Perspective
CME ASAP
A new idea to help us learn what we don’t know we don’t know.
By Donald L. Deye, M.D., FACP
Think back to those halcyon days of medical school. We were tabula rasa. We didn’t know what we didn’t know, but others who were wiser and more experienced did. They wrote textbooks and lectured to us in order to fill our brains with their notions of what we needed to know in order to practice high-quality medicine.
I recall feeling very grateful and almost unworthy of their heartfelt efforts. Mind you, as a member of the charter class of Mayo Medical School, I was spoiled by the fervor and motivation of the new instructors.
Once our brains got full and we had demonstrated competence during residency, we were cast into the ocean of clinical medicine to more or less fend for ourselves. We tried to keep up with new information by reading medical journals and attending periodic meetings, selecting what we wanted to read and study based on our own interests and awareness of what we might need to know.
Journal clubs helped us sift through the information. Gadgets such as audio cassette players and later CD and mp3 players made educating ourselves something we could do while driving, biking, or jogging—I used to listen to audio reviews while cleaning horse stalls. If we missed a diagnosis or noticed colleagues ordering a new test or medication that we were not familiar with, we might later go to UpToDate or another online resource to learn more. But we were largely self-directed learners.
There’s just one problem with this type of learning. It’s limited by what we know we don’t know. There’s a lot of stuff out there, some of which may be very important to our ability to provide optimal patient care, that we don’t know we don’t know. In other words, we all lack knowledge about our own ignorance. We just haven’t been hit hard enough on the head by a clinical event to become aware of our knowledge deficit.
This is not a new idea. It is the foundation of programs such as the Medical Knowledge Self-Assessment Program (MKSAP), which I have used over the last 30 years and for which I’ve recorded audio versions of the content. The audio is a dialogue between the dumb guy (me) and an expert, featuring the occasional bad joke. With MKSAP and similar programs, we base our learning on the results of a multiple choice test. Our test results reveal where we are clueless, and we target our learning efforts to those areas. This was and is a great idea, and many similar programs have since been developed—SESAP for surgeons, ESAP for endocrinologists, and ACCSAP for cardiologists, among others. But with electronic medical records, there’s a new way of figuring out what we don’t know.
A Profile for Learning
About 20 years ago, before electronic record systems appeared in clinics, all of us physicians at Cambridge Medical Center started reviewing charts from each others’ practices every three months. We studied the last progress note in a randomly selected chart and the related data, then commented on the quality of care the physician provided and attempted to identify any knowledge or practice deficits. We still do this. Only now, instead of receiving a stack of charts to review, we’re given chart numbers and visit dates and we pull up the information electronically.
So far, our efforts to use automated medical records to improve the quality of care have been pretty rudimentary. We track our performance on easy-to-measure outcomes such as the percentage of our diabetic patients with LDL cholesterol levels below 100 or A1c levels below 7 (or maybe 8 in certain cases). But we only are able to identify deficits in execution, not knowledge. We all know the target values for these outcomes.
Nonetheless, giving us this data on an individual basis has been very effective. We’ve moved the numbers big time. But our use of automated medical record information to improve clinical practice is at this point still crude. Very crude.
Much more elegant analysis of this same data is being done. It’s just that those results are being used to profile us rather than make us smarter. Several companies around the country have been working for years to develop sophisticated rules for analyzing our clinical behavior and competence. I know because I’ve done consulting work for more than one of these organizations. What bothers me is that this information is not consistently being used to improve care. It mainly is used to provide physicians with quality scores. To me, this seems a terrible waste.
But it gave me an idea for creating an automated self-assessment program (ASAP). Such a program would make use of what already exists in the electronic medical record by utilizing their analysis logic rules to identify gaps in knowledge and then provide resources to help close those gaps. Here’s how it would work: First, we would use the same computer program that analyzes claims and EMR data to profile physicians to create a knowledge deficit profile for each caregiver. The software would then link specific print, audio, and video CME content and current literature to each knowledge deficit. In addition, a medical librarian could look at monthly journal club reviews and, using automated search tools, select content that would be relevant to the caregiver’s knowledge profile. Then, all of this print and audio content, along with a CME quiz, could be transmitted to the physician’s smart phone, iPod, or personal digital assistant. Thus, providers would have CME content selected specifically for them, based on both their patient mix and their clinical practice performance metrics, in their pocket or clipped to their belt.
The knowledge deficit profile would be recreated periodically, so physicians could see how their clinical behaviors change in response to learning interventions. The result: learning designed to improve a physician’s practice based on an analysis of an individual’s performance.
Reimagining Recertification
Such a system could streamline our recertification process, which currently is expensive, time-consuming, and a major hassle. Because the mechanism for recertification is so cumbersome, we only recertify every five, seven, or even 10 years. The best measure of physician competence is what actually is done to care for patients, not how many CME credits we earn. If we could identify our knowledge deficits and target our learning to fill in the gaps in what we know and tie it to recertification, we could have a real-time, ongoing process for recertification as well as for maintaining our competence. I believe a program like ASAP is the key to being able to do that.
For years, I have devoted much of my time to developing and enhancing lifelong learning tools for physicians. I have found this rewarding. Pursuing this has expanded my own medical knowledge and made me aware of new possibilities. The ASAP approach could be realized without creating any new technology. It’s just a matter of putting together pieces that already exist and working on future enhancements. MM
Don Deye is an internal medicine physician for Allina Medical Clinic – Cambridge and medical director for Oakstone Medical Publishing, a CME provider.