Two major pharmaceutical companies — GlaxoSmithKline and Pfizer — recently changed their continuing medical education granting process to eliminate medical education and communication companies as prospective recipients of unrestricted grants. To many CME providers, this seems like a vote of no confidence in MECCs' ability to provide high-quality, independent, unbiased, and effective CME, compared to societies, academic centers, and others who provide accredited CME. What we wanted to know was if docs' beliefs about the quality and independence of the education offered by various provider types align with those of these major pharma players. Two-thirds of those surveyed said the quality does vary according to provider type. However, some of their conclusions on the how and why behind the variation might surprise you.

In addition to our usual questions about CME preferences, we thought it was time to get physicians' thoughts on continuous performance improvement CME. What prevents them from participating in these long-term, evidence-based series of activities that also measure improvement in physician behavior and, potentially, patient health? What do they believe would make the extra work entailed in PI CME — such as chart pulls, data entry, and follow-up activities — worth doing?

Not a Level Playing Field

When asked if they believe that the quality of education they received varied depending on the type of provider putting on the CME activity, 66 percent of the docs surveyed said it did: 21 percent said it varied significantly, 28 percent said it varied somewhat, and 17 percent said it varied minimally. Twenty-five percent said it didn't matter a whit as far as they were concerned (9 percent didn't answer the question). “A good speaker with knowledge of the topic is all that is required!” said one who didn't notice a difference between provider types.

The older folks leaned slightly toward perceiving no variance in CME quality, with 30 percent of those older than 55 not noticing a difference in quality between offerings by a MECC, an academic institution, a hospital, a medical society, or other type of provider. Of those younger than 45, just 22 percent perceived no variance, while 55 percent said that quality varied either somewhat or significantly among provider types.

So what differences did they notice? “Academic centers often provide more cutting-edge material, where medical societies provide more education/re-education on acceptable standards,” offered one respondent. Another noted, “Some of the best meetings I have attended have been offered by medical education groups, not medical centers.”

Bias did appear to be an issue, though respondents did not specify which type of provider they believe is most likely to offer education that is designed more to promote a commercial supporter's product than the educational needs of the learner. “Any CME that is funded by a pharmaceutical company is suspect,” said one person; another added, “Information funded by pharmaceutical companies cannot help but be biased.”

These commenters were balanced almost equally by those who noted that they saw the necessity for providers of whatever type to receive support from the pharmaceutical industry. “Funding attracts the quality lecturers,” said one. Others noted, “CME lectures would be too expensive” to attend without it, “hospital departments can't afford to bring in specialists without pharma support,” and “pharmaceutical support has been very helpful in improving meetings and making them more affordable.”

PI CME: Barriers and Incentives

It's been four years since the American Medical Association authorized providers to offer AMA Physician's Recognition Award (PRA) Category 1 credit for performance improvement CME, but many of the docs surveyed still didn't appear to know what it was, or confused it with traditional CME activities. PI CME is a three-stage process, with each stage offering five credits, and an additional five credits being awarded for completing all three stages (assessing current practice, implementing an intervention based on performance measures established during the first stage, and evaluating changes in performance that result). As one respondent said, “I'm not sure what it is, but I wouldn't do anything on a regular basis.” Another said the main barrier to PI CME was “the whole concept that physician performance has to be improved, when in reality it is insurance provisions that dictate what can be done for patients.”

Among those who did have knowledge of PI CME, only a few said that they already were participating. PI CME is “usually time-consuming and not very beneficial,” commented one respondent, while another said, “Performance improvement programs are worthless.” Other than lack of knowledge and a negative outlook toward PI CME, the main barrier people noted was, as one said, “time, time, and time.” Several also noted that the clerical and administrative work PI CME may entail can be a barrier, as can a dearth of access to electronic medical records and technical support that could enable the doc to efficiently track the data.

So it would seem some education and a lot of incentives might be needed to get docs to participate in PI CME. When we asked them what would make it worth their while to get involved in a continuous performance improvement activity, one had this suggestion: “Being paid $500 or more per hour.” Others had the same idea: “cash,” “financial bonuses to help defray the costs,” “reimbursement for my time,” and “nothing outside of paying me.”

While paying for participation likely will be outside the realm of possibility for most CME providers, it might help to spread the word about the AMA PRA 1 credit they can earn for doing PI CME: Outside of cash, credit was the next on the list of carrots that would get them to do the work involved in continuous performance improvement programs. Many noted that it was already required for Maintenance of Certification in their specialty, which is why they were participating or planning to participate in the near future.

Although physicians surveyed in 2008 said they planned to obtain credits through PI CME in the next 12 months, this year's respondents said they actually earned only about 1.5 percent of their credits that way. However, the percentage of those who obtained up to 25 percent of their credit hours through PI CME did go up from 2.4 percent last year to 7 percent this year, while those who received no PI CME credits fell from 94 percent to 89 percent, so it appears to be making some gains among survey participants.

CME Still Works

Despite the grumbling about the time CME takes away from their practices and the costs involved, an overwhelming 93 percent of physicians said that CME activities are either somewhat (57 percent) or extremely (36 percent) effective in meeting their needs. Six percent said they were only slightly effective, and 1 percent said they were not at all effective. Some complained that the CME activities they participated in tended not to cover cutting-edge research. Others stated they were often irrelevant to their practices, or primarily entailed reviewing basic science rather than key clinical information.

The average number of CME credit hours respondents earned over the previous year fell a bit from last year's survey — from 51 hours to 46 hours — though 69 percent said they did not earn fewer credits than in past years, while only 31 percent said they received fewer credit hours than in the past. Not surprisingly, time and money were again the culprits behind the drop for those who did earn fewer credits, with 53 percent saying they were too busy to take the time away from their practices and that participating in CME would be too costly. The next-biggest kibosh on credit earning came from a perceived lack of appropriate offerings, with 32 percent of those who earned fewer credits saying they did so because certified CME activities did not meet their needs.

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