How the changing face of CME will affect internists
By C. Anderson Hedberg, FACP
The face of continuing medical education (CME) is undergoing dramatic change, a trend aptly demonstrated last fall at a summit meeting of the Council of Medical Specialty Societies.
The group, which represents the major medical specialty societies in American medicine, held a symposium to look at ways to reform and reposition CME.
The preface to the summit agenda noted that a commitment to continuous learning is an integral part of our professional values: "The individual physician is responsible for the commitment, with assistance from the profession's institutions, which ensure the physician's access to the resources required to continue professional growth and learning."
Judging by some of the information reviewed at that summit, however, American medicine is doing a less than stellar job when it comes to educating physicians, a problem that hurts the overall quality of care. Meeting participants made that point by citing recent literature documenting some major deficiencies in our health care system.
The Institute of Medicine's 2001 study, "Crossing the Quality Chasm," for example, concluded that American health care needs to be redesigned to deliver safer, more effective and more equitable care. An article published in the June 26, 2003, issue of New England Journal of Medicine found that only about 55% of recommended care was being delivered across various conditions and treatments.
Still other studies have shown large gaps between when important medical advances are introduced and when they are widely incorporated into clinical practice.
Exactly what changes do we need to make to CME to be sure physicians stay on top of their game—and patients get the high-quality care they deserve?
At the summit, Robert Graham, MD, acting deputy director of the Agency for Healthcare Research and Quality, addressed that question by exploring the cycles in which physicians capture, assimilate and then apply a new piece of evidence-based knowledge.
The first part of the equation, Dr. Graham explained, is getting the attention of physicians so they ask themselves this simple question: Did I know that?
In the past, that was as far as the CME process went, and it was rarely followed up with any formal testing. In the evolving paradigm of CME, however, physicians will have to answer several additional questions that may include the following:
- Did you adopt the evidence in your practice?
- Did you incorporate it into your care of patients?
- Did you assess your outcomes?
- If the results had the desired effect, did it become a standard of care?
To answer these questions and complete this new CME cycle, physicians will need performance measurement techniques they can apply in their practice. The results of these measures can then be used to prove to physicians, patients and payers that we are engaged in high-quality medical care.
The good news is that some educational tools are already reflecting the new CME paradigm and can help physicians meet new educational goals.
As I mentioned in last month's column, broader requirements for recertification are being put in place by the American Board of Medical Specialties and its member organizations, including the American Board of Internal Medicine (ABIM). These requirements are based on six competencies: patient care; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; systems based practice; and professionalism.
Measuring CME activity will change from tracking credit hours as "seat time" to a new metric that will include processes and outcomes of patient care.
The new CME processes will complement these requirements—but incorporating CME into the recertification process is only the beginning. Point-of-care and "just-in-time" learning using electronic educational resources in the office and at the bedside, for example, will soon become more prominent. Episodic education will be replaced by an environment of frequent self-assessment, continuous maintenance of competence and lifelong learning.
CME activities will soon focus on skills such as system improvements in office practice, working in interdisciplinary health care teams and professionalism.
And measuring CME activity will change from tracking credit hours as "seat time" spent at meetings to a new metric that will include processes and outcomes of patient care. The goal will be to improve the quality and safety of medical care and prepare medical professionals for recertification, relicensure and recredentialing.
How ACP is helping
At the summit, John Tooker, FACP, the College's Executive Vice President and Chief Executive Officer, explained how the College is in a key position to meet the changing nature of CME.
For more than 30 years, for example, ACP's Medical Knowledge Self-Assessment Program (MKSAP) has helped internists stay current. The ABIM's decision earlier this year to give credit for completing specially configured electronic MKSAP modules as part of its self-evaluation process (SEP) is a recognition of MKSAP's relevance to continuous learning. (More information is online.)
And to help internists with ABIM's own SEP modules for recertification, the College has developed online links to those modules, guiding internists to educational material derived from its own sources.
The Web-based Physicians' Information and Education Resource (PIER) provides evidence-based material geared to point-of-care information and learning. PIER can be readily incorporated into electronic medical records as a source of clinical information and decision support.
The electronic medical record will be an important tool for measuring clinical performance, and the College has a seat on several national committees charged with developing health information technology and performance measurement standards. ACP officials are keenly aware that these systems must be efficient and not place excessive burdens or expense on our members.
The Practice Management Center is developing templates to help internists document performance measures through chart review. The idea is to give members the tools they need to measure performance until they put electronic medical records in place.
ACP's QNet initiative allows internists to conduct simple chart reviews in their office on certain clinical conditions. They can then compare their results with prescribed standards.
And the College's "Closing the Gap" program works with physician offices to improve their in-house system of delivering diabetes care.
Even as we develop new ways to earn CME credits, ACP will continue to hold traditional recertification courses that allow internists to complete SEP modules. And the annual and regional scientific meetings will continue to serve as a rich source of clinical information.
Improving patient care
Overall, I believe these changes in the philosophy and format of CME will eventually make acquiring new information more efficient and lead to better patient care.
We all know that our most active learning occurs when we have a patient who needs our knowledge, experience and judgment to solve a clinical problem. New information will be close at hand and immediately accessible. And while measuring our performance will never tell the whole story of our clinical expertise, it will highlight areas where we can do better.
All of these efforts will help fulfill the basic drive that brought many of us into clinical medicine in the first place: to give patients the most scientifically correct and compassionate care possible.
Correction: The President's Column in the June ACP Observer misidentified the gender of P. Preston Reynolds, FACP. She is chief of the primary care medical education branch in the HHS' Health Resources and Services Administration in Rockville, Md.
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