“One of my main fears is that if our CME groups do not understand what this is about, they can essentially put themselves out of business,” said Susan Adamowski, director, new assessment initiatives, American Board of Psychiatry and Neurology, Deerfield, Ill.
Adamowski was one of many presenters at the recent Alliance for CME annual conference who called on CME providers to face up to the implications of the new requirements imposed by the American Board of Medical Specialties and the Federation of State Medical Boards. Responding to the public's demand that the medical system be held more accountable for the quality of health care, the ABMS and the FSMB are rolling out new relicensure and recertification systems designed to better ensure physician competence.
We'll start with maintenance of certification (MOC). Here's the quick version: According to the ABMS' new system, rather than only taking exams every so many years, physicians have to prove a “maintenance of competency” throughout their careers and show a commitment to lifelong learning and improvement in their practices. (Note the use of the term lifelong learning — not CME. More on that later.)
Among other requirements, physicians have to demonstrate not only their medical knowledge, but their skills in areas such as patient communication. And they must evaluate their performance in their practices and show improvement. (For more information on this, visit www.abms.org.) The ABMS adopted the MOC program in 2000; now all 24 specialty boards are required to move toward the implementation of a maintenance of certification system. While the ABMS has generated guidelines, each specialty board is charged with developing its own set of requirements.
What's CME Got to Do With It?
Historically, boards have been responsible for certification, and specialty societies' turf has been education. But the new MOC system is challenging that tradition.
The ABMS and the Council of Medical Specialty Societies have raised numerous concerns about the effectiveness of CME in changing physician behavior, improving patient outcomes, and keeping physicians up-to-date. While some boards are working closely with their specialty societies in developing the MOC criteria, other specialty boards are not planning to use specialty society CME in their MOC requirements at all. Ouch.
Last year, the CMSS set up a task force on repositioning CME. Its goal was to analyze the strengths and weaknesses of the CME enterprise and to recommend and prioritize changes. The task force was scheduled to present its recommendations to the council for ratification in March. Among the recommendations: Specialty societies should set curriculum and offer physicians a means to meet the self-assessment requirements of the MOC system, and CME activities should address the ABMS core competencies.
Seize the Time
Because the boards have not yet finalized their new systems, providers have a window of opportunity to work with their boards. Don't wait, speakers emphasized. Start a dialogue about collaboration, and establish CME as the delivery mode for the MOC system.
And, as advocates for the physicians who will have to meet these new requirements, it's your responsibility to represent their concerns to the boards — and that can get sticky as some doctors view the new requirements as another intrusion into their already too-busy professional lives. To complicate matters further, since physicians are sometimes confused about the difference between the boards and the societies, they may blame societies for requirements imposed by the boards.
Ask Your Members
Despite those sensitive issues, the American College of Cardiology has succeeded in developing a collaborative relationship with the American Board of Internal Medicine — the first board to begin rolling out the new certification system.
First, the ACC conducted focus groups by phone with its members to gauge their reactions and needs. Since most diplomates were not aware of the proposed program, we had to describe it enough for them to give feedback, explained Marcia Jackson, PhD, senior associate executive vice president, education, with the Bethesda, Md.-based ACC. While some providers expressed concerns that physicians would drop their certification status rather than jump through the hoops involved in the new system, Jackson, who sat in on all the calls, said that the members surveyed thought that recertification is necessary and beneficial to them and their patients.
However, cardiologists, as members of a subspecialty, do not have to maintain certification with the American Board of Internal Medicine; they can choose to maintain only their certification in cardiology. About half of the physicians said they would not apply for recertification in internal medicine, due to time constraints, Jackson reported, although they did express regret.
The ACC also found the ABIM amenable to considering physician resistance to the system. For instance, ACC members were concerned about the validity of feedback that would be captured through the proposed phone surveys with patients. The ABIM listened, said Jackson, and said it would gather data to make sure the system was reliable and valid before finalizing the requirements.
“We asked members, ‘What can we do for you?’” Jackson continued. “They said, ‘We are very, very busy. The hardest thing for us is taking time to track down the reference materials we need to answer questions.’ They urged us to include electronic links from the ABIM's CPD [continuous professional development] modules to our education materials.” And that's exactly what the ACC intends to do.
