Continuing medical education, professional development, and requirements for medical licensure: a white paper of the Conjoint Committee on Continuing Medical Education

To provide the best care to patients, a physician must commit to lifelong learning, but continuing education and evaluation systems in the United States typically require little more than records of attendance for professional association memberships, hospital staff privileges, or reregistration of a medical license. While 61 of 68 medical and osteopathic licensing boards mandate that physicians participate in certain numbers of hours of continuing medical education (CME), 17 of them require physicians to participate in legislatively mandated topics that may have little to do with the types of patients seen by the applicant physician.Required CME should evolve from counting hours of CME participation to recognizing physician achievement in knowledge, competence, and performance. State medical boards should require valid and reliable assessment of physicians' learning needs and collaborate with physician and CME communities to assure that legislatively mandated CME achieves maximal benefit for physicians and patients. To assure the discovery and use of best practices for continuing professional development and for maintenance of competence, research in CME and physician assessment should be raised as a national priority.     

Continuing medical education and attitudes of health care providers toward treating diabetes

INTRODUCTION: Continuing medical education (CME) is an important tool in improving the care provided to patients with type 2 diabetes. Health behavior models suggest that attitudes are important factors in changing behavior. The aim of this study was to evaluate the immediate and 3-month impact of a diabetes educational program on the attitudes of health care providers toward treating diabetes. METHODS: Health care providers (including physicians, physician assistants, nurse practitioners, and nurses) were attending a 7-hour CME program on type 2 diabetes in one of eight states in the United States between May and September 1999. Attitudes were assessed using the Diabetes Attitudes Scale-3 (DAS-3), which was given immediately before the program, immediately after the program, and 3 months after the program. A convenience sample of 315 providers completed pre- and post-CME measurement. Three-month follow-ups were completed by 146 (46%) of the 315 providers. RESULTS: Following the CME program, physicians had significantly more positive attitudes on two of five DAS subscales. At 3 months, the change persisted on one subscale that measured beliefs related to type 2 being a serious disease. Allied professionals had significantly more positive attitudes on five subscales following the program; however, the change did not persist at 3 months. DISCUSSION: This CME program resulted in different patterns of attitude change for physicians as compared to allied professionals. In both groups, more positive attitudes toward treating diabetes were detected following the CME; however, the change tended to diminish by 3 months after the program. These findings mimic much of the research on knowledge retention following CME.     

A continuing medical education lecture and workshop, physician behavior, and barriers to change.

BACKGROUND: Continuing medical education (CME) is undertaken with the intention that it will affect the practice of medicine at the level of choices made by individual physicians. Inherent in this effort is the assumption that CME is sufficient to effect a change in physician behavior. METHODS: To further examine the relationship between a CME activity and physician behavior, we conducted a study of behavior and barriers to change associated with a CME lecture and workshop on breast cancer risk assessment and treatment. Using the assessment of learning outcomes model of the International Association of Continuing Education and Training, we developed an instrument for assessing physician behavior and barriers to change. RESULTS: Throughout the United States and Canada, the instrument was administered on-site immediately after a CME activity implemented at 79 hospitals and cancer centers. It was administered again 6 months after the CME activity. There were 1,244 responses collected from 4,537 participants. This study reports the survey findings of 176 physician-paired responses to both the first and second waves of surveys. Some physicians changed their behavior with regard to performing risk assessments on all of their eligible patients. Ninety-two of the 176 physicians indicated that they had changed their practice regarding the use of tamoxifen therapy. Twenty-one physicians indicated that they were already using tamoxifen in their practice setting. Three influential barriers to change were identified: a lack of consensus among colleagues and peers, lack of time for assessment and patient counseling, and lack of reimbursement by the patient's insurance companies. FINDINGS: The CME activity was effective in changing the self-reported behavior of some physicians. Others attended the CME activity to obtain more information or to become more skilled about a procedure they had already implemented. Because of formidable barriers, it is unlikely that a single educational intervention will be sufficient to effect a change in the clinical practices of all physicians who participate in a CME activity.     

