In 2004, more than 50% of the $2 billion spent on all certified continuing medical education in the U.S. was paid for by pharmaceutical sponsors. But that percentage appears to be dropping in 2005 -- and CME providers (and some physicians) are worried about the trend.
That was the thread that ran through the recent Annual Conference of the National Task Force on CME Provider/Industry Collaboration in Baltimore, MD, attended by some 600 providers, financial sponsors and regulators, including a sprinkling from Canada and Europe.
One major issue discussed was the ability of providers --whether medical school, medical society or medical education company -- to ensure independence from commercial bias. Despite new rules from the government, the Accreditation Council for CME (ACCME) and the industry itself, a number of speakers had concerns about the separation between promotion and education. Arnold Relman, a former editor of the New England Journal of Medicine, argued that the government should pay for CME rather than the pharma industry. Gardiner Harris, a New York Times healthcare reporter, saw a clear conflict of interest when physicians accepted "free" CME paid for by manufacturers of drugs they prescribe.
J. Patrick Kelly, president of Pfizer U.S. Pharmaceuticals, struck out at those critics who say: "Any relationship with a drug company is bad." Further, he said, "the continued tarring of the industry dampens enthusiasm for funding ... and is likely to lead to a decline in support over time."
Instead, Kelly urged providers and regulators to take advantage of "the enormous confluence of interest in improving patient care through the sharing of scientific and clinical information" rather than expending so much energy on managing conflict of interest. And he suggested that conflict of interest and bias could arise not only from a pharma sponsor but also from a health insurer, a group medical practice or a for-profit hospital, all of which appear to be exempt from any CME regulation.
Kelly's conclusion: "Whether the pharmaceutical industry funds CME at today's levels or not, we must stand on the bedrock of free scientific speech, always promoting protection of the unimpeded movement of credible information as the ultimate CME strategy." His comments received a round of applause.
As Kelly indicated, pharmaceutical funding of CME programs appears to be dropping. This is a cause of concern for many accredited providers -- who believe that the new regulations from the government and from ACCME are largely responsible. Primarily because of guidances issued by the Office of Inspector General of the U.S. Department of Health and Human Services, there has been a shift of CME funding control within companies. Product managers used to be able to decide how to spend their "education" budgets, with some review. Now they must cede responsibility for commissioning of certified CME programs (those from accredited providers) to professional education groups outside the marketing department - - but still put up the money. This has caused some product managers to decrease spending on certified CME and to increase spending on promotional or non- certified CME, over which they still maintain control.
A poll of CME providers recently conducted by the Coalition for Healthcare Communication bears out their fears regarding funding. 53% of respondents said their CME grants from industry declined more than 10% from 2003 to 2004. Besides the impact of the new rules, there could be another reason: a drop in introduction of new prescription drug products, which are often the basis for major CME spending.
Somewhat overshadowed by the debate on pharma support, another issue occupied substantial time at the conference (and is discussed further in the accompanying article on innovation): The rapidly approaching changes in the delivery of CME to include "point-of-care" or "just-in-time" CME, and to require measuring outcomes going beyond pre and post-testing of knowledge. These trends will move CME away from large-group didactic programs to more individualized learning. Are CME providers equipped to manage the change? How will the new activities be funded? These questions remain to be answered.
*********************************** Need help formulating a global CME strategy, or planning a CME campaign in another country? WentzMiller & Associates is available to help. Contact Lew Miller (lew@wentzmiller.org) or Dennis Wentz (dkwentz@aol.com).
Changes Ahead for U.S. CME
How different will CME be in the U.S. in 5 years? The articles in this issue describe some of the innovations, the pressures for change and the barriers to change, based on recent national meetings in the field.
·Repositioning CME: Can It Make a Difference?
"By 2010, we expect that members of the American Academy of Family Physicians (AAFP) will earn more than 50% of their CME credits from point-of-care and practice-improvement CME," stated Norman Kahn, vice-president, science and education, of the AAFP, which has more than 90,000 members.
Dr. Kahn was addressing a convocation of 200 CME providers and regulators at the Repositioning CME Summit in Chicago earlier this month. The theme of the meeting was how to move continuing medical education from a mostly passive experience for physicians to a series of practice-related activities that can improve patient care.
