What's Ailing CME?

Continuing medical education, the prime raison d’etre of medical/pharmaceutical meetings, has come under a chorus of criticism lately. The Manhattan-based Josiah Macy Jr. Foundation, a private philanthropic group founded in 1930 to improve the education of health professionals, recently warned that the industry is “in disarray,” and a number of policymakers and physicians alike are voicing concern that CME and its lifeblood, support from pharmaceutical companies, are in an unholy alliance based on bias and commercial greed.

There are other questions surrounding CME, such as whether the accreditation model should be reformed and even if the quality of the education itself is up to par. M&C asked insiders to weigh in on these pressing problems -- and offer possible solutions.

Under a spotlight

Last November, the Macy Foundation held a conference in Bermuda with 36 prominent members of the academic medical community -- professionals hailing from institutions such as the American Board of Internal Medicine, Harvard Medical School and the New England Journal of Medicine.

A report, released by the foundation this past May, summarized the three-day discussion about the quality of medical education, and no punches were pulled (see “A Troubling Report Card”). Among the gripes: CME does not adequately improve clinician performance, relies too much on outdated lecture formats, and blurs the line between education and commercial support.

Meanwhile, according to a U.S. Senate Finance Committee study released in April 2007, commercial sponsors spent more than $1 billion in CME support in
2004, a situation clearly rife for influence-peddling. Senator Chuck Grassley (R-Iowa) states in the report that “separation between medical education and marketing efforts...isn’t clean enough. Medical education funded by drug companies has to be real education, not a soft sell designed to sway treatment decisions.”

“There’s a lot at stake,” says Mindi McKenna, director of CME for the Leawood, Kan.-based American Academy of Family Physicians. “A lot of patients are not getting optimal care, despite the fact that lots of money is spent for education. I think all involved are dismayed that CME is not having as much impact on practice performance and health outcomes as patients deserve.”

Yet, not all in the medical community stand behind the recent criticism. In the wake of the Macy Foundation report, the Birmingham, Ala.-based Alliance for Continuing Medical Education released a statement emphasizing that the Alliance “does not endorse or condone” the report’s recommendations, and that “the Alliance believes the report includes broad generalizations of divisive issues [that have] not been studied and may not be in the best interests of the broader CME community.” McKenna said that despite the report’s clarity on three central issues -- educational methods, accreditation and funding -- she felt that “not all of the conclusions and recommendations are objective or evidence-based.”

A TROUBLING REPORT CARD

Here are some key extracts from the 243-page “Continuing Education in the Health Professions: Improving Healthcare through Lifelong Learning” report released by the Josiah Macy Jr. Foundation in May. View the complete report at www.josiahmacyfoundation.org.

* “Too much CE relies on a lecture format. The CE enterprise should shift to an emphasis on practice-based learning.”

* “Despite recent changes in CE accreditation...organizations with little professional expertise in health care, and supported almost entirely by commercial interests, provide accredited continuing
education.”

* “Accrediting organizations have not found ways to promote teamwork or align CE with efforts to improve the quality of health systems.”

Going pharma-free

One of the boldest recommendations of the Macy report was that the CME industry should eliminate commercial support completely within five years. In the report’s summary, the consensus among participants was that “health professions, especially medicine, threaten the ethical underpinnings of professionalism by participating in a multibillion-dollar CE enterprise so heavily financed by commercial interests.”

Dr. David C. Leach, a retired physician, member of the planning committee for the Macy conference and former CEO of the Accreditation Council for Graduate Medical Education, says pharmaceutical companies should have absolutely no role in continuing education and that the intent of CME “is contaminated by the sale of their product.” Leach and the Macy report propose that in lieu of commercial support, continuing education should be paid for by doctors themselves or their employers. The report also proposes creating a national Continuing Education Institute that would explore methods of support, among other duties.