Continuing medical education: what delivery format do physicians prefer?

BACKGROUND: Although physicians are in a unique position to prevent life-threatening outcomes by counseling patients to stop smoking, many of them miss the opportunity to intervene in their patients' use of tobacco. Nicotine Dependence Across the Lifespan was developed as a continuing medical education (CME) program to teach and encourage physicians to deliver effective tobacco prevention and tobacco cessation counseling. METHODS: This CME program was offered to Texas physicians, free of charge, in three formats: live lectures, videotapes, and World Wide Web-based training. The program targeted physicians in four rural areas of Texas (San Angelo, Harlingen, Tyler, and Lubbock), where high smoking rates are prevalent and the number of professional smoking cessation services is low. We examined the sociodemographic characteristics of the participating physicians, factors in their decisions to participate in the program, and the extent to which their reported CME format preferences were associated with age, gender, race, profession, and location. RESULTS: The four factors identified--professional development, cost, personal control, and convenience/complexity--explained 76.9% of the variance describing the reasons physicians participated in the CME offering. The physicians' preferred CME format was live lectures; based on responses, this did not differ across age, gender, race/ethnicity, and location. DISCUSSION: Live lecture continues to be a preferred format of CME for physicians in four rural areas of Texas, yet research continues to show that lecture results in only the lowest level of behavioral change.     

Educational skills and knowledge needed and problems encountered by continuing medical education providers

BACKGROUND: The objective of this study was to identify the training needs and difficulties encountered by continuing medical education (CME) providers in Quebec. METHODS: A questionnaire comprised of open-ended and closed questions was sent to 224 general practitioners across Quebec who organize CME meetings. To complement and validate the data, interviews were conducted with 18 physicians selected from this group, based on their years of experience with CME, and with the managers of two organizations involved in CME. RESULTS: The questionnaire response rate was 54%. Quantitative analysis was used to identify the main training needs expressed by CME providers affiliated with the Quebec Federation of General Practitioners, namely, methods for identifying needs (74%), group leadership techniques (69%), basic principles in adult education (69%), and organization of CME activities (66%). The main problems encountered by respondents in their duties are stimulating and maintaining the interest and participation of physicians in formal CME activities (52%), identifying and meeting physicians' educational needs (32%), and motivating physicians to get involved in any kind of CME initiative (18%). The interviews highlighted the wide disparity in the approaches used by CME providers when planning activities and the failure of providers to pass on relevant information to their successors. IMPLICATIONS: Based on the difficulties and the training needs identified, we were able to develop tools (structured training program, biannual newsletter, reference books, and resources) suited to the needs of general practitioners who organize CME activities.     

Shifting the culture of continuing medical education: what needs to happen and why is it so difficult?

A revolution in health care is occurring as a result of changes in the practice of medicine and in society. These include changing demographics and the pattern of disease; new technologies; changes in health care delivery; increasing consumerism, patient empowerment, and autonomy; an emphasis on effectiveness and efficiency; and changing professional roles. The issues raised by these changes present challenges for the content and delivery of the whole continuum of medical education. The ways in which continuing medical education (CME) needs to respond to these challenges are outlined. The Informed Shared Decision Making (ISDM) Project at the University of British Columbia is used as a case study to illustrate some of the practical problems in providing CME that address these current trends in health care, is effective, and is attractive to physicians. Two particular problems are posed: how to respond to a demonstrated need when there is no perceived need on the part of physicians and how to enable change agents on the margins to develop allies and get ownership from stakeholders and opinion leaders on the inside. Two strategies for change are discussed: the substantive incorporation of CME into the continuum of medical education and the involvement of patients in the planning and delivery of CME. A final challenge is raised for the leaders of CME to define and agree what "shifting the culture of CME" means and to make a commitment of time and energy into making it happen.     

