown amount of funds or no funds whatsoever. Sources of funds are identified but not amount or type of compensation.
  4. Starting September 2013: Compensation amount to speakers is public and will be known, but the amount is not required as a part of disclosure. Learners will need to figure it out on their own. (Sunshine Act)
Reference
  1. Physician Payment Sunshine provisions included in the Patient Protection and Affordable Care Act of 2009 (H.R. 3590, section 6002) 
  2. ACCME. ACCME 2010 Annual Report Data. Available at: http://www.accme.org/dir_docs/doc_upload/e7520312-92c3-4969-acf0-bdf4c5b8d289_uploaddocument.pdf

What do we mean by bias?

To continue the analogy, we can potentially get a free (or reduced fare) trip if we accept the cab driver's recommendations.

Let's assume we're comfortable that Cab Driver A is paid an amount of money by a restaurant (the amount of which you are currently not privy to). In exchange for the cab driver disclosing the arrangement, we willingly pay a lower fare.
  • Do we lose some control over where we are going to go?
  • Will our chance of going to the best restaurant be lessened?
  • If you know the cab driver was paid a certain amount, say $50 vs. $500 vs. $5,000 vs. $50,000, would that change your answer? (Note that currently you can't find this out and folks typically won't tell you.) 
In other situations, we understand that the less control we have, the cheaper it gets--hotel shuttles work just this way. But most of us would assume that we've lost something when we agreed to the lower fare.

But surprisingly enough, most physicians in one study (88% in Tabas 2011) believed that commercial support introduces bias, however when asked if bias exists most physicians said no (Kawczak 2010, Steinman 2010).

The key to a discussion of bias is not to attack the integrity of the recipient of funds, but to ask ourselves as experts in human nature if we believe there is a relationship between compensation and recommendations. Or perhaps, conversely, do we believe there is no relationship between compensation and recommendation?
  • If CME is 1/2 the price as usual, is that just a good deal or have we lost some control?
  • Is "free" CME offering equal value to CME that costs us some money?
  • If the speaker is paid more, does that increase the chance of bias?
Findings from review panels:
  1. "In general, industry financial relationships do not benefit the educational missions of medical institutions in ways that offset the risks created." (IOM 2009).
  2. Conflicts created by a range of common interactions with industry can for "medicine generally, and for academic medicine in particular … have a corrosive effect on three core principles of medical professionalism: autonomy, objectivity, and altruism" (AAMC 2008).
References
  1. Jeffrey A. Tabas, MD; Christy Boscardin, PhD; Donna M. Jacobsen, BS; Michael A. Steinman, MD; Paul A. Volberding, MD; Robert B. Baron, MD, MS, Clinician Attitudes About Commercial Support of Continuing Medical Education, Results of a Detailed Survey Archives of Internal Medicine, May 9, 2011; 171(9): 840-846. (archinte.ama-assn.org/cgi/content/abstract/171/9/840). Pubmed ID 21555662
  2. Kawczak Steven MA; Carey, William MD; Lopez, Rocio MPH, MS; Jackman, Donna, Academia-Industry Relationship The Effect of Industry Support on Participants' Perceptions of Bias in Continuing Medical Education , Academic Medicine: January 2010 - Volume 85 - Issue 1 - pp 80-84. http://www.clevelandclinicmeded.com/academic-med-article.pdf PMID: 20042829
  3. Steinman MA, Boscardin CK, Aguayo L, Baron RB. Commercial influence and learner-perceived bias in continuing medical education. Acad Med. 2010 Jan;85(1):74-9. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2801075/?tool=pubmed. PMID 20042828
  4. IOM (Institute of Medicine). 2009. Conflict of Interest in Medical Research, Education, and Practice. Washington, DC: The National Academies Press.  Accessed April 5, 2010. Available online at: http://www.nap.edu/openbook.php?record_id=12598
  5. AAMC. 2008. Industry Funding of Medical Education. Washington, DC: AAMC. http://www.law-lib.utoronto.ca/ghostwriter/AAMC%20report_DavidKorn.pdf (accessed October 10, 2008).
  6. Carolyne Krupa, Industry-supported CME offers potential for bias, study says: Despite perceptions, few physicians would eliminate commercial support of continuing medical education. amednews staff. Posted May 30, 2011 (http://www.ama-assn.org/amednews/2011/05/30/prsb0530.htm).
  7. Harriet Washington, Flacking for Big Pharma: Drugmakers don't just compromise doctors; they also undermine top medical journals and skew medical research, The American Scholar, SUMMER 2011 http://theamericanscholar.org/flacking-for-big-pharma/
  8. John W. McMahon, Sr., MD, Chair, Financial Relationships with Industry in Continuing Medical Education, REPORT OF THE COUNCIL ON ETHICAL AND JUDICIAL AFFAIRS, CEJA Report 1-A-11, 2011 (http://www.acme-assn.org/imis15/aCME/PDFs/Advocacy/2011_AMA_CEJA_Report_1-A-11.pdf)
  9. Todd Dorman, MD; Ivan L. Silver, MD, MEd, FRCP, Comment on 'Clinician Attitudes About Commercial Support of Continuing Medical Education,' " Archives of Internal Medicine, May 9, 2011;171(9):847-848 (archinte.ama-assn.org/cgi/content/extract/171/9/847). Pubmed ID 21555663 

