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.

Next Page: Get Out of Town

But earning the credits still is a key driver for more than just PI CME: 93 percent said their primary reason for participating in CME activities is to obtain credit for licensure or other requirements. Still, it's not all just about the credits: 72 percent said one of their main reasons for participating is obtaining the latest clinical data regarding patient treatment-management options; and 71 percent said they do it to validate their current patient treatment-management strategies. Having a dialogue with clinical experts was important for 31 percent of respondents, and another 23 percent value the opportunity to network with peers that CME provides.

Not much changed between 2008 and 2009 when it comes to the formats respondents said would motivate them to change their behavior. The most effective format, they said, is still a lecture that includes a Q&A session, followed by case-based learning. Hands-on skill-building sessions were the next-most-motivating format, followed by consulting with colleagues, small-group interactive sessions, and lectures without a Q&A segment.

Get Out of Town

While the economy may be holding some people closer to home, out-of-town meetings still are the most popular with docs. Respondents said they received 33 percent of their credits via out-of-town meetings, and 23 percent at local meetings that don't require overnight travel.

Twice as many female as male respondents said they didn't obtain any credit hours through out-of-town activities — in fact, half the female docs surveyed said they got their credits only locally, online, or through enduring materials. The older-than-55 age range was the only one that had a percentage who reported getting 100 percent of their CME through out-of-town meetings (4 percent); those younger than 45 and those in the 45-55 age range were roughly the same in the percentage of credits they got through non-local activities.

When asked how many out-of-town meetings they attended in the past year, 28 percent said just one, 21 percent said two, and just 3 percent said more than five. Looking forward to 2010, however, only 20 percent said they weren't going to get out of town for their CME, compared to 27 percent who said the same for 2009. Those who plan to attend at least one out-of-town event also rose to 34 percent, from 31 percent; and those who plan to go to two rose to 33 percent, up from 25 percent reported by those surveyed in 2008 about their 2009 intentions. But while more docs may be planning to go to one or two, when it comes to more out-of-town meetings than that, the numbers drop from the 2008 survey: 7 percent said they'd go to three, down from 10 percent in 2008; and those who said they plan to attend four or more dropped to 5 percent from 7 percent in the previous year's survey.

What makes it worthwhile to get on that plane for CME? Location, location, location, said respondents, giving the meeting site a 5 on a 6-point scale, where 1 equals “not at all important” and 6 equals “extremely important.” The length of the meeting also was of primary concern, earning a 4.9 rating, as was the date, which came in at 4.7. Credits came in fourth, rating 4.6. Speaker reputation; not being able to find a local equivalent for the education offered at an out-of-town activity; and travel, food, airfare, and lodging costs all came in at 4.4; while reduced availability of flights, increased hassles of flying, and the ability to tie the meeting to a family vacation all rated 4.1 with survey respondents.

CME Isn't Just for Meetings

While online services came in a distant third behind long-distance and local CME activities, at 16 percent, that represents a percentage point rise from last year's survey. Journals followed at 15 percent. Along with PI CME at the bottom of the heap were audio conferences (1.9 percent) and DVDs and CDs (2.5 percent).

For those who do use online services, an average of 76 percent of the credits earned online came from Internet point-of-care (online self-directed learning), up from 62 percent last year. While those younger than 45 were more likely to get their credit through online self-directed learning than those older than 55 (74 percent versus 68 percent), the biggest adopters of Internet point-of-care learning are those in the middle: 83 percent of those 45-55 years old said they obtained a percentage of their credits through POC.

While docs may love to listen to their iPods while they're working out at the gym, they don't seem to be listening to CME on them. Less than 1 percent of online credits were earned through MP3s or podcasts, down from almost 5 percent last year. Again, the 45-55 age group was most likely to earn credits through podcasts, trailed by the under-45s. Webcasts seemed to hold steady, with respondents saying they earned roughly 9 percent of their credits through live Internet activities. In this case, though, the generational stereotype kicked in, with 12 percent of the younger-than-45 age group earning a percentage of their credit hours through webcasts, as compared to 9 percent of the 45- to 55-year-olds and 8 percent of those over 55. The number of credits earned through enduring Internet activities (i.e., pre-recorded presentations) fell to 13 percent this year, from a high of 20 percent in 2008.

Fifty-three percent said they planned to earn credits through Internet POC learning, 15 percent through performance improvement, and 9 percent through MP3s and podcasts (35 percent said they planned to get their credits through other methods; 21 percent didn't answer).

Sidebar #1: Methodology

This is the 17th Annual Physician Preferences in CME Survey. It is the longest-running horizontal study of physician preferences and participation in CME. Penton Media mailed postcard alerts on November 2, 2009, followed by cover letters and questionnaires, to 1,500 U.S.-based physicians selected from an American Medical Association file provided by KM Lists, Marlton, N.J. A follow-up mailing was sent to nonrespondents. Letters in the first mailing were affixed with first-class stamps to differentiate them from competing direct-mail pieces, and contained a one-dollar incentive and a postage-paid response envelope. We received 127 usable surveys, a response rate of 8.7 percent.

Past Performance

docs said they attended five or more out-of-town meetings in 2009 than in 2008.
docs said they attended four out-of-town meetings in 2009 than in 2008.
docs said they attended three out-of-town meetings in 2009 than in 2008.
docs said they attended no out-of-town CME activities in 2009 than in 2008.

Top 10 Factors Affecting Decision to Travel

Meeting's geographical location 5.0
Meeting length (days away from home/work) 4.9
Registration fee 4.7
Meeting date(s) 4.7
Need/desire for continuing education credits 4.6
Speaker reputation 4.4
Airfare expense 4.4
Miscellaneous costs (travel, food, lodging) 4.4
Availability of education (no local equivalent) 4.4
CME provider's reputation 4.1

Point-of-Care Most Popular

Physicians earned
of their online credits through Internet point-of-care activities.

planned to earn credits through point-of-care activities during the next 12 months.

Credit Drop

Respondents earned an average of 46 credits during the 12 months prior to the survey, down from an average of 51 credits reported in last year's survey.

36% find CME activities extremely effective in meeting their needs; an additional 57% find them somewhat effective.

Making the Case

When attending a CME meeting covering new clinical information, how effective are each of the following formats in motivating you to change your practice behavior?

Ratings are based on a 6-point scale where 6 represented “extremely effective” and 1 represented “not at all effective.”

Lectures with Q&A 4.9
Case-based learning 4.4
Hands-on, skill-building sessions 4.2
Consulting with colleagues 3.9
Small-group interactive sessions 3.8
Lectures without Q&A session 3.5
Lectures with pre- and post- test 3.4
Unstructured topic discussion 3.2