But some leaders in the industry think getting rid of commercial support entirely could do more harm than good. McKenna says the industry shouldn’t be so quick to eliminate such financial backing without a better alternative in place. “My question is, who will pay?” she asks. “Shutting off the flow of money could solve one problem and create another that could be damaging to public health. We have a social responsibility to accelerate the use of medical devices and drugs that are beneficial for patients.”

However, three state chapters of the American Academy of Family Physicians -- Maine, Oregon and Washington -- recently decided to completely ban commercial support from their CME programs. “Studies have shown that aggressive marketing practices from pharmaceutical representatives can create conflicts of interest,” says Kerry Gonzales, executive director for the Oregon group of about 1,300 doctors. “We felt it was important to eliminate any appearance of influence and also make a statement that we are committed to decision-making based on scientific evidence.”

Doctors have to pay a bit more -- registration fees increased from $200 to $225 -- but hospital systems and health insurance companies continue to support the pharma-free education program as sponsors.

The learning curve

One point most sides agree upon is the Macy report’s finding that “insufficient research currently is directed at improving and evaluating continuing education.” McKenna notes that current research is “not standardized, not rigorous enough and is too anecdotal. The challenge is, there is not enough funding dedicated to systematic research.”

Yet, there is some consensus in the field regarding what types of learning are most effective. Mike Saxton, team leader for medical education at New York City-based pharmaceutical giant Pfizer Inc., says multifaceted, sequential education is best. “The debate is over, because the literature is clear about what works,” he states. “The CME profession is moving toward practice-based learning and improvement methods.” Education, he says, should veer away from widespread “one and done” methods, where a doctor learns about something once in a lecture, for example, and never has the follow-up chance to translate this knowledge into practice via other educational methods.

Sources also tend to agree with the Macy report’s finding that “too much CE relies on a lecture format and counts hours of learning rather than improved knowledge, competence and performance.” Numerous studies back this claim, including a report released in March by Chapel Hill, N.C.-based Best Practices LLC, a research and consulting firm with a focus on the health-care industry, showing that while face-to-face CME delivery is most common (including didactic lectures and slide shows), such sessions are rated least effective.

Shawn Commerford, director of education for the Knoxville, Tenn.-based TeamHealth Institute, an in-house educational hub for some 4,000 physicians and other medical professionals, says education should take multiple routes: “For some, the best format is a didactic session; for others it’s a discussion or an experience using interactive tools.”

Providers also need to appeal to different generations of physicians. The AAFP offers online and interactive CME in all of its educational product lines, says McKenna, but not all physicians embrace it. “There are some who still prefer traditional lectures and print materials,” she notes.

The Macy report highlighted that so-called eCME, or online education, isn’t being propelled fast enough. “It is another missed opportunity,” says Leach.

Working together

The Macy report and individual experts also are calling for better teamwork -- within learning environments and among accrediting organizations.

Leach says most CME should take place within the medical office, with doctor and staff learning and working together, rather than doctors jetting off to sit through a three-day conference. “Health care is practiced in teams, and doctors need to know how to function in those teams and how to have clarifying conversations to improve performance,” he says.

In addition, the report recommended that the Accreditation Council for Continuing Medical Education and the Silver Spring, Md.-based American Nurses Credentialing Center “develop a vision and plan for a single accreditation organization for both nursing and medicine” to ensure the process is parallel between differing medical professions. In February, the ACCME announced such a move, to take place with the participation of a third body, the Accreditation Council for Pharmacy Education.

Combining these organizations, says Leach, will make it much easier for nurses and doctors to learn together, resulting in better patient care.

What’s next?

Despite anxiety spawned by the Macy report, most of the experts contacted by M&C say they’re happy to see many of the criticisms come to light, because it opens the door for debate.

“I have a great deal of interest in reading reports like this,” says McKenna. One of the CME industry’s biggest challenges, she says, will be to prioritize and clarify key objectives and next steps. “We need to set a relatively concentrated set of specific goals. We need to close the learning gap.”