Let's first define point-of-care and practice- improvement CME:
Point-of-care CME, sometimes called "just-in- time" CME, occurs when a physician needs help solving an immediate clinical question, goes online to an evidence-based source, and gets the help he/she needs.
Practice-improvement CME occurs when a physician measures his/her level of care in a given area, say, diabetes, against evidence-based norms, identifies deficiencies, remedies these, and then re- measures after a period of time to see if improvement has resulted.
The AAFP has launched a practice-improvement program called METRIC (Measuring, Evaluating and Translating Research Into Care). The program is designed to provide up to 20 CME credits and to assist family physicians in fulfilling the requirement for Part IV of Maintenance of Certification, a new direction in recertification for all U.S. physicians. The Clinical Assessment Program is a similar concept for osteopathic residents, developed by the American Osteopathic Association.
Point-of-care CME is starting to roll out under programs developed by the AAFP, the American Medical Association and the American College of Physicians, whose program, PIER, is available to its members now. Data show that the average office practitioner in the course of one day encounters 4-5 clinical questions that are difficult to answer. A structured approach to an online search can earn an AAFP member .5 CME credit per episode.
Central to providing CME that makes a difference is the ability to develop individual physician practice profiles. In the U.S., this will take some time, as electronic health records are used in a minority of practices. Meantime, some physicians are beginning to select a random set of paper patient charts by diagnostic entity to develop profiles that can lead to performance improvement. The Federal government is encouraging this activity in 36 categories, linked to a pay-for-performance initiative.
What does this mean for those who offer CME programs? Dr. Robert Galbraith, director of the Center for Innovation at the National Board of Medical Examiners, suggests these changes:
Assessment of needs based on comparing present performance to evidence-based norms
Readily accessible, authoritative source material -- beyond lectures
Content driven by a practice profile, not by physician desire
Flexible formats and delivery methods in which feedback is quickly available
What will motivate physicians to pursue these new directions in obtaining required CME credits? Probably four elements are necessary:
Increased use of computerized records in practice
Incentives from medical care payors for performance improvement
A rapid increase in availability of point-of-care and practice-improvement programs
A change in credit systems to give bonuses for performance-based rather than traditional CME
The Summit sponsor, the Council of Medical Specialty Societies (CMSS), promises to post presentations on its web site in the near future.
·CME Required in Lithuania
CME is mandatory in Lithuania. The country's 13,400 physicians have to be re-licensed every 5 years, by documenting that they have been practicing their specialty for a certain defined period and have attended CME/CPD activities for 200 credit hours. Of these, 60% should be courses in universities and 40% lectures, seminars and conferences organized by professional societies together with universities. Physicians who fail to meet the 200-hour requirement may have their licenses suspended.
There is no assessment of physicians needs for CME in Lithuania. For licensing purposes, however, the physician has to provide certificates for courses in his own specialty, and only 20% of conference credit hours may be from other specialties or non-clinical areas such as management, computers, etc.
Conferences are mainly sponsored by pharmaceutical companies, but cannot be included in credit hours for licensing unless there is participation by universities. Payment for courses in universities is changing. Most were financed by the Government and employers but now the majority will be paid by the employer (working institution) and physicians themselves. -- Egle Zebiene MD, president, EURACT, Vilnius, Lithuania
For example, neglected tropical diseases are responsible for 500,000 deaths annually. (See Neglected Diseases.) Authors David H. Molyneux, Peter J. Hotez and Alan Fenwick, all tropical diseases specialists, identify 13 such diseases, which are particularly prevalent in Africa (neglected, they say, because the emphasis is on HIV/AIDS, malaria and tuberculosis):
Little in the existing large battery of CME programs in the West deals with these diseases, yet the authors point out that an integrated control program can have a major impact on 7 of these diseases --using only an armamentarium of 4 drugs: albendazole, ivermectin, azithromycin and praziquantel. The cost effectiveness is great, they add. "For just US$200 million per year for 5 years, it is estimated that over 500 million individuals could benefit from preventative chemotherapy, which would rapidly contribute to poverty reduction" and other economic goals.
In a report from the United Nations Population Fund, "State of World Population 2005", reproductive health is identified as a major problem as well. "Worldwide, an estimated 250 million years of productive life are lost every year as a result of reproductive health problems," the report notes. These are the leading cause of ill health and death in women aged 15-44.
