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Back to Table of Contents | November 2010

Clinical and Health Affairs

Is the CME System Obsolete?

By Barbara Brandt, Ph.D., and Janet Shanedling, Ph.D.

Abstract
Changes in medical practice and a greater emphasis on lifelong learning are prompting a closer look at the efficacy of continuing medical education (CME). This article outlines the shortcomings of the current CME system, describes findings from two recent reports about its status, and presents recommendations for a new system to make continuing education more relevant to medical practice.

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.1 In 2010, the Institute of Medicine report Redesigning Continuing Education in the Health Professions and the Josiah Macy, Jr. Foundation-funded report Lifelong Learning in Medicine and Nursing detailed numerous problems with continuing education and recommended an overhaul of the system.2,3 The authors suggested establishing a national institute for research and creating new regulations and financing mechanisms for continuing education. They also acknowledged changes in medical practice including the fact that health professionals need to not only be clinically competent but also be adept at using new technologies and working in teams.

In addition, the reports’ authors noted that a redesigned continuing medical education (CME) system would formally recognize lifelong learning as a set of core competencies and place emphasis on demonstrating continuing professional development rather than simply accumulating continuing education units. Some of the competencies physicians would need to develop include the ability to determine their learning needs based on what is happening in their practices; effectively search for and appraise the value of various educational resources; apply those resources to practice-related questions; and use self-assessment and external feedback to evaluate performance within the context of their practice. The professional development process would involve documentation of and recognition for learning and performance outcomes in medical practice.3

This continuing professional development system would resemble those that are being developed in Canada, Australia, and the United Kingdom, as those countries attempt to reform their CME systems. For example, the Royal College of Physicians and Surgeons of Canada, to which 90% of certified Canadian physicians belong, now requires members to formally assess their learning needs, document participation in continuing education activities, and record resulting outcomes in their practices.

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

Continuing Medical Education in the United States

Continuing medical education in this country emerged in the 1920s in response to the 1910 Flexner report, which documented the inadequate medical training that many U.S. physicians had received during that era. In 1934, urology became the first specialty to require participation in CME. 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.2,4 During the 1930s, the University of Minnesota became an early leader in postgraduate and “continuation” studies. By the late 1940s, the university took advantage of the Kellogg Foundation’s national interest in CME and received funding to support continuation studies for physicians for a number of years. In 1957, Robert B. Howard, M.D., Ph.D., director of continuation medical studies, filed a report that documented how the university’s large educational enterprise served nearly 3,500 physicians on campus, 340 physicians in rural Minnesota, and 749 “persons other than physicians” during a two-year period. One regional meeting, described as a three-day event at Lake Itasca State Park, was conducted by university faculty members who provided “only five lectures with the remainder of time being devoted to informal discussion groups.”5

By the mid-1950s, the American Medical Association (AMA) created the first set of medical practice guidelines that incorporated CME participation. In the late 1960s and 1970s, large-scale post-war investments in scientific research caused an explosion of new information relevant to medical practice. As a result, concerns arose about physicians’ knowledge becoming obsolete and the “half-life of professional knowledge,” which at the time was considered to be five years.6 By the late 1960s, the AMA introduced the Physician’s Recognition Award, which recognized voluntary participation in 150 hours of CME in three years.

Since the early 1970s, CME has become 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.

A System Under Scrutiny

Because the current CME delivery system evolved out of the need for physicians to keep up with the latest scientific discoveries, the predominant teaching method was to have experts lecture on various topics. This was considered an efficient way of transmitting information to large groups of physicians, and it was further codified by the mandatory system that equated seat time, or time spent sitting in lectures and training programs, with professional competence. Furthermore, as technological discovery spread beyond academic institutions, industry became an important partner in educating health professionals. Thus, an entire CME industry was created. In 2007, of the $2.54 billion spent on CME, physicians paid 42%, or $1.05 billion. That figure equates to an average of $1,400 per physician per year.2

Although this has come to be the accepted way of providing CME, there is still debate about whether or not it is effective. A number of indicators suggest that current forms of continuing education may not be what is needed in 21st century medicine:

