“The Politics of CME are overwhelming. If you ignore them, you won't be successful,” said Joseph Green, PhD, founder and president of Professional Resource Network, Chapel Hill, N.C., at the opening plenary session of the Alliance for Continuing Medical Education 2007 Annual Conference, held in Phoenix in January. After making what was once a rare acknowledgement that managing an effective program depends on more than just following the rules and applying adult-education principles, Green and panelists representing a spectrum of CME organizations spoke frankly about the roles politics and economics play in CME.
Ronald Cervero, PhD, professor and department head, University of Georgia Department of Adult Education, Athens, Ga., and co-author of Working the Planning Table: Negotiating Democratically for Adult Continuing, and Workplace Education, said, “One of the great disabling myths is that we have two sides: one for patient needs and the other for politics and economics. We'd go to sessions [at CME professionals' conferences] and learn about outcomes measures and needs assessments, then go into the hallway and talk about what's really going on. I'm glad to see we've moved from the hallway to the plenary session: Economics and politics are a part of where we live.”
Collaborate or Die
The primary message of Cervero's book (written with Arthur L. Wilson, published by Jossey-Bass, 2006) is that providers must apply democratic principles to the CME process, involving all the stakeholders and balancing their interests. Providers have to go beyond addressing needs assessment and content and also manage the social and political relationships among different players. This can be quite complicated, as there are myriad stakeholders in CME, from physicians and providers to hospitals, health systems, pharmaceutical companies, and patients, and there is a power differential among all these groups.
When managing the politics of partnership, it helps to determine which type of collaboration you are developing: consultation, where common interests outweigh conflicts; bargaining, where there are both common and conflicting interests; or disputes, where conflicting issues outweigh common interests. And you do have to do this now, Green added, because, practically speaking, the Accreditation Council for CME requires successful collaboration under its new accreditation criteria. For example, for a hospital to create a grand rounds activity based on patient care quality data, the provider must involve patient safety and quality improvement offices, the pharmacy and therapeutics committee, and the department chair coordinator. “We need to collaborate,” said Green, “if we don't want to become irrelevant.”
The speakers used democratic principles to design the session, by developing a list of strategic imperatives and asking conference registrants to vote on which were the most important. (See sidebar, left.)
Under the first category, “Advancing the CME Profession,” participants selected “provide support and training in the updated accreditation criteria of the” as the most important issue to tackle. As Green had noted, collaboration is an essential aspect of implementing the new criteria. Karen Overstreet, EdD, RPh, president, Indicia Medical Education, North Wales, Pa., said, “These new criteria give us a great opportunity to identify our own competencies” and promote them to new potential partners.
But the level of collaboration required by the new criteria is causing some consternation among providers, said Harry Gallis, MD, director, Charlotte Area Health Education Centers, Carolinas HealthCare System, Charlotte, N.C. “I had to spend some time trying to talk a CME provider down out of the trees. Many of us have complex systems in which we work, with stakeholders from the top administration to physicians and others in the healthcare network.” He also questioned why, given the obvious synergies, “Quality improvement staff and patient safety officers aren't knocking on our doors asking, ‘How can we integrate CME into our QI efforts?’”
Regarding the need for training, ACCME's chief executive, Murray Kopelow, MD, assured attendees that the ACCME planned to continue to provide education in the new criteria through workshops and sessions. All the panelists acknowledged that training has to move far beyond traditional accreditation requirements to focus on adult learning and quality improvement, and that all pro-vider types bring something to the table.
Share the Data
In the second category in the strategic imperatives list, “Designing Appropriate CME,” participants chose “base CME on appropriate assessment of physician knowledge and performance, healthcare quality, and patient safety” as the most important topic.
Providers should share their resources in order to improve overall patient care, said Marcia Jackson, PhD, senior advisor, education, American College of Cardiology, Washington, D.C. For example, national specialty societies have national needs-assessment data, which they can make available to local providers. Societies also have a second role: developing valid measures that can be used to evaluate physician performance, she said. “Many have already developed these, and they should share them with the CME community.”
Continuing the theme of collaboration and information-sharing, George Mejicano, MD, assistant dean for CME, University of Wisconsin School of Medicine, Madison, said, “The time has come when we can no longer talk about education for education's sake. [Teaching hospitals] have to integrate into quality assurance/quality improvement — we can't afford to sit on the sidelines. We have to be able to show we can make a difference.” Before providers can work with these other departments, though, “we have to openly share data and confess what we do well and what we don't do well. For example, how well do we do educating nurses and pharmacists in our activities? QI may do that better. While we might be terrific with meeting planning and educational design, how much do we know about Six Sigma [a quality-measurement system]? We have a lot to learn from our QI colleagues. A lot of what they deal with — such as medical errors — are highly confidential. We have to earn their trust,” he said.