Access to speaker payment data is coming

Partial disclosure of amounts is currently available from companies that have started to voluntarily collect and report that data.

Starting in 2012, pharma will be required to collect data regarding payments, whether cash or in-kind transfers to all covered recipients (physicians and teaching hospitals - PhDs are safe for now) including: (See #1 Sunshine Act)
  • Compensation
  • Food
  • Entertainment
  • Gifts
  • Travel
  • Consulting fees
  • Honoraria
  • Research funding or grants
  • Education or conference funding 
  • Stocks or stock options
  • Ownership or investment interest
  • Royalties or licenses
  • Charitable contributions
  • Any other transfer of value
Soon (Sept 2013) anyone will be able to go online and see who is paying the speaker (aka cab driver) and how much.
  • Are we still more likely to end up at the restaurant that paid the cab driver?
  • Does knowing the amount of compensation change the learner's perception?
  • Does financial disclosure resolve the prior issues? 
There is still no plan for a requirement that speakers will provide this data prior to giving a talk. In other words, imagine a talk starting--
  • Hi, I'm John, and I receive $20,000 in speaker fees from Pharma #1 and travel benefits of $5600 from Device Manufacturer #2.
They won't, but you will be able to go online and find it out yourself.

Unfortunately, disclosure may not have the intended effect (Cain 2011, Loewenstein 2011). "While transparency is essential, disclosing financial relationships is necessary but not sufficient to mitigate the potential for influence in CME" (McMahon 2011).

In the (more distant) future, perhaps we'll pay for the trip and the cab driver will get money from only our fares (or our organization), and we will decide where we go for dinner.
References
  1. Physician Payment Sunshine provisions included in the Patient Protection and Affordable Care Act of 2009 (H.R. 3590, section 6002)
  2. Cain, Daylian M., George Loewenstein, Don A. Moore, When Sunlight Fails to Disinfect: Understanding the Perverse Effects of Disclosing Conflicts of Interest. Journal of Consumer Research, Inc., Vol. 37, February 2011. Electronically published August 27, 2011 https://apps.olin.wustl.edu/cres/research/calendar/files/LoewensteinG.pdf
  3. Loewenstein, George, Daylian M. Cain, and Sunita Sah. 2011. "The Limits of Transparency: Pitfalls and Potential of Disclosing Conflicts of Interest." American Economic Review, 101(3): 423–28. http://www.aeaweb.org/articles.php?doi=10.1257/aer.101.3.423
  4. McMahon, Sr., MD, John W., Chair, Financial Relationships with Industry in Continuing Medical Education, REPORT OF THE COUNCIL ON ETHICAL AND JUDICIAL AFFAIRS, CEJA Report 1-A-11, 2011 (http://www.acme-assn.org/imis15/aCME/PDFs/Advocacy/2011_AMA_CEJA_Report_1-A-11.pdf) 

Access to learner compensation data is coming too!

