CME Reform From People Who Don't Have to Participate in CME

There is a particular irritation to be found in the criticism of continuing medical education (CME) by a nonphysician. There is even more irritation to be found in the criticism of CME by a purveyor of sociology. There may be practical benefits of the so-called science, but its merits have eluded me in a life that's had its fill of academia.

In the latest issue of JAMA—a journal becoming known for its overbearing editorials—sociologist Eric Campbell, PhD, and health economist Meredith Rosenthal, PhD, condemn the current state of physician CME by applying general critiques from the landmark Flexner Report of 1910. They also advocate investment in something they call "physician human capital," a term adapted from economists to convey the medical knowledge and skills that are required to provide "high-quality, efficient, and cost-effective care."

By using the Flexner Report, Campbell and Rosenthal attempt to draw parallels between the heterogenous state of early American medical education and the quality of today's CME, which they allege is equally scattershot. The comparison is meant to empower their criticism of CME, but the comparison is invalid.

In the early twentieth century, educator Abraham Flexner visited more than 100 US medical schools at the behest of the Carnegie Foundation for the Advancement of Teaching, which conducted its survey at the behest of the AMA's Council on Medical Education. The 2 major reforms for graduate medical education that were promoted (and ultimately realized) by the AMA Council were 1) the standardization of the preliminary requirements for entry into medical school and 2) the implementation of a nationally recognized curriculum of 2 years of basic sciences and 2 years of clinical instruction in a teaching hospital.

Among Flexner's findings in 1910 was, as suspected, the fact that medical curricula varied widely from school to school. But Campbell and Rosenthal wrongly apply Flexner's observation to today's CME by maligning physicians' autonomy when selecting from the varied number of certified CME activities. They argue, "While the diversity of CME offerings provides benefits to physicians, it also deprives CME of representing the mastery of an essential core set of knowledge and competencies."

The problem with the authors' criticism is that, for practicing physicians, the foundation or "essential core" of medical education has already been established, thanks to the Flexner-inspired curriculum of accredited medical schools and postgraduate clinical-training programs. Perhaps if Campbell and Rosenthal had undergone medical education themselves, this blatant fact would not have been so stunningly overlooked. 

It is also entirely reasonable to assume that individual physicians are in the best positions to select the CME activities that may be most beneficial to their practices. Moreover, as Campbell and Rosenthal indicate, the mastery of an essential core set of knowledge and skills is already periodically reinforced by the required maintenance-of-certification examinations through the American Board of Medical Specialties (ABMS). It hardly seems necessary, or even desirable, that participation in specific CME activities should be dictated to practicing physicians beyond the state-mandated requirement of so many certified hours per year. I would be no more inclined to require that Dr. Campbell read certain sociology journals.

Flexner also lambasted the for-profit medical schools of his time, largely because of their substandard curricula. Campbell and Rosenthal proceed to make a very loose correlate between Flexner's observation and the "excessive commercialization" of current CME activities. They cite the ACCME's 2007 report, which indicated that 58% of the income of accredited CME providers came from industry. (The 2008 report indicates that about 44% of total income came from industry, a drop of nearly 25%.) However, there are no objective data to show that commercially supported CME is inferior or less effective at improving medical practice or patient outcomes than CME activities funded by other sources. In fact, Campbell and Rosenthal acknowledge, "[T]here is scant evidence that CME actually improves patient outcomes." In this statement, Campbell and Rosenthal do not distinguish between commercially and noncommercially supported CME. The inferiority of industry-funded CME is merely assumed by the authors, apparently because it has been argued or assumed by others.

Campbell and Rosenthal also maintain that CME relies too heavily on the lecture format, a criticism that Flexner threw at unregulated medical schools 100 years ago. By extension of their argument, the authors claim that CME "is not adequately focused on improving patient outcomes." However, later in their editorial, while advocating CME reform the authors anticipate a transition to CME that is provided by hospitals. But already overburdened hospitals are unlikely to pioneer innovative formats for CME activities.

To realize their "new model of CME" and to ensure physician human capital, Campbell and Rosenthal conclude by advocating 3 lofty reforms. They might as well advocate a tilt of the Earth's axis without proving why it's really better or specifying how to bring it about. Two of their reforms require monumental changes to US medical practice: 1) physician-payment reform to motivate practice quality and efficiency (as if physicians aren't sufficiently motivated to achieve these ends at present) and 2) the use of "sophisticated health information technology" to facilitate on-the-job learning. In addition, the authors propose specialty certification as a requirement for state licensure—an admittedly nice idea that will never happen.

"Boston Ivy" from Flickr.