Reform of Continuing Medical Education: Title and subTitle BreakInvestments in Physician Human Capital

In 1910, Flexner published a scathing indictment of undergraduate medical education at the time.¹ The Flexner report demanded reform of medical education, arguing that it should consist of rigorous preclinical education and supervised clinical training in hospitals and be isolated from commercialism. The report established the current system of undergraduate medical education.¹

A century later, another component of the continuum of medical education requires equally sweeping reform—continuing medical education (CME). Continuing medical education exhibits failures that parallel those defined in the Flexner report. If CME became a productive means of investing in physician human capital and if physicians could appropriate the returns to that capital, the profession would demand CME of an entirely different character. Furthermore, CME should apply new knowledge and skills that directly benefit patient and societal outcomes (ie, providing high-quality, efficient, and cost-effective care)—domains that have not been the traditional focus of CME.

Three of Flexner's chief criticisms of undergraduate medical education in 1910—excessive commercialization, unstandardized curricula, and lack of a patient-centered orientation—are true of CME today.

Continuing medical education has become an enterprise with high profit margins (23.5%) due to commercial support, which accounts for 58% of income of accredited CME provider organizations.² Additionally, medical education and communication companies are almost exclusively for profit and overwhelmingly dependent on industry funding. These 2 factors have prompted criticism that CME has become primarily a marketing tool.³

In general, physicians must fulfill a designated number of accredited CME credits to maintain their licenses in most states. However, physicians have broad autonomy in selecting course topics, types of learning experience, and activity locations. While the diversity of CME offerings provides benefits to physicians, it also deprives CME of representing the mastery of an essential core set of knowledge and competencies—a problem Flexner identified with undergraduate medical education in 1910. However, the American Board of Medical Specialties' (ABMS’) periodic, proctored maintenance-of-certification examinations provide physicians the benefit of declaring to the public that they have mastered an essential core set of knowledge for their area of specialty.

Flexner was concerned that many medical schools had an overreliance on lectures and rote memorization. Today, CME is subject to an analogous critique. Traditional CME is not adequately focused on improving patient outcomes. In fact, there is scant evidence that CME actually improves patient outcomes.⁴

The overall purpose of CME should be to maintain and improve the quality and efficiency of the US health care system—rather than to nominally fulfill a requirement for state licensure. Integral to this goal is ensuring that physicians have the requisite knowledge and skills—human capital—to catalyze gains in quality and efficiency. Continuing medical education therefore can be an investment in the human capital of physicians and an essential component of health care reform.

Viewing CME as an investment in human capital begs the question: what changes are needed to generate a sufficient return so physicians will rationally choose the optimal levels and types of CME? Three potential answers to this question are as follows. First, payment reforms would create financial incentives for more meaningful CME. Currently, most physicians are not paid based on the quality or efficiency of their practice. If all physicians faced meaningful economic incentives for quality and efficiency, they would have greater incentive to invest in effective CME to maintain and enhance their skills. To do so also requires that providers of CME refocus their offerings toward this goal.

Second, mandatory participation in well-conceived maintenance-of-certification processes is necessary. The ABMS has developed a new approach for certification that embodies continual engagement with the process of professional improvement. Making maintenance of certification a mandatory requirement for licensure should be strongly considered. Even though it is not a legal requirement for licensure, 85% of practicing physicians were certified by at least 1 ABMS board, but the number of uncertified physicians is in the ten thousands.⁵ For these physicians, the current minimum permissible investment in their human capital (20-50 CME credits per year) is likely too low. Mandatory maintenance of certification or some other formalized process like maintenance of licensure would help to ensure that all practicing physicians met baseline standards for skill maintenance and enhancement and competence.

Third, viewing CME through the human capital perspective, the experience of repeated clinical interactions—the essence of a physician's work—is a major contributor to physicians' knowledge and skills. It is essential to find ways to enhance physician learning from their routine clinical duties. Sophisticated health information technology has the potential to do so. For example, an electronic health record could be used to assess the quality of care physicians provide and could be used to suggest important areas for improvement through CME. Also, several specialty societies have created online platforms that help practicing physicians link their CME activities with clinical problems encountered in day-to-day practice.

According to the Institute of Medicine⁶ and Steinbrook,⁷ CME “has become far too reliant on industry funding” and that this funding “tends to promote a narrow focus on products,” not “a broader education on alternative strategies for managing health conditions and other important issues.” Reorienting CME toward the goals of health system reform and away from marketing drugs will require a new system of funding with increased contributions from individual physicians, hospitals, and other sources.

The primary insight offered by the human capital perspective is that the system should provide physicians with incentives to personally invest in their own CME, since they will appropriate the returns from that asset. Such incentives would ultimately derive from a payment system that rewards physicians for practicing high-quality, efficient medicine. Elements of such a payment system might include specific performance-based incentives and risk sharing for costs associated with an episode of care or population. This view is analogous to the economic explanation offered for the low wages of residents; through graduate medical education, physicians invest in their own human capital, an “asset” they own on completion of training.⁸

Alternative sources of support for CME could come from specialty boards, which have the infrastructure to operate and enforce large-scale maintenance-of-certification programs. In addition, much CME already funded and provided by medical schools and teaching hospitals will likely continue because it is a highly valued service for their faculties. In fact, in an environment where attendance at CME courses becomes more costly to the individual physician, hospital-provided CME will become even more valued.

Viewing CME as human capital accrual provides a useful alternative to the current model of CME as a requirement for licensure. If physicians viewed CME as a means of improving their human capital—and if the returns on that capital were substantial—new CME accountability would arise. The CME enterprise's current problems would be substantially reduced if physicians paid for CME and stood to benefit from its results.