Continuing Medical Education News

Reforming the Continuing Medical Education System

Tuesday May 12, 2015

In the modern era of medicine, the accelerating rate of change in medical knowledge represents an enormous challenge to the ability of physicians to offer patients the highest-quality care. A particularly striking example is the rate of introduction of new drugs. In the 1930s, the US Food and Drug Administration (FDA) approved an average of fewer than 2 new molecular entities annually, accelerating through the ensuing decades to an annual rate of more than 30 new drugs per year.1 For a physician who completed postgraduate training in 1985, more than half of all the critically important newly available pharmaceutical agents were introduced after they completed their training. Many therapies in common use a few years ago are now consider ineffective or harmful (eg, digoxin, niacin). Similarly, diagnostic methods such as medical imaging or laboratory testing and new surgical techniques have evolved at an extraordinarily rapid pace, rendering obsolete a considerable fraction of knowledge acquired during medical training.

Continuing medical education (CME) represents the most widely applied approach for keeping physicians apprised of these rapid-paced medical advances.

If effective, the CME delivery system should contribute to a high utilization of evidence-based medicine and adherence to practice guidelines. However, considerable evidence suggests that CME is unevenly applied within the US health care system and relatively ineffective in achieving the desired goals. Physicians at major academic medical centers have access to many educational opportunities compared with physicians practicing in smaller community hospitals. Physician knowledge of guideline recommendations for many important diseases is fair to poor, and adherence to these guidelines even lower. In a study of primary care physicians (N = 455) who commonly treated patients with chronic obstructive pulmonary disease, only 33% knew the correct criteria for diagnosis.2 In a large study of patients with heart failure (N = 15 381), only 27% of patients received all of the guideline-recommended therapies for which they were potentially eligible.3 These knowledge gaps reflect poorly on the effectiveness of CME in disseminating contemporary disease management recommendations.

Some scientific research has focused on determining whether CME is effective at improving physician performance, but these studies have not been particularly rigorous. The findings generally support the concept that CME has a favorable effect on the quality of practice, but the magnitude of benefit is small. A 2009 Cochrane Collaboration review examined 81 trials involving more than 11 000 health professionals and concluded that the median adjusted improvement in compliance with desired practice was only about 6%, and the effect on patient outcome even smaller, about 3%.4 The Cochrane review judged 20 of the 81 trials as having a high risk of bias and commented that 13 of the studies had no baseline data. More concerning was that a funnel plot of studies showed publication bias, with large improvements in physician performance in nearly all of the smaller studies and little or no improvement demonstrated in larger studies.

After a 2007 conference, the Josiah Macy Jr Foundation issued a report that was highly critical of the CME system, requesting that the Institute of Medicine (IOM) examine the effectiveness of CME in producing favorable effects on medical practice.5 The comprehensive IOM report (2010) contained particularly candid and disturbing comments, concluding that “the CE system, as it is structured today, is so deeply flawed that it cannot properly support the development of health professionals."6 Most critics describe CME delivery as fragmented, poorly regulated, and lacking well-developed, scientifically based methodology for educating physicians. Many educational offerings focus on helping physicians meet the regulatory requirements for licensure, not on practice improvement or enhancement of patient outcomes.

The delivery of medical education relies on the traditional methods for didactic learning such as lectures and seminars in customary settings such as auditoriums or classrooms. The content is largely driven by the educator without any assessment of the true educational needs of the learner. Using these traditional delivery methods, there are few opportunities to assess whether the educational program actually changed physician behavior or resulted in improvement in patient outcomes. If the perceived goal is obtaining “CME credits" for licensure, then any accredited educational activity is sufficient, and the location and content are largely irrelevant. Frequently these educational programs take place in settings poorly conducive to meaningful learning. Every year, countless courses are held in resorts where participants may attend 2 to 4 hours of CME presentations in the morning and then enjoy recreational activities in the afternoon. Such meetings are the antithesis of practice-based learning, which ideally should occur in a patient care setting.

