Experts Debate Need to Improve Quality and Oversight of Continuing Education

Although continuing education of physicians and other health professionals is essential to ensure that patients receive current and correct medical care, experts are questioning the nature and funding of many programs.

“Continuing education in the health professions is in disarray” and the accreditation mechanisms for it are “unnecessarily complex yet insufficiently rigorous,” concluded a summary of a conference last fall on continuing education in the health professions (http://www.josiahmacyfoundation.org/index.php?section=home). The conference, convened by the Josiah Macy, Jr Foundation, included 36 leaders in medicine, nursing, and education who debated how best to keep clinicians abreast of new developments and who should pay for such efforts.

“Health care professionals must keep up to date, because what we learn during our training is just not going to sustain us throughout our careers—medicine is just too fast-changing a field,” noted conference chair Suzanne W. Fletcher, MD, MSc, who drafted the summary and outlined recommendations stemming from the conference.

In the report, Fletcher, professor emerita of ambulatory care and prevention at Harvard Medical School, cites the need for improvements in a variety of aspects of continuing education, including how clinicians learn, the role that information technology might play in helping clinicians update their knowledge, how it is financed, and how certification is accomplished. “There are messages relevant for various groups: individual professionals, institutions, and the supporters of continuing education,” said Harvey Fineberg, MD, PhD, president of the Institute of Medicine, who participated in the conference.

The conference participants suggested that continuing education programs should do better at addressing the many needs of clinicians across a wide spectrum. The critique applies to entities such as the Accreditation Council for Continuing Medical Education (ACCME), the Chicago-based body that certifies institutions and organizations offering continuing medical education (CME) programs for physicians. The ACCME identifies, develops, and promotes standards for these programs, which include lectures, conferences, workshops, symposia, regularly scheduled grand rounds, and other activities. More than 2000 entities—including medical schools, government agencies, physician groups, and organizations (such as hospitals) identified as medical education and communication companies—are accredited by the ACCME or state medical societies.

ACCME policy states that clinical recommendations in a CME activity must be based on evidence that is accepted within the medical profession and that all scientific research used must conform to generally accepted standards.

Fletcher maintained that although this is a suitable policy, accredited programs place too much emphasis on lectures instead of on activities that allow health professionals to evaluate and enhance their own performance. “More effort should be made to get [continuing education] closer to daily clinical practice,” she said. However, according to the ACCME's Chief Executive Murray Kopelow, MD, lectures are not the predominant form of CME used today. Rather, “our requirements are focused on physicians reviewing their own practices to identify gaps that can be remediated by the educational system,” he said.

Fletcher and colleagues noted that current educational efforts do not make sufficient use of information technology as a tool in this practice-based learning. For example, an effective continuing education program might incorporate a database of clinician performance at both the individual and group practice level, which could be compared with best practices and used to make plans for improvement.

The Internet also could help health professionals learn about issues that come up at the time and place of clinical decision making. The American Medical Association currently awards CME credit for Internet point-of-care learning by physicians on topics relevant to their clinical practice. One program, called PIER (created by the American College of Physicians-American Society of Internal Medicine), offers peer-reviewed guidance on the diagnosis and treatment of diseases and links to articles and patient information (http://www.acponline.org/clinical_information/pier/). Another online clinical point-of-care decision support tool produced by leading medical societies is called UpToDate, which answers clinical questions and provides specific recommendations for patient care (http://www.uptodate.com/).

In addition to using technology, participating in professional conferences should be encouraged, noted Fletcher. These gatherings play an important role in continuing education by promoting socialization and collegiality among physicians and other health professionals, and they provide unique opportunities for cross-disciplinary and cross-generational learning and teaching.

Critics of current CME efforts also suggest that programs should promote interprofessional teamwork and improve the quality of health systems. They note that the individual clinician has been the focus of most continuing education programs, but because the performance of health systems has a substantial effect on patient care, efforts should also be directed at teams of health care professionals. For example, interactive scenarios and simulations with groups could help health professionals gain skills in both basic and highly technical procedures.

According to Harry Gallis, MD, president of the Alliance for CME, a Birmingham, Alabama–based association of CME professionals, efforts to make these and other changes are already under way. “This is something that has been discussed by the accrediting bodies in medicine, pharmacy, and nursing,” said Gallis. “Maybe it hasn't moved forward at as fast a pace as it could, but it's not being ignored.” Kopelow added that the American Nursing Credentialing Center, the Accreditation Council for Pharmacy Education, and the ACCME have been involved for the past few years in a joint project to unify their accreditation systems. “That's clearly of value to interprofessional education,” he said.

To better assess the effectiveness of various types of programs currently available and in development, the conference participants advocate for establishing a national institute dedicated to evaluating and improving continuing education. “When we decided as a country that it was important to develop basic biomedical and clinical research for the good of the public, the National Institutes of Health was formed,” said Fletcher. “It's on that model that a national institute should be formed whose mandate is to promote the scientific underpinning of how to advance [continuing education].” Such an institute should help establish effective methods for educating health professionals, promote and fund evaluations of policies and standards for continuing education, and conduct and encourage research into the quality of programs, she said.

Leaders in medicine, nursing, and education who participated in the Continuing Education in the Health Professions conference convened last fall by the Josiah Macy, Jr Foundation (http://www.josiahmacyfoundation.org/index.php?section=home) cited the substantial and growing reliance by continuing education providers on commercial support as a significant problem in the medical education enterprise. “We are very concerned about the need to minimize bias, in both reality and appearance,” said conference chair Suzanne W. Fletcher, MD, MSc.

According to the Accreditation Council for Continuing Medical Education, in 2006, commercial support from pharmaceutical and medical device manufacturers accounted for more than half of the $2.4 billion total income for accredited activities (http://www.accme.org/dir_docs/doc_upload/e2843247-7cae-40fe-a0eb-27a982b8fcc0_uploaddocument.pdf). Fletcher pointed out the conflicting obligations between pharmaceutical companies, which have a responsibility to shareholders to generate a profit, and physicians, who have a responsibility to patients to provide high-quality care based on scientific findings.

Fletcher would like federal and state policy makers to step in and fund continuing education activities, but some continuing medical education professionals question whether creating and sustaining such an institute is financially feasible. “When Congress refuses to fund adequately the US Food and Drug Administration, it seems unrealistic to expect a new public funding program for continuing medical education,” said John Kamp, PhD, JD, executive director of the Coalition for Healthcare Communication, a New York–based organization composed primarily of advertising and publishing association members.

Others propose allowing companies to put money into a central repository, instead of earmarking it for specific continuing education activities, which would allow recipients to remain free from influence by any one donor company. The central agency would in turn disburse funds to approved programs (Brennan TA et al. JAMA. 2006;295[4]:429-433).

Still others have suggested that physicians themselves might pay for continuing education programs, “but that would not be a popular notion, since we're already constantly debating issues about health care reimbursement,” said Harry Gallis, MD, president of the Alliance for Continuing Medical Education, an association of continuing medical education professionals.

The Institute of Medicine's president, Harvey Fineberg, MD, PhD, added that whether continuing education is funded by the government or by health professionals, it is the public that will end up footing the bill. “The idea that it would be paid for by the profession doesn't mean patients aren't going to ultimately pay,” he said.—T.H.