Place matters in physician practice and learning

Since the early 1960s, most discussions about the improvement of continuing medical education (CME) have begun by seeking a better understanding of how physicians learn. The goal of this movement has been to put physician learners and their learning needs, not new research findings, at the center of the educational process. This has led CME away from the update model of education and into many innovative and exciting educational developments. However, as the conditions of medical practice have been changing in the past 20 years, the possibilities and conceptions of CME have also changed. Many in medicine and CME now recognize that the real world of physician decision making takes place in a highly charged political-economic context, where the interaction between the patient and physician is perhaps the least complex element. From this fundamental starting point, an emerging discourse has begun in CME that addresses physicians' changing work environments, the accountability schemes and financial incentives built into medical practice, and the importance of physicians' community of peers in making practice changes. We need to build on these observations to change the focus from "how physicians learn" to "where physicians learn." From this new perspective, physician practice and learning are seen as fundamentally social acts, and our attention is drawn to all of the ways in which "place matters." Attention to where physicians practice and learn can be used to improve CME.     

Council ofMedical Specialty Societies: committed to continuing medical education reform

The Council of Medical Specialty Societies (CMSS) recognizes the need for continuing medical education (CME) reform and intends to be actively engaged in that process. While recognizing that CME reform must involve many organizations, the CMSS and particularly the 23 societies that make up the CMSS are in a position to affect many of the needed changes. Of these, perhaps the most important is the need to link CME to a change in physician behavior and patient outcomes. Other important tasks involve the expansion and improvement of available needs assessment modalities, the development and updating of curricula, the official recognition of multiple modalities available for physician learning, the broadening of the CME research agenda, and the need to explore alternate ways of financing lifelong learning. With the accomplishment of these reforms, medical education may finally be viewed as a continuum from undergraduate education through education of the practicing physician, and patient safety will be favorably impacted. Education will change from an episodic experience to a continuous process and one that is based on the realities of practice. These reforms will take time to accomplish and to be accepted by a profession that currently views itself as besieged by regulatory agencies and without the time and resources needed to comply with the changes.     

Need for comprehensive women's health continuing medical education among primary care physicians

BACKGROUND: The Council on Graduate Medical Education's (COGME) Fifth Report on Women and Medicine states that "changes in undergraduate and graduate medical education, in addition to continuing medical education, are needed to address adequately the comprehensive health needs of women." Primary care physicians (PCPs) who completed residency training prior to the establishment of new guidelines for women's health education are dependent on continuing medical education (CME) to update their knowledge and skills. METHODS: Primary care physicians attending a university-based CME program in family medicine were surveyed (n = 300) about their need for CME in women's health topics. Responses were analyzed using chi-square analysis and Pearson correlations. Topics of interest were compared with women's health competencies published in 1997 by the American Board of Internal Medicine (ABIM) and in 1997 by the American Academy of Family Physicians (AAFP). RESULTS: Of 30 women's health topics listed, 22 were of interest to 50% or more of respondents and 11 were of very high interest (p < .05). Respondents most interested in women's health CME were most likely to believe CME would reduce the number of referrals currently required to evaluate women's breast problems. Topics of interest also align well with ABIM and AAFP competencies in women's health. CME in comprehensive women's health care is therefore of high interest to our respondents and topics of greatest interest are identified. IMPLICATIONS: Areas of interest correlate well with new requirements by ABIM and AAFP and should be targeted by CME programs.     

American Osteopathic Association commitment to quality and lifelong learning

The American Osteopathic Association (AOA) initiated programs to enhance quality for 54,000 doctors of osteopathic medicine (DOs) practicing in the United States. Seven core competencies are required in undergraduate and graduate medical education standards. They include osteopathic philosophy and osteopathic manipulative medicine, medical knowledge, patient care, professionalism, interpersonal or communication skills, practice-based learning, and systems-based practice. The AOA Clinical Assessment Program (AOA-CAP) is a quality improvement tool for physicians to evaluate the safety of patient care. Osteopathic residents and practicing physicians measure the quality and safety of patient care using evidence-based standards through an AOA-supported, Web-based architecture. Alternative models for recertification, including a Maintenance of Certification process, are under review by the AOA, the Bureau of Osteopathic Specialists (BOS), and osteopathic certifying boards. The BOS establishes and maintains standards for the various osteopathic certifying boards and oversees matters of policy, jurisdiction, and standards review. The American Osteopathic Board of Emergency Medicine is the first osteopathic board to adopt a Maintenance of Certification process. The goals of the AOA's continuing medical education (CME) program are continued excellence of patient care and improvement of health and well-being of individual patients and the public. The AOA agrees that CME will play a critical role in recertification and continual assessment of physician competence. The AOA believes that proposed activities of the Conjoint Committee on CME and quality initiatives of the osteopathic profession are in tandem with goals and quality initiatives of the AOA.     