ACC and ABIM are also discussing a collaboration agreement, Jackson said, whereby physicians can complete two of ACC's self-assessment modules in lieu of two of the medical knowledge modules required by the ABIM.
“I think there is a role for every CME provider in responding to these changes,” Jackson concluded. “Doctors who are working on certification want help. Don't see yourself just as a program planner and ‘put-er-on-er.’ You can perform a wonderful service for doctors by providing educational support. You are in a service field, that's what you are here to do — help doctors learn and practice better medicine.”
Adamowski of the American Board of Psychiatry and Neurology put it even more strongly. “Physicians are desperate for help in meeting the MOC requirements, she told providers. “If they can't get what they need from you, they'll get it elsewhere.” In fact, she said, companies are springing up to help physicians through the new system.
But I'm Not a Specialty Society
Speakers urged providers to not only collaborate with their boards, but to collaborate with other types of providers. For instance, specialty and subspecialty societies should consider partnerships with medical schools and hospitals in order to offer CME in practice settings, lessening the burden on physicians.
“This isn't just a specialty society issue,” said Donald E. Moore Jr., PhD, Alliance president; and director, division of CME, Vanderbilt University School of Medicine, Nashville, Tenn. CME is a major part of what is being called for — but it is a different CME. Is your organization set up to really collaborate with others?
Moore also addressed providers' concerns about their own increased workloads. “Maybe it's time to stop complaining about the documentation load, and look for ways to simplify within our own operations and move forward. This is a sea change in the world of CME. We are pushed into a new conceptualization of how CME is done.” And then he added: “The final question is, Who will pay for all this?”
The Accreditation Council for CME is also under pressure to make its content requirements more stringent.
“We received clear messages from the Federation of State Medical Boards, the American Medical Association, and the American Board of Medical Specialties that the content of the CME that is used for the maintenance of certification and licensure…is assumed to be valid,” said Murray Kopelow, MD, executive director, Accreditation Counsel for CME. “It was made clear to us that if our system didn't feel the same, then these organizations would find another system.”
In August, the FSMB ratified the elements of what it deems valid CME. Among the criteria: CME must be evidence-based, scientific, current, objective, and presented in an unbiased format. It also must be a credible mechanism for assuring the public of a physician's competence.
The criteria have been sent to the boards in the 50 states responsible for licensing and relicensing physicians. Currently, 39 state boards mandate CME for relicensure. Those boards are in the process of reevaluating and changing their relicensure systems.
The new criteria were also sent to the ACCME's content validation task force, which, in turn, issued a proposal for new content requirements for accredited organizations. The draft stated that “all content and recommendations involving patient care aspects…must be based on sound scientific evidence generally accepted within the profession of medicine.” The draft also said that providers would have to document the process they used to meet those standards.
Providers received the draft guidelines right before the Alliance for CME conference — and the reactions appeared to be mostly unfavorable. Besieged by criticism, Kopelow said the objections made him realize that, “We haven't explained very well what we mean.”
Mandating the Middle Road?
Several providers were concerned that the requirements would restrict them from putting on CME that dealt with new science, and off-label or unapproved uses of drugs and devices.
“I work at the National Institutes of Health,” said one attendee. “Most of the topics we concentrate on have to do with research and cutting-edge areas. There are many times where the truth as we know it has not been accepted by general physician practitioners. In the '70s, few people said that a high-fiber diet could have a positive impact on certain medical conditions, for example. This kind of approach can mandate the middle road, the lowest common denominator in CME.”
“We wouldn't want that to be the outcome,” responded Kopelow, garnering loud applause from the audience. He clarified, saying that the guidelines apply to “clinical areas that have to do with actual recommendations in practice.”
Straitjacket of Truth
Another objection along the same lines came from Morris Blachman, PhD, assistant dean, CME anddevelopment, Office of CME, University of South Carolina, Columbia, with the caveat that he was a strong supporter of the content validation principles, and that the problem may be in the language, not in the concept.
“When I think about the component in the CE process that you have called wisdom — I think of that as not just judgment, but as experience that tempers knowledge. This new requirement, as it is currently written, would wipe out use of that wisdom. The wording here [all content and recommendations regarding patient care must be based on sound scientific evidence] seems to indicate that there is a straitjacket of truth. Science is a process of validity, not truth. Science is a process where there is continuous improvement. The notion of having to be responsible for what's generally accepted science imposes a burden that is virtually impossible.”
