ABSTRACT
To provide the best care to patients, a physician must commit to lifelong learning, but continuing education and evaluation systems in the United States typically require little more than records of attendance for professional association memberships, hospital staff privileges, or reregistration of a medical license. While 61 of 68 medical and osteopathic licensing boards mandate that physicians participate in certain numbers of hours of continuing medical education (CME), 17 of them require physicians to participate in legislatively mandated topics that may have little to do with the types of patients seen by the applicant physician. Required CME should evolve from counting hours of CME participation to recognizing physician achievement in knowledge, competence and performance. State medical boards should require valid and reliable assessment of physicians' learning needs and collaborate with physician and CME communities to assure that legislatively mandated CME achieves maximal benefit for physicians and patients. To ensure the discovery and use of best practices for continuing professional development and for maintenance of competence, research in CME and physician assessment should be raised as a national priority.
Commitments to continuous learning and practice improvement are fundamental to every physician's professional life;1 yet a complex system of continuing medical education that currently values passive attendance equally with measured achievement continues to flourish in the United States.2,3 This article examines the tentative nature of linkages between medical licensing requirements and evidence for the effectiveness of continuing medical education (CME) participation, the abilities of physicians to self-assess, and policymaking in CME. In the process, conclusions are reached and recommendations are made about medical licensure and its relationship to physician learning and competence.
Currently, 61 of 68 medical and osteopathic licensing boards mandate that physicians participate in a certain numbers of hours of CME, as a condition for reregistering their license to practice medicine. Although jurisdictional requirements may vary from state to state, most simply require a number of hours of CME to be completed annually to satisfy licensure needs. Hourly requirements range from 12 hours in Alabama to 50 hours in a few states.4
Of the 61 jurisdictions that require CME, 16 states and one territory require participation in topics that are legislatively mandated.4 For example, to qualify for a medical license, all physicians in Florida must complete a one-hour CME course on human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS),5 and in Iowa, internists must complete two hours of CME on dependent adult abuse.6 As a consequence of these requirements, many physicians may be participating in CME in areas in which they do not need to perform competently within their current scope of practice. It is unclear how much CME is the “right amount” to change behavior and over what period this CME must be completed. Further, it is unclear as to the value of the specific selected topics, as they relate to physician performance and medical care, when the topics may be unrelated or relate only generally to the patients a physician sees in practice.7
EVIDENCE FOR THE EFFECTIVENESS OF CME AND SELF-ASSESSMENT
The evidence observing relationships of CME participation to change in practice is complex and varied in quality, with several findings repeating themselves. For example, to be effective, CME should be based upon assessed need;7 yet physicians show limited success with self-assessment.8 The processes currently used to implement professional development and evaluate competence should focus on external assessment.8 Also, CME formats should be interactive9 and should include multiple interventions over time.9,10
In 2001, an overview of systematic reviews of interventions intended to change provider behavior suggested that passive approaches (e.g., reading and didactic lectures) are generally ineffective in changing physician behavior.11 In 2004, a systematic review12 studying clinical guideline dissemination and implementation strategies included more effective alternatives to traditional CME formats, including single interventions such as reminders, educational materials and audit and feedback. Multifaceted interventions often included educational outreach in combination with other interventions: here, the majority of interventions observed modest to moderate improvements in care.12 While a recently reported systematic review evaluating the effectiveness of CME (1981–2006)13 judged many studies of CME effectiveness to be poorly designed, the most rigorous studies suggested CME using multiple formats and methods can be effective in changing the knowledge, attitudes, skills, behavior and clinical outcomes of practicing physicians.13
CHANGES IN CME, ACCREDITATION, CREDIT AND CERTIFICATION
A shift in thinking is occurring—away from the hourly system of award for attendance toward a credit system that recognizes active participation, learning, competence and performance.14–16 Organizations including the American Academy of Family Physicians (AAFP), the American Medical Association (AMA) and the Association of American Medical Colleges are working to determine national standards for professional development, encouraging continuous improvement through audits of patient care, feedback of performance data and follow-up measurement to compare pre- and postperformance, as well as performance benchmarked against similar practices and panels of patients. Since 2002, the Conjoint Committee on Continuing Medical Education, an ad hoc group of representatives from 16 major stakeholder organizations (see Table 1), has endeavored to integrate performance improvement into CME, ensure the content validity of CME and evaluate the effectiveness of CME in improving the quality of care.