Teaching performance improvement: an opportunity for continuing medical education

Practicing physicians generally are not engaged in either the methods of performance improvement for health care or the measurement and reporting of clinical outcomes. The principal reasons are lack of compensation for such work, the perception that the work of performance improvement adds no value and is a waste of time, the lack of knowledge and skill in the use of basic tools for outcomes measurement and performance improvement, the failure of medical educators to teach these skills, and the inability of mentors to model their use in practice. In this article, an overview of the history of quality improvement or performance improvement in general and the adoption of two methods of improvement (Plan-Do-Study-Act and SIX SIGMA) by health care is given. Six simple tools that are easy to understand and use and could be used in every continuing medical education (CME) program are then explained and illustrated. Postgraduate medical educators and CME program directors must step up to the challenge of teaching these skills. By learning to include them in planning, evaluation, policy making, and needs assessments of CME programs, the skills of every physician could be improved. Additional goals of every CME program could be accountability for outcomes, reduction of errors, alignment of incentives, and advocacy for the very best in evidence-based health care. To develop activities that affect physician practice and population health, CME professionals must partner with performance improvement experts for needs assessment and evaluation of outcomes data. An understanding of performance improvement principles helps those in performance improvement and those in CME to determine which educational activities might be expected to influence physician competency and performance.     

Credentialing physicians: challenges for continuing medical education

BACKGROUND: Professionals involved in the regulation, credentialing, and certification of physicians around the world met in Chicago in June 2000 to discuss systems to ensure the competence of physicians. We learned that public demand for evidence of continuing competence in practice is driving the profession in most countries to explore new approaches to the education and assessment of physicians. Most groups have called the value of traditional continuing medical education (CME) into question and are exploring the use of self-directed CME methods, self-assessment, and quality improvement as the main instruments for maintenance of certification. It seems likely that teachers will be required to integrate assessment with enhancement of competencies, in much the same way that a coach uses an athlete's performance as a basis for continuous improvement. Recognizing the tough challenges ahead and the demand for CME to adapt to complement future plans for continuous assessment of physician competence, conference participants agreed to create a communication network that would facilitate information sharing and avoid duplication of research efforts.     

Attributes of an ideal continuing medical education institution identified through nominal group technique

INTRODUCTION: Continuing medical education (CME) is an important resource physicians use to maintain their clinical competence. While many options for CME programs are available, there are few measures of their impact and few measures for physicians to use to systematically gauge their efforts in maintaining competence. This study initiates a process designed to identify key attributes of an ideal CME institution, defined as one that facilitates ways for individual physicians to maintain their competence. METHOD: Using a nominal group technique (NGT), two sessions were conducted with panels of experts in the field. The NGT systematically elicits and prioritizes panelists' responses to a specific question. A larger review panel then rated the importance of each attribute. RESULTS: Panel I: Highest priority attributes: Develops programs based on gaps in healthcare outcomes (8 votes); Has ready access to performance data (6 votes); Has measurement capability that enables tracking individual practice and program performance (6 votes). Panel II: Highest priority attributes: Has adequate resources to accomplish objectives (5 votes); Conducts outcomes assessments (5 votes); Links CME and continuous improvement (5 votes); Employs staff that is able and willing to "think out of the box" (5 votes). The highest rated attributes of the larger panel were: links CME and continuous improvement; develops and promotes programs based on gaps in healthcare outcomes and evidence-based content; and has access to needs data. DISCUSSION: Using an expert panel to define the key attributes of an ideal CME institution creates a roadmap for excellence. An ideal CME institution is one that provides CME that demonstrates effectiveness in supporting physicians' efforts to maintain competence.     