That same currently available partial disclosure of amounts also includes payments to learners from some companies that have started to voluntarily collect and report that data. Yes, it is possible that the "free CME" you received wasn't free after all and the cost to the pharma/device manufacturer is being reported to the Internet and thus able to be inspected by your patients and your affiliated organizations.

As mentioned, starting in 2012, pharma will be required to collect data regarding payments whether cash or in-kind transfers to all covered recipients (including all physicians) including:
  • Food
  • Entertainment
  • Gifts
  • Travel
  • Any other transfer of value
And as mentioned, your patients or anyone with access to the Internet will be able to go online in September 2013 and see how much compensation you have received in terms of free meals, entertainment, and gifts. If you let pharma pay for pizza for your staff, the pizza cost will be listed under your name.
  • Will you tell your patients the value you obtain from pharma/device manufacturers?
  • If they searched themselves and asked you about it, what would you say?
References
  1. Physician Payment Sunshine provisions included in the Patient Protection and Affordable Care Act of 2009 (H.R. 3590, section 6002)
  2. Sah S, Loewenstein G. Effect of reminders of personal sacrifice and suggested rationalizations on residents' self-reported willingness to accept gifts: a randomized trial. JAMA. 2010 Sep 15;304(11):1204-11. http://jama.ama-assn.org/content/304/11/1204.full.pdf+html. Pubmed ID 20841534
  3. Pew Prescription Project, Federal Reporting Requirements on Payments to Physicians: Impact on State Laws. November 2010. http://www.prescriptionproject.org/tools/initiatives_factsheets/files/Sunshine_State-Impact.pdf

CME Mandates: Who decides what health professionals should learn?

The tend is toward states [pdf] and federal governments requiring certain topics of CME. Personally, you may hate mandates, but mandates tend to be in topics we care about as addiction professionals.

Mandate examples in the substance use field:
References
  1. Drug Addiction Treatment Act of 2000. http://buprenorphine.samhsa.gov/data.html
  2. Opioid Drugs and Risk Evaluation and Mitigation Strategies (REMS). http://www.fda.gov/drugs/drugsafety/informationbydrugclass/ucm163647.htm

CME Changes

From the learner perspective it is not readily apparent that ACCME's rules have undergone substantial change in order for providers to qualify as ACCME accredited providers and for ACCME accredited providers to provide AMA PRA Category 1 Credit ™. Here are the changes you may not have noticed (yet):
  • Upfront more transparent disclosure by speakers
  • Firewall between marketing and CME in providers
  • Knowledge -> Competence, Performance, and Patient Outcomes - rolled out from 2006 to 2010. More of a focus on practice.
  • Measuring outcomes: Starting in July 2011 INTERNET only activities need a post-test
  • Credit vs. Hours - 2007
  • CHPD doesn't have to be AMA PRA Category 1 Credit ™
    • MoC not necessarily CME
    • Risk Evaluation and Mitigation Strategies - REMS for opioids - originally not CME but pharma created/delivered.
  • CME delivered more by academia vs. MECCs. Drops in funding are mostly resulting in drops in MECCs - there are likely to be fewer MECCs providing CME in the future.
  • New types of CME: 
Type of CME
Courses
Internet (enduring materials)
Regularly scheduled series
Enduring materials (other)
Journal CME
Internet (live)
Performance improvement
Internet searching and learning
Total		Activities
36,374
23,310
9,740
6,230
3,329
1,767
168
143
81,543		%
44.61%
28.59%
11.94%
7.64%
4.08%
2.17%
0.21%
0.18%
100.00%
References
  1. The Physician’s Recognition Award and credit system: Information for accredited providers and physicians [monograph on the Internet]. Chicago, IL: American Medical Association; 2010. Available from: http://www.ama-assn.org/resources/doc/cme/pra-booklet.pdf.
  2. CME as a bridge to quality: Leadership, learning, and change within the ACCME System [monograph on the Internet]. Chicago, IL: Accreditation Council for Continuing Medical Education; 2008 Jan. Available from: http://www.accme.org/dir_docs/doc_upload/e2843247-7cae-40fe-a0eb-27a982b8fcc0_uploaddocument.pdf
  3. Institute of Medicine. Redesigning Continuing Education in the Health Professions. Washington, DC: National Academies Press; 2009. Available at: http://www.nap.edu/openbook.php?record_id=12704
  4. ACCME. ACCME Essential Areas & Elements (2006 Accreditation Criteria). 2006. Available at: http://www.accme.org/dir_docs/doc_upload/f4ee5075-9574-4231-8876-5e21723c0c82_uploaddocument.pdf
  5. Institute of Medicine. Health Professions Education: A Bridge to Quality. National Academy of Sciences April 18, 2003. Available at: http://iom.edu/Reports/2003/Health-Professions-Education-A-Bridge-to-Quality.aspx

