For a typical physician who will practice medicine for 30 to 40 years over the course of his or her career, assessments, treatments and procedures learned in medical school and residency quickly become outdated with advances in medicine and technology. To facilitate the continued integration of new advances into patient care, the medical community follows a system of continuing medical education (CME).
Certified continuing medical education (CME) is defined as education that is planned, implemented, and evaluated in accordance with the Accreditation Council for Continuing Medical Education (ACCME) nationally mandated accreditation policies for all accredited CME providers.
CME is recognized as an essential part of continued professional development for physicians and a key resource in ensuring both the quality and effectiveness of health care delivery. CME is so important for health care quality and patient access that many states mandate CME as part of physician licensing requirements.
CME takes many forms, including live and Internet-based course instruction, lecture series, and publications. Hundreds of organizations participate in providing CME opportunities, and several hundred thousand physician and non-physician participants engage in multiple accredited CME activities each year. Accredited CME providers are committed to the integrity of information that is provided to physicians as part of certified CME activities and have taken critical steps over the past several years to increase transparency, strengthen accreditation guidelines, and monitor and enforce policies.
Moreover, CME plays a vital role in the delivery of innovative health care to American patients. The rapid pace of scientific discovery and innovation increases the need for CME as a means of communicating advances to medical practitioners and patients.
Today, much of this education is underwritten by life sciences companies that recognize the value in broadening awareness of disease states, standards of care and new therapies. However, the percentage of industry funded CME is decreasing each year, which will have a tremendous impact on training and patient outcomes. Despite the existence of rigorous standards that ensure that all certified CME curricula be evidence-based and free of bias, there still remains a misinformed perception that CME can be tainted by industry support.
Consequently, a new group, the CME Coalition, formed to address these issues. The mission of the CME Coalition is to:
- Educate federal policy makers on issues related to the provision of CME,
- Monitor state policy initiatives that could adversely impact CME, and
- Advocate for sensible federal and state policies to advance its practice. The CME Coalition will fulfill this mission by developing, managing, and implementing a government affairs and public relations strategy to further the interests of CME on Capitol Hill, with the Administration and among the states.
Meeting its mission, the CME Coalition recently held its first of two informational policy briefings on Capitol Hill. The meeting, which took place in the House of Representatives Rayburn Building included:
- Dr. Jonathan Sackier, Professor of Surgery, University of Virginia
- Dr. Charles M. Balch, MD, FACS, Professor of Surgery, Division of Surgical Oncology, Dept of Surgery, University of Texas Southwestern Medical Center; and
- Dr. Dana Simpler, Family Doctor & Internist, Mercy Medical Center, Baltimore
The second meeting took place on the Senate side and discussed CME issues and HIV.
Dr. Sackier, a surgeon with over 120 peer-reviewed articles, authorship in 7 textbooks on surgery, and the inventor of various surgical equipment and medical devices, noted how he came to America from the United Kingdom because he did not like what was going on there with regard to physician-industry collaboration.
Dr. Sackier gave a brief introduction about CME and the issues the CME community face as well as the broader healthcare climate. Sackier also pointed out the present atmosphere surrounding CME, particularly CME with industry support. He asserted that there has been a significant overreaction by people about industry supported CME that has demonized good people who are seeking to educate their peers and improve patient outcomes, all of which reduce health care costs.
He also noted how CME is not alone in its attack, and that day-to-day interactions and good promotional practices are being criticized as well as payments for true innovation and collaboration between physicians and industry for clinical research, education, and consulting.
Dr. Sackier also took issue with the fact that critics of industry believe there is an “inherent conflict of interest” when any support from industry in any kind of educational program is present. However, he recognized that highly trained physicians and medical professionals are aware of commercial support, disclose their potential conflicts of interest, and always have the patient’s best interest in mind.
He also recognized how physicians and researchers who work with industry developing and researching new drugs and devices are the best people to educate because they have the most hands on experience and knowledge. He asked the audience, “Would you rather have a surgeon who learned how to perform your surgery from a journal article or from a surgeon who invented and mastered the particular procedure or equipment used in the surgery?”
Dr. Sackier also noted why CME is crucial and how industry support is critical to achieving better patient outcomes. Factors that make CME and industry support crucial include the fact that:
- The scope and volume of medical literature is immense and complex
- Doctors time is the commodity in shortest supply
- Funding allows broader educational possibilities (i.e. national, local meetings)
He noted how CME costs thousands of dollars for individual physicians, many of whom do not attend events they and their patients would benefit from because of financial concerns. He closed by noting that with an aging population facing continued chronic and severe diseases, CME will be crucial for doctors to learn about this population to better treat them.