Didactic CME and practice change: don’t throw that baby out quite yet

Skepticism exists regarding the role of continuing medical education (CME) in improving physician performance. The harshest criticism has been reserved for didactic CME. Reviews of the scientific literature on the effectiveness of CME conclude that formal or didactic modes of education have little or no impact on clinical practice. This has led some to argue that didactic CME is a highly questionable use of organizational and financial resources, and a cause of lost opportunities for physicians to engage in meaningful learning. The authors' current program of research has forced them to reconsider the received wisdom regarding the relationship between didactic modes of education and learning, and the role frank dissemination can play in bringing about practice change. The authors argued that the practice of assessing and valuing educational methods based only on their capacity to directly influence practice reflects an impoverished understanding of how change in clinical practice actually occurs. Drawing on case studies research, examples were given of the functions didactic CME served in the interest of improved practice. Reasons were then explored as to why the contribution of didactic CME is often missed or dismissed. The goal was not to advocate for a return to the status quo ante where lecture-based education is the dominant modality, but rather to acknowledge both the limits and potential of this longstanding approach to delivering continuing education.     

Accreditation for learning and change: quality and improvement as the outcome

Increased accountability for facilitating and demonstrating the continued competence of physicians and improvements in the quality of health care are being called for by government, the public, and organized medicine. Areas of critical skills have been identified by the Institute of Medicine, the Accreditation Council for Graduate Medical Education, and the American Board of Medical Specialties. These "competencies" serve as the framework around which medical school curricula, residency programs, and continuing medical education (CME) can be built. Much discussion revolves around the reform of CME, and the organizations most involved have developed innovative plans and initiatives to ensure that CME is optimally positioned to support physicians in learning and change. The Accreditation Council for Continuing Medical Education (ACCME) supports a new and expanded role for the CME provider in physicians' lifelong learning, including periodic self-assessment and practice performance improvement. CME providers can assist in the determination of need (self-assessment) by the physician, the delivery of education to meet that need, and the evaluation of education used to meet the need, especially as it relates to the practice performance of the physician. The ACCME, working with accredited providers, has embraced these expectations and believes that CME can meet these challenges with an approach that also expects independence from commercial interests and freedom from commercial bias. The CME enterprise is uniquely positioned to deliver effective education for learning and change.     

A community-based trial of an online intimate partner violence CME program

BACKGROUND: There is a broad need to improve physician continuing medical education (CME) in the management of intimate partner violence (IPV). However, there are only a few examples of successful IPV CME programs, and none of these are suitable for widespread distribution. DESIGN: Randomized controlled trial beginning in September 2003 and ending in November 2004. Data were analyzed in 2005. SETTING/PARTICIPANTS: Fifty-two primary care physicians in small (fewer than eight physicians), community-based medical offices in Arizona and Missouri. INTERVENTION: Twenty-three physicians completed a minimum of 4 hours of an asynchronous, multi-media, interactive, case-based, online CME program that provided them flexibility in constructing their educational experience ("constructivism"). Control physicians received no CME. MAIN OUTCOME MEASURES: Scores on a standardized self-reported survey, composed of ten scales of IPV knowledge, attitudes, beliefs, and self-reported behaviors (KABB) administered before randomization and repeated at 6 and 12 months following the CME program. RESULTS: Use of the online CME program was associated with a significant improvement in eight of ten KABB outcomes, including physician self-efficacy and reported IPV management practices, over the study period. These measures did not improve in the control group. CONCLUSIONS: The Internet-based CME program was clearly effective in improving long-term individual educational outcomes, including self-reported IPV practices. This type of CME may be an effective and less costly alternative to live IPV training sessions and workshops.     