Knowledge -> competence, performance and outcomes

"Knowledge is clearly necessary but not in and of itself sufficient to bring about change in physician behavior and patient outcomes. Such didactic interventions should ... receive less credit than do more effective methods and perhaps no credit" (Davis 1999).

Existing CME and physician training and education:
  • Is often passive and didactic
  • Focuses on knowledge transfer
  • Does not seek to directly enhance clinical skills or improve performance (IOM 2009)
ACCME (2008) asks us to focus instead on competence, performance and outcomes. Knowledge attainment as the focus of CME is no longer sufficient. Without a focus on skills training, practice does not change and patient care remains the same.

To effect practice gap and improve patient health outcomes, we need to effect simple improvements in physician competency and performance and attitudes.
References
  1. Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A.  Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999 Sep 1;282(9):867-74. PMID 10478694. http://jama.ama-assn.org/content/282/9/867.long
  2. Accreditation Council for Continuing Medical Education; CME as a bridge to quality: Leadership, learning, and change within the ACCME System [monograph on the Internet]. Chicago, IL: 2008 Jan. Available from: http://www.accme.org/dir_docs/doc_upload/e2843247-7cae-40fe-a0eb-27a982b8fcc0_uploaddocument.pdf
  3. Institute of Medicine. Redesigning Continuing Education in the Health Professions. Washington, DC: National Academies Press; 2009. Available at: http://www.nap.edu/openbook.php?record_id=12704

CME Effectiveness: Does standard (passive-learning) CME work?

Imagine your colleague prescribes a drug that has no/minimal evidence that it works. "We're scientists," you say, "Physicians should practice based on science not fiction or wishful thinking."
  • So what is the evidence that all the money and time spent on CME is producing results?
  • How can we measure outcomes if we don't collect data?
  • Who is going to collect the data and who is going to pay for it?
  • Is satisfaction an outcome? 
To outline the future of CME, let's first review the findings of reviews of existing passive CME (including webminars, journal CME, PDF CME and other examples of passive CME).
  1. "Widely used CME delivery methods such as conferences have little direct impact on improving professional practice" (Davis 1995). The data on the effectiveness of standard CME is not impressive.
  2. "Based on a small number of well-conducted trials, didactic sessions do not appear to be effective in changing physician performance" (Davis 1999).
  3. "Education in small doses (days) is ineffective, likely because it pales in comparison with the prior 20 years of education physicians have already received. Guideline dissemination is too passive to effect behavior change without active implementation strategies" (Smith 2000).
  4. "Didactic sessions alone are unlikely to change professional practice" (O'Brien 2001).
  5. "Even though the most-effective CME techniques have been proven, use of least-effective ones predominates. Such use of ineffective CME likely reduces patient care quality and raises costs for all, the worst of both worlds" (Bloom 2005).
  6. "Educational meetings alone are not likely to be effective for changing complex behaviours" (Forsetlund 2009).
  7. "Presentation of research data in most CME programs is inadequate to allow learners to make fully informed therapeutic decisions. " (MacLeod 2010)
  8. Study of hypertension CME found no change in case vs. control for patients with uncontrolled hypertension. A clinically insignificant change of 2mm overall. (Allaire 2011)
We face an inconvenient truth that our strategy to keep health professional skills up to date is not working and certainly not efficient.
References
  1. Davis DA, Thomson MA, Oxman AD, Haynes RB.  Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995 Sep 6;274(9):700-5. PMID 7650822 http://jama.ama-assn.org/content/274/9/700.full.pdf+html
  2. Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A.  Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999 Sep 1;282(9):867-74. PMID 10478694. http://jama.ama-assn.org/content/282/9/867.long
  3. Smith WR. Evidence for the effectiveness of techniques To change physician behavior.  Chest. 2000 Aug;118(2 Suppl):8S-17S. PMID 10939994 http://chestjournal.chestpubs.org/content/118/2_suppl/8S.long
  4. Thomson O'Brien MA, Freemantle N, Oxman AD, Wolf F, Davis DA, Herrin J. Continuing education meetings and workshops: effects on professional practice and health care outcomes.  Cochrane Database Syst Rev. 2001;(2):CD003030. PMID 11406063.
  5. Bloom BS. Effects of continuing medical education on improving physician clinical care and patient health: a review of systematic reviews. Int J Technol Assess Health Care. 2005 Summer;21(3):380-5. PMID 16110718.
  6. Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O'Brien MA, Wolf F, Davis D, Odgaard-Jensen J, Oxman AD. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003030. PMID 19370580. http://apps.who.int/rhl/reviews/CD003030.pdf
  7. Presentation of evidence in continuing medical education programs: a mixed methods study. Allen M, MacLeod T, Handfield-Jones R, Sinclair D, Fleming M. J Contin Educ Health Prof. 2010 Fall;30(4):221-8. PMID: 21171027
  8. Measuring the impact of a continuing medical education program on patient blood pressure. Allaire BT, Trogdon JG, Egan BM, Lackland DT, Masters D. J Clin Hypertens (Greenwich). 2011 Jul;13(7):517-22. PMID: 21762365 

