In the October 28, 2009 edition of JAMA, an editorial appeared by Eric Campbell and Meredith Rosenthal entitled, “Reform of continuing medical education: Investments in physician human capital”. Unfortunately these authors seemingly ignored the entire CME improvement process that is already in place in this country. Academic CME in particular has examined itself, has begun an improvement project of its own and has undergone a profound sea change well in advance of this publication.
CME wasn’t created to change patient outcome in a direct effect model. Physicians believed that they were no longer novices, but masters in the craft of health care requiring only continued exposure to the most current information. Thus the published literature demonstrates that CME is indeed most effective at advancing knowledge. The implication that scant evidence of improved patient outcomes means no evidence is incorrect. This is an issue of lacking evidence not being the same as evidence of no effect.1 Physicians don’t practice in a vacuum and their sources to learn and improve are through a variety of concurrent mechanisms. Consequently, defining a causal pathway for any single activity may never be achievable.
Performance Improvement CME already exists and early projects have shown beneficial outcomes.3,4 Point of care CME is being utilized by many physicians to directly impact care decisions. Simulation-based CME is just beginning.
The goal is not a system of no funding, but a system of no influence that improves practice and patient outcomes. This goal was established by the CME profession itself and is in concert with the IOM. 2 These newer forms of CME which target patient outcomes are much more expensive to conduct and given the steady advance of knowledge in healthcare the costs for CME recur in full each and every year. Training within one’s practice team may require the closing of one’s practice adding additional costs and concerns regarding access to care.
Commercial funding for CME was indeed on a steady increase until 2004 when the revised Standards of Commercial Support were released. 2008 saw a decrease in commercial funding of almost $200 million dollars and the expectations is that the 2009 data will show an even larger fall, a fact supported by preliminary data analysis from the 2009 Harrison Survey. Thus this call by Campbell and Rosnethal for a change in funding ignores what is already at play.
Regulated change comes and goes (e.g. prohibition). Introspective performance improvement is indeed the pathway to sustainable change and this is a path that CME has already begun. In this, the 100th anniversary year of the Flexner report, CME is honored to have seen the need to change and to have embarked on this process. It is unfortunate that Campbell and Rosenthal did not acknowledge the significant improvements already occurring.
References:
1) Marinopoulos SS, Dorman T, Ratanawongsa N; et al. Effectiveness of Continuing Medical Education. Rockville, MD: Agency for Healthcare Research and Quality; January 2007. Evidence Report/Technology Assessment 149. AHRQ publication 07-E006.
2) Institute of Medicine. Conflict of Interest in Medical Research, Education, and Practice. Washington, DC: National Academies Press; April 28, 2009. http://www.iom.edu/CMS/3740/47464/65721.aspx. Accessed June 24, 2009.
3) MB S, Mullikin EA, Loose AS, Olson CA . Learning to collaborate: A case study of performance improvement CME. Journal of Continuing Education in the Health Professions. Summer 2008;28(3):140-147.
4) Laprise R, Thivierge R, Gosselin G, Bujas-Bobanovic M, Vandal S, Paquette D, Luneau M, Julien P, Goulet S, Desaulniers J, Maltais P. Improved cardiovascular prevention using best CME practices: A randomized trial. Journal of Continuing Education in the Health Professions Winter 2009;29(1):16-31.
Tags: cme, COI, IOM, performance, performance improvement