Blachman suggested that the ACCME apply the same principles of disclosure as it does when regulating off-label discussion. “We could say ‘Look, if you're going to discuss content that is not well-accepted, your responsibility is to tell the audience.’”
But even with guidelines, CME providers should not be held completely accountable for what speakers say, he said. “There's no way for me to guarantee what every presenter is going to do. There has to be due diligence and a mechanism of good faith. For example, we talk to speakers before they come about scientific integrity and validity being critical. Our moderators are told that if somebody does something untoward or that appears inappropriate, they are to respond right there.”
Kopelow explained: “We will ask you to describe your good-faith effort at meeting the requirements. You can't guarantee the outcome.”
Just Say No
Patrick Sweeney, MD, associate dean, CME, Brown Medical School, Providence, R.I, started with his own disclosure: “As you know, I'm opposed to this. It will be insulting for me to give this to my chairman of medicine or surgery, with whom I've worked for 15 years.They're going to look at me like I'm from outer space and wonder what in hell I am doing. They already think a lot of the things we require them to do are ridiculous.
“Having worked with the ACCME for many years, as a surveyor, and for the past six years with the Accreditation Review Committee, I'm disappointed that the ACCME doesn't have enough faith in the system that we have worked so strongly to implement,” Sweeney continued. “And when these organizations, like the AMA, the ABMS, and the CMSS, come to you and say ‘Your providers are going to have to prove that this information is generally accepted practice,’ I'd wish you'd say ‘No.’” Once again, attendees applauded.
“We did say no,” answered Kopelow. “We said we're not going to create a system where Patrick Sweeney has to go to his department of medicine and say ‘You have to provide me with the evidence that everything your speakers say is true.’ That idea was ridiculous.”
Adding Insult to Injury
Sweeney wasn't the only provider to feel that the proposal was an insult. Melinda Steele, director, CME, Texas Tech University Health Sciences Center, Lubbock, said, “The day the content validation information came, I made the mistake of taking it to my committee immediately because I wanted to keep them informed. The reaction was just short of violence. It's not that they object to content validation, the objection is a logistical one. ‘You expect me now to document what we are already doing, and I, as a course author, am not going to spend the time to give you all of the documentation. You as the CME office can do it.’ My office doesn't have the time or ability to do that. That's where the objections come from, beyond the insult that the academics feel. When you're attacked, and the violence occurs — I felt that I was in your shoes Murray.”
Replied Kopelow, “It was not intended that those people have to document anything and give it to you. It was intended that they would say “I'm glad I'm meeting muster already, and this is how I practice medicine and education.'” Kopelow reiterated that most providers were already meeting the new requirements. The comment period ended March 9; the task force is now analyzing the feedback.
Take Action Now
Here are recommendations speakers and attendees made concerning the maintenance of certification (MOC) system mandated by the American Board of Medical Specialties.
View the MOC mandate as an opportunity to support your members, revision your CME, and position CME as a critical component of the new system.
There is still is a lack of awareness in the CME community about MOC: Educate your CME committee.
Meet with your respective certification board and aim to establish a collaborative relationship. Open communications regarding your members' concerns as well as the role your CME program can play in implementing the new requirements.
Create partnerships with other CME providers in a variety of settings.
Reflect on how the mission of your CME program might parallel the definition of a competent physician.
Compare your current CME curriculum to the ABMS six general competencies. Look at gaps that may lead to new programming opportunities.
Research specific MOC requirements for physicians in specialties your serve, and create relevant education activities.
Don't think of MOC as an added layer for your CME; rather integrate it into the fabric of your program.
Seek opportunities to measure outcomes related to physician practice improvement.
Promote content that relates to competencies. Wheneducation activities, list as part of the subtitle which core competency the activity addresses. This will help physicians document evidence of their commitment to lifelong learning.
This is a great opportunity to restructure and improve your annual conference, said one specialty society provider during a breakout session. But the new MOC criteria shouldn't dictate everything you do; as another attendee pointed out, “Just because we don't meet the criteria at our annual conference, doesn't mean we shouldn't do the annual meeting.”