Assessing CME effectiveness: Its all about outcomes

First we need to measure outcomes so we can find out what approaches are most successful and demonstrate impact.. (Leong, 2010) measured practice change outcomes [from a 12 hour seminar required by the state]
  • immediate intention to change
  • longer term (4 month) actual change 
Reference
  1. Evaluating the impact of pain management (PM) education on physician practice patterns--a continuing medical education (CME) outcomes study. Leong L, Ninnis J, Slatkin N, Rhiner M, Schroeder L, Pritt B, Kagan J, Ball T, Morgan R. J Cancer Educ. 2010 Jun;25(2):224-8. Epub 2010 Mar 5. PMID: 20204577

Effectiveness and time efficiency

Many of us think of CME in terms of hours
  • Does it makes sense to measure impact in terms of the reported hours spent attending an AMA PRA Category 1 Credit ™ based CME activity?
  • Do we measure resident performance by hours spent?
In fact, the CME system actually only refers to "credits" earned (AMA, 2010)

As CME changes (ACCME, 2008), eventually we may be better able to distinguish between efforts that are more time efficient. Credits would then be awarded based on:
  • required measurements to assess pre-existing skills and post-training changes
  • task accomplishment such as required post-test score attainment.
  • the anticipated value of the activity (perhaps it requires more effort or more effort over time) rather than its time commitment
References
  1. American Medical Association, The Physician’s Recognition Award and credit system: Information for accredited providers and physicians [monograph on the Internet]. Chicago, IL: 2010. Available from: http://www.ama-assn.org/resources/doc/cme/pra-booklet.pdf.
  2. Accreditation Council for Continuing Medical Education; CME as a bridge to quality: Leadership, learning, and change within the ACCME System [monograph on the Internet]. Chicago, IL: 2008 Jan. Available from: http://www.accme.org/dir_docs/doc_upload/e2843247-7cae-40fe-a0eb-27a982b8fcc0_uploaddocument.pdf

Pay attention

Attention is required for learning.

CME as a time to sleep, zone out, play with the iPhone, eat is not compatible with what we know about more effective strategies to confer skills and enhance practice. To be effective we need CME that requires attention and effort.
  • If our kid is taking driver's ed, would we expect them to attend all of the classes before we got in the car with them? 
  • Can you ski and attend a lecture at the same time? 
Should we require evidence of actual participation?
    Participation can now be easily verified by via electronic tools tracking
    • for online learning time spent on a certain task is easily measured
    • attendance can be tracked via RFID tags when you enter/exit (or being asked to scan a badge when you enter if you want credit). 