Organizations Represented on the Conjoint Committee for Continuing Medical Education
In 2004 and 2005, the AMA and the AAFP introduced two new forms of CME credit. By being more connected to a physician's practice, they have the potential to ensure the public that physicians are continually assessing and improving the care they deliver to their patients. Point of Care CME15 reinforces the learning experience by relating it to an immediate patient problem within the context of the physician's practice. Performance Improvement CME15 begins with audits of the physician's patient records, provides feedback based on national benchmarks, compares the physicians' performance to peers', offers educational interventions to improve documented performance and remeasures the physician's performance after an appropriate period.
The American Board of Medical Specialties (ABMS) recently introduced its Maintenance of Certification program. 3 To maintain board certification, physicians must demonstrate that they are participating in practice-based learning and improvement and that this continuing education is leading not only to improved practice procedures but also to improved outcomes for patients.
Similarly, in 2005 the Clinical Assessment Program (CAP) of the American Osteopathic Association was extended from graduate education to practicing physicians. The CAP is a Web-based performance measurement program that analyzes data abstracted directly from patient charts. Three sets of measures, Diabetes, Coronary Artery Disease and Women's Health Screening, were developed using evidence-based guidelines for standards of care and tracking patient outcomes in order to improve the quality of care.17
In 2007, the Accreditation Council for Continuing Medical Education (ACCME) introduced new criteria for CME provider organizations to achieve accreditation with commendation. Under this model, the participant's knowledge, behavior, or practice would be evaluated subsequent to participation in CME to assess whether any change in patient care outcomes had occurred and what impact the CME had on the participant's deficiencies.18
RECOMMENDATIONS
Learner-focused CME with measurable outcomes enhances the medical profession's emphasis on core competencies, training and assessment and satisfies the public's expectation for maintenance of physician competence. CME has the potential to be a viable tool for use in ensuring ongoing physician competence if it is part of a system of continuous professional development that includes assessment, remediation and reassessment, all essential components for improved CME and health care performance. In reviewing the linkages between licensing requirements and effective CME, assessment and policy, the following directions are recommended:
Required CME should evolve from counting hours of CME participants to recognizing physician achievement in knowledge, competence and performance.
State medical boards should require valid and reliable assessment of physicians' learning needs and the provision of education that enables physicians to improve their knowledge, competence and performance in the delivery of care.
The physician and CME communities should collaborate to provide resources for working with legislators and state medical boards in assuring that legislatively mandated CME is achieving maximal benefit for physicians and patients alike.
Research in CME and physician assessment should be raised as a national priority, eventually allowing for greater uniformity of CME for licensure requirements, as well as creating best practices for physician continuing professional development and maintenance of competence.
Lessons for Practice
State medical boards should require valid and reliable assessment of physicians' learning needs.
CME planners should create learning activities on the basis of the assessed practice needs of physicians.
Planners and policymakers should raise research in CME and physician assessment to a national priority.
CONCLUSION
While there is evidence to suggest the contexts of professional practice and of learning influence the outcomes of education and care, interventions to produce the right outcome every time with every physician or patient have not been observed. Education and care remain largely individualized practices involving thoughtful assessment of changing needs expressed and addressed through multiple interventions with interaction facilitated over extended periods. States should require valid and reliable assessment of physicians' learning needs and the provision of education that enables physicians to improve their knowledge, competence and performance in the delivery of care. State medical boards can be proactive by fostering educational consortia involving them, medical societies and academic medical centers to create a culture of learning and improvement that features the best in current CME practices.19
ACKNOWLEDGMENTS
This article is being published concurrently in Volume 28, Number 2, of the Journal of Continuing Education in the Health Professions, a journal that is owned by the Alliance for Continuing Medical Education, the Society for Academic Continuing Medical Education and the Council on CME, Association for Hospital Medical Education.
- Copyright 2008 Federation of State Medical Boards. All Rights Reserved.
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