The American Board of Medical Specialties’ white paper on how the continuing medical education system can support its maintenance of certification requirements, released in late January, raised concerns that it is calling for an alternative accreditation system to provide for the special needs of CME for MOC, in addition to the existing Accreditation Council for CME, American Academy of Family Physicians, and American Osteopathic Association systems.

The ABMS recognized CME as being important to the MOC—the four-part process physicians undertake to remain board-certified—in its 2009 revisions, which include a 25 CME credit requirement for Part II (lifelong learning and self-assessment). The white paper was released as a next step in the process of determining whether CME under the current systems is rigorous enough for MOC.

Thomas Sullivan, president of medical education company Rockpointe Corp., was first off the block with a February 14 post on his Policy and Medicine blog saying that the ABMS “is considering recommending to their 24 member boards [that they] set up additional accreditation systems” to cover the special needs of CME for MOC. Adding another accreditation system, he says, would require “at the very least multiple sets of paperwork, creating multiple systems of compliance standards.” The Alliance for CME’s official response also saw the call for “the development of a ‘standard currency’ for MOC CME that would … identify the special nature of CME programming that meets the identified characteristics of MOC CME” as potentially suggesting that the ABMS and/or its member boards would create a tiered system of CME, with MOC CME at the top.

“If this were to happen, then the ABMS and/or its member boards would be functioning as a secondary accreditation system,” according to the Alliance statement.

Say It Ain’t So
Nancy Davis, executive director of the National Institute for Quality Improvement and Education and a participant in the working group that explored the issues for the white paper, says that, while some read into the white paper a call for a new accreditation system, “that’s not the conclusion the working group came to at all.” Davis says that the “standard of currency” language relates to developing one set of criteria that can be used across the ABMS’s membership “so we don’t have 24 boards making 24 sets of criteria.” No one wants that, including the boards, which lack the capacity to do all that review and approval, she says. Part of the confusion may arise from the white paper’s failure to acknowledge the current accreditation systems.

Murray Kopelow, MD, the ACCME’s chief executive, says that the paper correctly articulates a set of needs and expectations that are based on age-old adult-learning principles, which are also included in current ACCME accreditation requirements. “You could go through these items and write an ACCME Criterion number next to each one of them,” he says. When ABMS mentions developing a “standard currency,” it’s simply saying it wants some way to distinguish that a CME activity meets these requirements, says Kopelow. “Maintenance of Certification has emerged as a continuing professional development system, just as the American Medical Association’s Physician Recognition Award and maintenance of licensure systems have. The certifying boards have a right to say ‘this is what counts.’” The boards would just be adding their rules on top of what the current accreditors require, just as the American Medical Association’s Physician Recognition Awards, MOL, and state CPD system requirements already do.

Kopelow adds, “If the rules were in conflict, that would be a problem, but there’s nothing in the white paper that’s in conflict with our rules. Our requirements are the right ones in the right place at the right time.”

However, says Davis, “I do think it’s good to discuss whether the CME we have now is rigorous enough for MOC to ensure the competence of physicians. I think much of it is not.” For example, while the AMA PRA, AAFP, and AOA have defined what performance-improvement CME should be, “my criticism is that there are no teeth in those criteria. No one’s enforcing them.” If the certifying boards could be assured that PI CME truly was PI CME as defined by the AMA, AAFP, and AOA, they could simply say it meets the criteria for Part IV, she says. “Unfortunately, there’s a lot out there that’s called PI CME that doesn’t meet the criteria, and there are lots of ways to get other types of CME credit that don’t ensure physician competence. That’s what ABMS is concerned about.”

Questioning Commercial Support
The white paper’s recommendation to eliminate or reduce, to the extent possible, influence exerted by commercial entities also raised some hackles. “The reality is that commercial influence in CME is almost nonexistent today” due to recent regulations and guidelines, says Sullivan. The Alliance also said the Standards for Commercial Support, as long as they are enforced, are sufficient, though it would like the working group to consider recommending the development of new funding sources as well. As Davis says, “We’re all in agreement that there needs to be no commercial bias in CME.”

Kopelow says that the white paper in fact reflected “a lot of movement, from some people saying CME for MOC cannot be commercially supported, to the place where there is room for commercial support.” He points to this statement as very important: “Commercial support may become less of an issue if educational content is relevant to practice, evidence-based, practice-based, and includes core competencies,” a statement that reflects the ACCME’s philosophy, he adds. “If you start, as they say, using a relevant, practice-based need and use evidence-based content a supporter cannot control, it doesn’t matter who pays for it.”

What About the Learners?
Some say the white paper is missing a key element. “The problem with the current CME system is that physicians are not taking responsibility for their learning,” says Pam Beaton, speaking of her own personal opinion and not that of her employer, the American College of Phlebology, where she serves as manager of continuing medical education. “If evaluations aren’t required to claim credit, the percentage of physicians who will actually evaluate the activity is not great.” She would like the MOC to encourage learners to be active participants in their CME, and perhaps require learners to participate in subsequent evaluations to receive MOC credit.

Kopelow also says he would like a next iteration to explain how all this translates into learner expectations, as well as explicitly link the ABMS’s and its member boards’ expectations and needs with the current CME system. “Right now, there’s no benefit to learners to fill out evaluations,” he says. “As soon as the certifying boards say to learners, ‘Show us that the CME you’re doing matches your scope of practice, is associated with measurements of change, and is giving you feedback about your improvement,’ those docs won’t leave the room until they give accredited providers the data.”

While some feel it contains some missteps, the white paper was also just a first step. The ABMS requested feedback on the white paper from all the stakeholders, and most expect it will continue to explore what the role of CME will be for MOC in the future.

More Responses to the ABMS white paper:
Society of Academic CME
Council of Medical Specialty Societies

Responses to Sullivan’s initial blog post:
-Nancy Davis, Executive Director, National Institute for Quality Improvement and Education
-Lewis A Miller, Principal, WentzMiller & Associates LLC,
- George C. Mejicano, MD, MS, FACP, FACME,Professor and Associate Dean, School of Medicine and Public Health, University of Wisconsin - Madison