  • Numerous reports and systematic reviews of the literature on continuing education describe the relatively small impact that the mandated classroom education model has on learning, clinician performance, and patient outcomes.8,9 More interactive methods such as the use of opinion leaders, academic detailing, reminders, and protocols also show only a small-to-moderate impact.3
  • Self-assessment, self-reflection, and practice-based learning and improvement are critical skills that are now being introduced in undergraduate and graduate medical education.10,11 However, they are not regularly part of continuing education programs for physicians. The literature suggests that when compared with objective observation, physicians are unable to assess their own performance accurately enough to guide their own learning.12
  • Significant attention is now being paid to the influence of industry on CME and other commercial support of CME.13,14 Many now question the appropriateness of having market- and interest-driven CME offerings rather than needs-based ones.
  • The CME system rewards participation rather than learning. Accreditation agencies focus on the number of hours it takes to complete educational activities such as reading an article and answering questions or the amount of time it takes to complete an online program rather than documentation of learning or impact on practice.
  • Formal continuing education activities are accredited by specific organizations for individual professions such as medicine, nursing, and pharmacy, and often are targeted to specialties and subspecialties, rather than to health care teams. Little interaction occurs between health professions groups in terms of accrediting CME activities, and there is little incentive for interprofessional learning and application of skills. The recent implementation of health care homes, for example, makes taking an interprofessional approach to practice imperative and something that must be emphasized in continuing education activities.

The Quality Chasm and Lifelong Learning: Elements of a New System Emerging from the patient safety, quality, and performance- improvement movements is awareness of the need to link education and patient outcomes. The IOM’s report Health Professions Education: A Bridge to Quality outlined five competencies that all health professionals need to master: the ability to provide patient-centered care, work in interprofessional teams, employ evidence-based practices, apply quality-improvement methods, and utilize informatics.15 This has led to new thinking about lifelong learning: that education for both practicing clinicians and health professionals-in-training ought to build on these core competencies.

If physicians are to master the new competencies, clinical practice, learning, and professional development must be inextricably linked.16 Thus, CME needs to move beyond formal regulated activities in which an individual is a participant to practice-based learning and professional development that is focused on patients and populations. A new CME model would incorporate learning in the workplace and, more specifically, at the point of patient care for the entire health care team, not just for the physician. The authors of the IOM and Macy Foundation reports envision that, in the future, CME would have: 2,3

  • Physicians identify their learning needs based on their own practices. They would focus on issues related to their patients’ health such as asthma, spinal injury, or diabetes;
  • Information specialists such as health science librarians locate timely and relevant information for physicians about standards of practice that can be used at the point of care. These professionals also would teach physicians to use electronic services that can continuously and automatically provide them with the latest reports as they become available. In addition, they would provide physicians with “just-in-time” answers to practice- related questions;
  • Data from electronic health records mined to inform physicians and other members of the health care team about possible gaps in care or poorer-than-expected patient outcomes;
  • Electronic health record data used to confirm that what teams are doing meets or exceeds anticipated benchmarks. Validation of current practice is as important as recognizing gaps in care, and both require a commitment to continuous learning and a willingness to change;17
  • Patient satisfaction data used to inform members of the health care team of the quality of discharge planning, care navigation, and handoffs between professionals; and
  • Physicians (and their teams) self-assess, reflect upon, and document their learning needs, create action plans, and begin to identify relevant resources for addressing their needs. They might fulfill their educational needs by attending professional society meetings, taking online courses, participating in grand rounds, or visiting other clinics individually or as a team. These activities may or may not be formally accredited CME. In addition, simulations, e-mentoring, and online assessments linked to national accreditation databases could be used to document physicians’ ongoing continuing education and demonstrate their competencies. Electronic portfolios also may be used for documenting and sharing an individual’s learning and for awarding credit.18

Accrediting agencies such as the Association of American Medical Colleges and the Liaison Committee on Medical Education are requiring new sets of core competencies and methodologies such as simulation and electronic portfolios to document attainment of those competencies. These are now being integrated into health professions schools at the University of Minnesota and throughout the United States. Such methodologies are also informing the redesign of CME. As health professionals assume greater responsibility for assessing and meeting their own learning needs, the role of the CME provider needs to change beyond that of a meeting planner. CME providers need to become consultants and facilitators who support physicians as they create and implement their lifelong learning plans. CME providers must be taught to assist in and provide external validation of and feedback about physicians’ self-assessment, and to help physicians design, adapt, and assess their lifelong learning experiences.

Conclusion

Restructuring CME, like reforming health care, is a daunting task. Both systems are entrenched in the status quo, and both have been resistant to change. However, the momentum to reform health care over the past decade has provided an opportunity to also redesign the continuing education system for health professionals.

In response to mandates from the IOM and accrediting bodies, medical education and residency programs are changing their programs to better address patient care and quality improvement challenges. We need to extend those initiatives to CME so that we can better meet the needs of physicians in the workplace. MM

Barbara Brandt is associate vice president for education at the University of Minnesota Academic Health Center and director of the Minnesota Area Health Education Center Network. Janet Shanedling is the director of educational development at University of Minnesota Academic Health Center Office of Education.
 
References
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2. Institute of Medicine. Redesigning Continuing Education in the Health Professions. Washington, D.C.: The National Academies Press; 2010.
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