    Keys to effective CME - Practice integration and interactivity

    Strategies to improve CME efforts

    Interactivity and skills practice:
    • "Our data show some evidence that interactive CME sessions that enhance participant activity and provide the opportunity to practice skills can effect change in professional practice and, on occasion, health care outcomes" (Davis 1999).
    Integration with practice:
    • "The interventions that best succeed in changing performance and health care outcomes are those using practice-enabling strategies (office facilitators or patient educational methods, for example) or reinforcing methods (feedback or reminders)" (Davis 1995).
    • "Strategies which enable and/or reinforce appear to 'work' in changing physician performance or health care outcomes, a finding which has significant impact on the delivery of CME, and the need for further research into physician learning and change" (Davis D 1998).
    References
    1. Davis DA, Thomson MA, Oxman AD, Haynes RB.  Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995 Sep 6;274(9):700-5. PMID 7650822 http://jama.ama-assn.org/content/274/9/700.full.pdf+html
    2. Davis D. Does CME work? An analysis of the effect of educational activities on physician performance or health care outcomes. Int J Psychiatry Med. 1998;28(1):21-39.  PMID 9617647
    3. Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A.  Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999 Sep 1;282(9):867-74. PMID 10478694. http://jama.ama-assn.org/content/282/9/867.long

    Keys to effective CME #2 - flexibility and technology

    Multiple media and educational techniques:
    • "The review shows improved results with the use of multiple media and multiple educational techniques; this finding is entirely consistent with principles of adult learning theory" (Davis 2009).
    • "Multiple media, multiple techniques of instruction, and multiple exposures to content are suggested to meet instructional objectives intended to improve clinical outcomes." (Mazmanian 2009).
    Use of technology: computer-assisted instruction, web-based education, simulation, and virtual reality
    • Technology-assisted education was superior to traditional teaching methods in 66% of studies, equal in 29%, and inferior in 5%. (Jwayyed 2011)
    References
    1. Davis D, Galbraith R;  Continuing medical education effect on practice performance: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines. American College of Chest Physicians Health and Science Policy Committee. Chest. 2009 Mar;135(3 Suppl):42S-48S. PMID 19265074. http://chestjournal.chestpubs.org/content/135/3_suppl/42S.long
    2. Mazmanian PE, Davis DA, Galbraith R; American College of Chest Physicians Health and Science Policy Committee. Continuing medical education effect on clinical outcomes: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines. Chest. 2009 Mar;135(3 Suppl):49S-55S. Review. PMID: 19265076 . Available at: http://chestjournal.chestpubs.org/content/135/3_suppl/49S.long
    3. Jwayyed S, Stiffler KA, Wilber ST, Southern A, Weigand J, Bare R, Gerson LW. Technology-assisted education in graduate medical education: a review of the literature. Int J Emerg Med. 2011 Aug 8;4:51. PMID 21824405. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3162483

    CME Interactivity over the years

    CME providers should acquire skills in improving interactivity (Parboosingh, 2011).

    Interactivity over the years...

    1980:
    • Panel discussions and Q&A Sessions at the end of lecture 
    • Great if you are asking the question
    1990:
    • ARS, polls, and simple feedback 
    2000:
    • Case-based or "Hey this talk actually relates to patient care!"
    • Internet-based CME
    2010:
    • Cognitive clinical simulations 
    • Hands on clinical simulations and skill sessions
    • Role playing and live acting
    • Standardized patients
    • Game shows
    • Reflective learning
    • Mobile technology (including smart phones, and tablet computers): A convenient and novel training tool based on touch-based experience that is potentially more interactive.
    Reference
    1. Enhancing practice improvement by facilitating practitioner interactivity: new roles for providers of continuing medical education. Parboosingh IJ, Reed VA, Caldwell Palmer J, Bernstein HH. J Contin Educ Health Prof. 2011 Mar;31(2):122-7. PMID: 21671279