In addition, providers no longer can be happy with ‘anonymous learners,’ Mejicano said. “We have to follow learners over time, and give feedback to them, and continuously learn from them across the continuum.” One way to get there, he said, was to tap into existing databases that monitor hospital and health-system performance.
In the third topic category, “Ensuring the Validity and Responsiveness of CME Content,” the vote went to “ensure that CME content reflects the changing realities of medicine.” Among those changing realities are an aging population, the healthcare requirements of minority patients, gender healthcare issues, the newly empowered patient consumer, and new genetic diagnostic and therapeutic tools.
Mejicano pointed to a recent Institute of Medicine report that suggested up to 20 percent of physicians should have degrees in public health. “We need to diversify our activities [to reflect] the public health issues. Look at how medical school curricula have changed. You're going to have learners who are asking if a therapy will work for a population with a certain genetic structure.” CME providers should study the changing curricula of university and graduate medical education, including topics such as the importance of population health and the promise of genomics and proteomics.
The ACC's Jackson said that thinking about changing content to fit new realities makes her “begin to freak out. I don't have a clue about how to do this. We really ought to be developing more team-based education. But, if we do it, will anyone come?” She said that her society has already added a new category of membership for nurses and plans to add physician assistants and pharmacists as well. A similar dilemma comes with education about things like genomics, she said. “If [healthcare professionals] didn't grow up with it, their eyes glaze over. We may see some of where we need to go, but what if we build it and they don't come?”
Maureen Doyle-Scharff, director, health education, Ross Products Division, Abbott Laboratories, Columbus, Ohio, said industry has a role to play in this area. “CME providers ask us if they can use our data — I challenge commercial supporters to look at their resources and see if they can open some doors.”
Pharma companies must link their educational objectives to their commercial outreach when it comes to serving seniors, minorities, and other groups at a healthcare disadvantage. “Don't ignore pharmacoeconomic data — we're moving toward having the right medicine for the right patient at the right time at the right price,” she said.
Summarizing the discussion, Cervero said, “We need to put [all the issues] all on the table. But it's not enough just to see — we have to do. We have to recognize all the power relationships.”
It will become increasingly important for CME providers to have three skill sets, he said: technical skills, such as budgeting and needs assessment; political and organizational strategic skills; and the ability to represent all of the stakeholders' issues. “It's messy, but it's critical,” he said. “Plan CME responsibly, think politically. It's the only strategy that's going to get us where we need to go.”
CME's 12-Step Program
While interactivity was a little difficult in a ballroom full of about 1,800 participants, the plenary session speakers at the Alliance for CME annual conference did their best to involve the audience. They came up with 12 strategic imperatives for the future of CME, divided among three larger categories. They then e-mailed the imperatives to a sample of the registrants ahead of time, and asked them to vote on the relative importance of each of the 12 ideas. During the session, the panelists discussed the top three — one from each category — from the perspective of their particular niche in the CME community. The result, many who attended said, was the most enlightening, and most real, session they had ever attended.
Here are the 12 strategic imperatives:
Advancing the CME Profession
1 Identify the causes and solutions to the marginalization of CME offices.
2 Develop an educationally sound and competency-based curriculum for staff and physicians involved in CME.
3 Train the next generation of CME leaders.
4 Provide training and support in the updated Accreditation Council for CME accreditation criteria.
Designing Appropriate CME
5 Ground CME in adult- learning principles.
6 Base CME on appropriate assessment of physician knowledge and performance, healthcare quality, and patient safety.
7 Alter current formats and methods to better meet the needs of individual, self-directed physician learners.
8 Work collaboratively with others also involved in training physicians across the continuum of medical education.
Ensuring the Validity and Responsiveness of CME Content
9 Ensure that CME content reflects the changing realities of medicine (e.g., aging population, gender issues, minority patients, globalization of healthcare and medical education, prospective healthcare based on study of genetics).
10 Make CME content responsive to competencies and curricula being created by the medical boards and specialty societies for their physician members.
11 Protect the integrity and validity of CME content by developing effective conflict-of-interest resolution processes.
12 Diversify CME funding sources.