The financing of CME is also problematic and raises concerns about bias and conflict of interest. Commercial sources, such as pharmaceutical and device companies, provide funding for a majority of CME offerings. The Macy Foundation report found that 60% of the $2.4 billion spent on CME was funded by commercial sources and concluded that “no amount of strengthening of the firewall between commercial entities and the content and processes of CE can eliminate the potential for bias." In fact, such firewalls largely do not exist. Commercial sources fund CME through a group of entities known as medical education and communication companies (MECCs) via lucrative contracts. The MECC then pays CME presenters (academic or nonacademic physicians) to deliver the educational content, thereby providing the appearance of independence from the funding source.

In a report issued in 2007, the Senate Finance Committee wrote, “it seems unlikely that this sophisticated industry would spend such large sums on an enterprise but for the expectation that the expenditures would be recouped by increased sales."7 During hearings conducted by the Senate Committee on Aging in 2009, my testimony indicated that “communications companies solicit funds from industry to conduct a wide variety of 'educational' offerings, providing a veneer of independence that camouflages the promotional nature of educational programs" and that “communications companies select speakers and topics that they know will please the sponsors."8 In other testimony, Lewis Morris, Chief Counsel to the Office of the Inspector General of the US Department of Health and Human Services, opined, “The surest way to eliminate commercial bias in CME is to eliminate industry sponsorship by funders who have a significant financial interest in physicians' clinical decisions."9

Oversight and accreditation of CME activities in the United States are under the purview of the Accreditation Council for Continuing Medical Education (ACCME), an entity that has been widely criticized as ineffective and resistant to reform. After each of the reports criticizing the effectiveness of CME, the ACCME has responded with defensiveness rather than thoughtful introspection. After the Macy report, the ACCME issued an open letter to the president of the foundation stating, “we disagree with, or take exception to, most, if not all, of the Conference Proceedings."10 The letter stated, “We strongly believe that neither CE accreditation, nor CE itself, is in 'disarray' as is purported in the Chairman's Summary in the Conference Proceedings." The ACCME letter concluded, “The United States has an excellent and admirable continuing education system." More recently, in a report issued in 2014, the ACCME offered an impassioned self-defense, complaining that both the Macy Foundation and IOM reports were “paradoxically critical of CME." The ACCME report suggested that more learning is now occurring through contemporary delivery systems such as the Internet but provided no evidence that such innovations actually have improved physician performance and patient outcomes.

How can and should the CME system in the United States be reformed? Several actions are critically needed. Better research is necessary to understand what approaches lead to actual improvements in physician behavior and outcomes for patients. The current system should be replaced with a prospectively designed accreditation organization tasked with studying CME effectiveness, providing rigorous oversight of quality and leading educational innovation designed to change medical practice and improve patient outcomes. Systems are needed for assessing individual physician knowledge and customizing education to fill identified gaps in knowledge based on an objective assessment of shortcomings. Commercial funding of CME is incompatible with an objective and unbiased approach to medical education and should not be permitted for CME used to meet licensure requirements.

Standardized and consistent national requirements for licensure and certification are needed to replace the current patchwork of individual state regulations. Physicians should accept the financial responsibility for their own education rather than relying excessively on “free" programs. Replacement of traditional lectures and symposia with practice-based learning has the potential to more meaningfully improve patient care. Better documentation of the effect of educational programs on physician behavior is needed to ensure that CME produces the desired improvement in physician performance. Funding the study of the science of medical education by government entities such as the National Institutes of Health and the Agency for Healthcare Research and Quality would be essential to developing better educational methodology.

Medical knowledge continues to accelerate, and physicians have an obligation to ensure ongoing learning and lifelong education. Failure to reform the approach to physician CME will inevitably lead to a future with physicians falling further and further behind in needed medical knowledge. Medicine as a profession, the health care system, and especially patients deserve better.