Women physicians are early adopters of on-line continuing medical education

INTRODUCTION: On-line continuing medical education (CME) provides advantages to physicians and to medical educators. Although practicing physicians increasingly use on-line CME to meet their educational needs, the overall use of on-line CME remains limited. There are few data to describe the physicians who use this new educational medium; yet, they clearly are the innovators and early adopters who will facilitate the growth of this educational technology. It would be useful to instructional designers and CME developers to better understand the characteristics of this influential group. METHODS: We studied the actual use of several different on-line CME programs within three different groups of physicians. The on-line programs were developed as part of research studies funded by the National Institutes of Health, with no relationship to commercial interests. They were presented to physicians using mass mailouts (two physician groups) or personal contact and were accompanied by incentives to reduce resistance to the new technology. We compared the characteristics of physicians who chose to use these on-line programs with demographic data from larger populations representing the groups from which these users originated. RESULTS: We found that physicians who used these on-line CME programs were younger than average and, importantly, more likely to be female than expected. This finding was consistent across different types of physician populations and different types of CME programs. DISCUSSION: Based on data reflecting actual use of on-line CME, younger physicians appear to be adopting on-line CME more rapidly than others, and women physicians appear to be adopting on-line CME at a faster rate than their male counterparts. This latter finding conflicts with the impression provided by some survey-based studies that male physicians are more likely than female physicians to use on-line CME. The data suggest that the growth of on-line CME is most likely occurring in diffusion networks dominated by relatively new medical school graduates and, possibly, women physicians. These results provide valuable insight to those who seek to develop and market on-line CME and those who seek to reach women physicians with CME programs.     

Continuing medical education in the United States: why it needs reform and how we propose to accomplish it

As the continuing medical education (CME) enterprise evolved over the last half century, a variety of rules, national and state regulations, and reporting requirements developed, with a resultant substantial variation in what is required of a physician. That CME needs fundamental reform is not news to those who read the literature. Yet many of the physicians who are served by the current CME system are comfortable with it. Following an initial report of the Council of Medical Specialty Societies, representatives of major stakeholders in CME met voluntarily over 3 years to explore, agree on, and finally propose changes to the present CME system. Their belief in the need for change and their recommendations achieved a collegial outcome; fundamental systemwide changes must occur in CME. This involves educational methods and physician performance, particularly in self-assessment. It also involves the leadership of organized medicine in accreditation, certification, credentialing, licensure, and credit recording, reporting, and funding. The multiple parties involved who control various aspects of CME agreed to focus on the physician end user and to create a revised CME system that would allow simplified and identical reporting of the CME experience and credits for individual physicians. The system also would offer a simplified and more rational approach to credit. Recommendations and action plans to accomplish the objectives were agreed on and have been assigned to organizations according to commitment and relevant historical interest.     

A collaborative program between a school of public health and a local health department to increase HIV testing of pregnant women

OBJECTIVE: This study evaluates the effectiveness of a continuing medical education (CME) program that sought to increase HIV testing of women attending maternity clinics of the City of Houston Department of Health and Human Services (HDHHS). The CME program consisted of 14 training sessions given in 1995, 1996, 1997, 1999, and 2000. Educational objectives included increasing patient knowledge of HIV perinatal testing, increasing patient appreciation of the importance of HIV testing, and developing staff skills in educating and counseling women to accept HIV testing during pregnancy. METHODS: The CME program was based on assessment of clinician learning needs and an algorithm of the testing process, both jointly developed by faculty from the University of Texas Health Science Center at Houston School of Public Health and HDHHS personnel. The algorithm was also used to assess the care delivered. The CME was evaluated by examining changes in the percentage of women tested in the maternity clinics. RESULTS: In 1995, the year before the education program, 5.7% of women seen in the maternity clinics were tested for HIV. After the program began, testing rates rose to 64.2% in 1996, 65.5% in 1997, and 43.3% in 1998. Given the decline in testing in 1998, additional CME sessions were conducted in 1999-2000. The rate of testing rose to 62.3% in 1999 and 76.5% in 2000. CONCLUSION: Cooperative planning between university and health department personnel can create CME programs that alter provider behaviors and service delivery patterns to increase HIV testing. Outcomes need to be regularly monitored, however, to determine the need for maintenance or performance reinforcement.