Breast Cancer and CME
Dr. Balch told the audience that he strongly believes in the CME and medical education process because the content is evidence-based. He has vast experience in academia, professional medical organizations, and as a CME participant and faculty. He noted how, before giving any CME talk:
- Needs assessments are compiled by a CME accredited organization in collaboration with experts
- The Program Committee determines subject matter and speakers INDEPENDENT of any funding source
- Speakers must disclose all sources of commercial funding relevant to subject material; conflicts must be declared and/or resolved; and
- Speaker slides are reviewed to ensure lack of bias, appropriate disclosures, and scientific integrity
Consequently, Dr. Balch tailored the rest of his presentation to show the audience what a very brief and not so “scientific” CME program would look like.
Dr. Balch began his discussion about breast cancer, and noted how 1 in 8 women will develop breast cancer in their lifetime and how there are over 250,000 new patients every year, making breast cancer a major public health issue.
Over 40,000 deaths each year come from breast cancer, which is 15% of all cancer death in women; second after lung cancer. And while rapid advances in breast cancer have led to over 2.5 million of breast cancer survivors in US, these survivors are still at risk for relapse.
Moreover, although fewer patients are dying from breast cancer, the treatments are complex and expensive, which demand continuing education, particularly because the management of breast cancer is multidisciplinary and there are over 100 kinds of sequences to treat breast cancer. For example, the John Hopkins Multidisciplinary Breast Cancer Team consists of almost ten (10) different doctors.
As a result, Dr. Balch recognized how treating breast cancer is very much individualized and personalized. He recognized how available prognostic/predictive tools can now identify patients who benefit from specific treatments and can eliminate patients who either do not need the therapy or will not benefit from it. Thus, treatment plans have the right combination and sequence, at the right time, matched with biological /biomarkers and quality of life issues. But doctors need CME to learn this.
Dr. Balch noted how there has been dramatic changes in cancer management, including:
- Exponential growth in knowledge about oncology management
- Frequent use of preoperative & postoperative chemotherapy & radiation therapy
- New technical advances in the operating rooms, i.e. surgical devices, CT scans, ultrasound
- Complete response rates with hormones and drugs at 50%; expansion to surgery for late stage cancer
- Expansion of surgical intervention for prevention of cancer in high risk people
- Targeted, non-toxic drugs (increasingly by oral agents)
He noted that once, breast cancer used to be a death sentence and now, it is becoming a chronic disease, with death rates declining by 30%. Consequently, with all these advances and FDA approved drugs, Dr. Balch asked, “how do we deploy them in the right combination to patients?”
While there are hundreds of combinations and sequences of beneficial treatments, physicians need to learn about them. Physicians from multiple specialties and practice locations must keep current on new advances based on evidence from clinical trials.
That is where CME comes in, Dr. Balch said. He noted how the CME guidelines provide a rigorous process to ensure appropriate content of medical education to practicing physicians. However, because industry support is declining, coupled with recent scrutiny by a small minority in academia and the press, the availability of CME courses is diminishing, especially in smaller centers, rural populations, and inner cities.
Ultimately, Dr. Balch said that moving forward, the CME and medical community need to ensure that we do not demonize CME and support from industry because there are significant processes in place to ensure high quality CME and reduce any potential for bias.
Primary Care and Internal Medicine
Dr. Simpler, who works closely with CME providers, also emphasized the importance of CME and industry support and collaboration. She said, “CME is how doctors keep up with medical advances,” and alternatives are not adequate.
For example, she noted that while journal articles are good, they are just limited to a specific subject area. Additionally, she noted that textbooks and online information may be good as well, but the information is to research only a particular patient problem, and does not translate to improved practice or competency.
As a result, she maintained that CME lectures are the best because this is where experts present the old and new information, making sense of the science data and offer guidelines for practicing physicians.
For example, Dr. Simpler noted how several years ago, she attended a CME event, which exposed the risky use of hormone replacement therapy. Because of her attendance at the program, she was able to take her patients off hormones years ahead of others, which saved the lives of numerous patients from suffering heart attacks or other complications. She recognized that in this instance, CME not only saved lives, but also saved dollars to the health care system.
Another area she said doctors need education in is ACOG Pap Smear guidelines. The 2009 consensus was that less frequent pap smears was appropriate, every 2-3 years instead of every year. However, only 16% of gynecologists follow this guideline, demonstrating an area where more CME would be very beneficial and cost saving.
Finally, she noted how the U.S. Preventive Services Task Force (USPSTF) has recommendations based on hard science, however they are not particularly well followed.
Moreover, she emphasized the fact that even though the government issues recommendations and guidelines, they provide no funding for continuing medical education to implement them.
Advances in medical science during the past 20 years have rapidly outpaced the ability of academic centers, hospitals, societies, journals, and medical education companies to fully educate physicians and other healthcare professionals. The gap between clinical research and practice continues to widen.
To motivate practitioners to change practice and improve medical care for patients, an expansion of the numbers and types of educational offerings will be required. Despite the pressing need, public funding for certified CME has remained flat during the past two decades; private sources of support increased until 2008, but have continued to decline despite the growing healthcare need.
CME providers support transparency regarding all sources of their funding, but curtailing commercial support for CME through unnecessary restrictions, burdensome reporting requirements or outright bans would dramatically diminish access to education, and negatively impact patient care.