    Group course focused CME that works

    Key components of CME that works:
    1. Half day program (longer experience)
    2. Series of short (25–30-minute) didactic lectures, with several audience response system questions designed to promote faculty-learner interaction. 
    3. Patient communication: participants watched a video about the correct use of inhaler devices (to enhance their patient education skills)
    4. Practice intervention: workshop focused on a detailed case discussion, with challenges related to diagnosis, staging, initial treatment, and management of COPD exacerbations, and follow-up care. 
    5. Skills intervention: workshop, learners participated in hands-on demonstrations of handheld spirometers, and engaged in active role playing of spirometry coaching, reading, and interpretation to reinforce accurate office spirometry use.
    6. Measure non-satisfaction outcomes
      • comparing responses to a series of case vignettes from physicians who participated in a CME activity with those obtained from a comparable group of physicians who did not receive the same education
      • more likely to recognize COPD correctly in a patient presenting with dyspnea (74% versus 94%). 
      • Poor response rate (33% vs. 19%)
      • Not changes over time
      • Not related to patient outcomes
    Reference:
    1. Measuring the impact of a live, case-based, multiformat, interactive continuing medical education program on improving clinician knowledge and competency in evidence-based COPD care. Drexel C, Jacobson A, Hanania NA, Whitfield B, Katz J, Sullivan T. Int J Chron Obstruct Pulmon Dis. 2011;6:297-307. Epub 2011 May 23. PMID: 21697994 Free PMC Article

    Online CME: Online enduring materials (non-live) are growing



    Online has grown and keeps growing. What is so great about online?
    • Reproducable and consistent yet updateable 
    • Scalable 
    • Manageable and trackable 
    • Available 24/7
    • Supports different learning styles 
    • Can track outcomes 
    • CAN be interactive (can also be a canned lecture so interactivity is not guaranteed)
    Will online enduring material based CME keep growing?
    Who wants to bet against China? 
    References

    Online physician participants

    "Online "Internet Enduring Materials" is even more impressive in terms of physician participants. Although the relative number of live courses is staying mostly stable, actual participation is dropping quickly in favor of online education and training.

    References

    Successful Online Training

    Internet-based CME
    Strengths
    • works in general
    • richer experiences are more effective
    • more clinically focused efforts (e.g, case-based) are more effective
    • includes the ability to assess outcome (and require participation)
    Weaknesses
    • challenged by the inability to follow longer term outcomes
    • not integrated easily with patient outcomes
    Study looked at effect size and % non-overlap between participants and non-participants (increased likelihood of making evidence-based clinical choices) for 114 Internet CME activities by format (Casebeer, 2010)
    CME ActivityNEffect size
    (average)    		Increased likelihood
    of making evidence-based
    clinical choices
    Multimedia: mainly live or roundtable presentations with video lectures101.2664%
    Interactive case-based: contain questions within the activity that participants respond to and receive immediate feedback, usually involving patient cases401.0858%
    Interactive text-based: are mainly conference coverage, special reports, and basic clinical updates640.5837%
    All Internet CME activities1140.8248%
    Earlier study in 2008 showed similar findings
    • interactive case-based activities, 51% (effect size 0.89),
    • text-based clinical updates, 40% (effect size 0.63)
    References

    Games

    Results from knowledge testing immediately after the event and 3 months later showed no significant difference in scoring between game-based learning, compared with traditional case-based learning, in a continuing medical education (CME) event on stroke prevention and management. Participants in the game-based group reported higher levels of satisfaction with the learning experience. (Telner, 2010)

    Weaknesses
    • Study only looked at knowledge 
    • No control group. Did either have any benefit?
    • Still very much uncommon and untested
    • Will game excitement wear off?
    • Limited number of topics it can work for
    Reference

    Simulations: Actions and consequences

    "Simulation technology is a powerful tool for the education of physicians and other healthcare professionals at all levels... Medical simulation complements, but does not replace, educational activities based on real patient-care experiences" (McGaghie 2009).

    Key Components
    • Used for assessment as well as practice opportunities
    • Can provide tailored feedback, 
    • Engages learners in deliberate practice, 
    • Can be integrated into an overall curriculum and improve motivation 
    • Dependent on instructing faculty (and their subsequent competence. 
    "High-fidelity medical simulations are educationally effective and simulation-based education complements medical education in patient care settings" (Issenberg 2005)

    "Simulation training generally was effective, especially in the dissemination of psychomotor skills (e.g., procedures or physical examination techniques) (Marinopoulos , 2007)
    Reference
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    Copyright 2011, Bradley Tanner