There are four key policy and scrutiny trends facing today’s continuing medical education community, according to a white paper released this past fall by Littleton, Colo.–based Global Education Group. These are incorporating adult learning principles into CME, producing better outcomes, heightening CME regulations and enforcement, and addressing conflicts of interest. The white paper also recommends some ways to move forward from what the authors call CME’s “crossroads” status.

“CME Crossroads: A Survey of Continuing Medical Education Analysis, Criticism, Research, and Policy Proposals” summarizes an analysis of more than 100 articles, research studies, and policy proposals published over the past five years. It was peer-reviewed by representatives of major players in continuing medical education.

Trend 1: Adult Learning
The call to incorporate adult learning principles in CME comes through clearly in the literature cited in the report, from articles in journals such as Academic Medicine, to the American Medical Association’s insistence that CME should “advance the science of adult learning in medicine” in its Council on Ethical and Judicial Affairs Industry Support of Professional Education in Medicine (Report 1-A-08). The white paper also points out the inclusion of “adult/organizational learning principles” in the Alliance for CME’s key competencies and associated skill sets. The paper notes that the Accreditation Council for CME also emphasizes incorporating adult learning principles in its 2006 updated accreditation criteria, and its 2008 “CME as a Bridge to Quality” publication also stresses that adult learning principles are essential to improved quality.

The CME community appears to be heeding the call. The study points to the National Commission for Certification of CME Professionals’ development of the Certified CME Professional designation—which more than 250 people have earned since its launch in 2008—and faculty training initiatives by the Society for Academic CME and the Alliance for CME. Another indicator, it concludes, is the rise in performance improvement CME, though the jury is still out on whether PI CME is either effective or cost-effective.

Trend 2: Better Outcomes
The point behind incorporating adult learning principles is to achieve better outcomes for CME efforts, which is the second trend the white paper notes. The AMA, the Alliance for CME, and individual CME leaders offer some ideas on how to improve outcomes methodologies. Documenting improved outcomes also is an important trend moving forward, as is determining practice gaps that future activities could address. Many papers were written on this over the past five years, including a much-discussed article published in 2009 in The Journal of Continuing Education in the Health Professions in which Donald Moore and his co-authors suggested that CME activities should be built with outcomes in mind. In fact, more than half of the ACCME’s accreditation criteria now in some way touch on outcomes-related issues, the paper notes. Other indications of this growing trend are the rise of outcomes-specific journals and organizations dedicated to outcomes measurements.

Trend 3: Regulations and Enforcement
CME began moving away from its former “Wild West” status and toward a stricter regulatory framework just before 2005, the study notes, “resulting in what was to become a radical transformation of the way in which CME is managed.” The study authors point out that many of the “egregious, albeit rare, examples of unethical behavior” discussed in the literature of the past five years happened prior to the building and strengthening of this CME regulatory framework, and some of the commentary about “medical education” confuses CME with promotional activities. Regulatory efforts include the ACCME’s 2005 implementation of its updated Standards for Commercial Support, its 2006 accreditation requirements update, implementation guides, FAQs, other redefinitions, and proposals for additional changes.

The new rules and regulations came so quickly and frequently over the past five years that some accredited providers found it difficult to keep up, the study finds, and some declined to renew their accreditation or became ineligible to renew it. This rapid rate of change hasn’t silenced the critics, however, who said at a 2007 conference sponsored by the Josiah Macy Jr. Foundation that accrediting bodies still have much to do to enforce the rules. The Senate Finance Committee, led by Chairman Max Baucus, D-Mont., and the 2009 Institute of Medicine’s report on “Conflict of Interest in Medical Research, Education, and Practice” also questioned the effectiveness of the regulations and regulatory bodies in ensuring CME remains fair and balanced.

Trend 4: Conflicts of Interest
Many trees died between 2005 and 2010 for the sake of COI discussion, the study found. Among the bones of contention were how to identify and resolve COI. Most of the literature, it says, defines COI as physicians having financial relationships with industry that could unduly influence them. Most also recommend the two-step process of disclosing COI, then finding ways to either resolve or manage it. The study points out that the literature on COI often commingles certified CME with promotional activities. CME also is often lumped together under a general “education” umbrella, which also could cover everything from grants for clinical research to samples given to docs.

The COI literature, the study says, looks at four main questions: whether certain types of providers are more prone to having conflicts that lead to bias than other types of providers, the feasibility of eliminating COI by eliminating industry support of CME, what exactly bias is, and the willingness to come to conclusions without supporting evidence. The CME community has been addressing these issues by trying to produce some hard evidence on COI and CME, including recent studies by Medscape and the Cleveland Clinic that found no proof that industry support of CME inherently brings bias into an activity. It also cites a number of quality-improvement indicators tied to this trend, from ACCME requirements that all conflicts be disclosed and resolved; to pharmaceutical companies developing separate CME departments to handle all grant requests; to more transparency from industry, ACCME, and providers around their COI-related policies and procedures.

Moving Forward
The literature, the study concludes, shows that the CME enterprise has been quick to react to criticism, and recommends that it become more proactive by widening the discussion to include everyone who touches the CME community, from physicians and faculty to patients, providers, and commercial supporters. It also recommends that both CME proponents and those who believe the system is broken should rely on evidence and data for future discussions, that all involved should give the changes over the past five years some time to take effect before judging the effectiveness of these changes, and that CME stakeholders should educate others on the current system’s safeguards and goals for improving CME quality.

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