The report makes these points:
99% of all maternal deaths occur in developing countries
8 million more women suffer lifelong illness as a result of pregnancy consequences
Newborns of women who die in childbirth are 3-10 times more likely to die prematurely
Most pregnancy related deaths and illness ARE preventable
Access to safe and effective methods of family planning, including contraceptives, is key
These are health problems of enormous proportions. Clearly, CME is only part of the solution. Those of us in the developed nations have an opportunity to work with health care systems in developing countries to make a difference, through helping to change national health policies, through increased availability of medicines and condoms, and through education of health professionals and populations.
Some of you receiving this newsletter may currently be involved in one or more countries to bring about reductions in mortality and morbidity. If so, let us (lew@wentzmiller.org) know what you are doing.
Meantime, we will keep you posted on Project Globe. In 2006, we hope to identify 4-5 pilot countries where we can start a CME needs assessment process in collaboration with a local organization that can reach front-line GPs. Then we will need to identify the resources that begin to fill the identified needs. As noted above, there may be a paucity of such resources dealing with the health problems mentioned above. If you know of such resources, please let us know (dennis@wentzmiller.org).
************************* WentzMiller & Associates is available to help you develop global or regional CME strategies, solve problems in CME delivery around the world, or improve what your organization is now doing in the field. Contact lew@wentzmiller.org.
********* Back Issues Now Available! You can access past issues of the WM&A newsletter at www.wentzmiller.org.
A World View on CME
In this issue, we present a wide range of topics, from changes in European CME accreditation, to the problems with guidelines implementation, to the needs for CME in developing nations. It's hard to keep up with the changing world of CME, but that's our objective in this newsletter from month to month!
What's New in European CME as Seen by EACCME
Since the European Accreditation Council for CME (EACCME) was set up some 5 years ago, major progress has been made. The parent organization, the European Union of Medical Specialists (UEMS), is headed by Dr. Bernard Maillet, who serves as Secretary General of both organizations. In his recent reports and newsletters appear the following indications of growth and acceptance:
To date in 2005, the EACCME has accredited more than 400 programs, submitted through 3 sources: organizers, European specialty accreditation boards, and national accreditation authorities. While the number is small compared to accredited programs in the U.S., it represents major improvement from the handful of programs accepted in 1999-2000.
In an effort to promote uniformity among nations in the principles and outcomes of CME/CPD, representatives of European and North American organizations have arrived at a consensus regarding these critical elements of CME/CPD:
CME should enhance physician performance and thereby improve health
Physician-learners should base CME/CPD on individual needs relevant to practice
Providers/organizers must ensure that commercial support should not influence content and must be disclosed to learners and accrediting bodies
Providers/organizers must have in place outcome measures based on knowledge, competence or performance
Accrediting bodies must have reasonable standards for providers/organizers and verify that these are observed
Accrediting bodies should promote collaboration among themselves and with providers/organizers
The participating organizations included, from Europe: EACCME, Bulgarian Union of Scientific Medical Societies, Federation of Royal Colleges of Physicians (UK), French National Medical Council, Italian Federation of Scientific Medical Societies, Italian National CME Commission, Spanish Accreditation Council for CME, and Bavarian Chamber of Physicians. From North America: Accreditation Council for CME (ACCME), American American Association (AMA), College of Family Physicians of Canada, and Royal College of Physicians and Surgeons of Canada.
There are still outstanding issues to be resolved, among them recognition of CME credits for enduring materials such as print, CD-ROM and Web-based learning. Some countries such as Spain accept these, but EACCME does not. Nor does EACCME deal with credit systems for GPs -- only for specialists.
Perhaps some of these issues will be discussed in a major conference on continuing professional development in Europe, to be held at the end of 2007. UEMS is already planning to organize a working session on "Ethical obligation vs. formal regulation of CPD."
Do Guidelines Get Applied in Practice?
Often they don't say the authors of a recent study published in Quality Management in Health Care. Although practice guidelines are effective in assisting providers with clinical decision making, ineffective implementation strategies often prevent their use in practice.
The authors interviewed 500 randomly selected physicians from 4 major US health systems who were treating patients with acute myocardial infarction or pediatric asthma. They preferred guidelines located on the front of the patient chart, in Palm Pilots, or in progress notes -- presented in flow charts or preprinted orders.
But the keys to use, the authors went on, are a combination of CME and discussions with colleagues. The CME needs to not only present the guideline content but also provide tools for implementation.
A Call for CME in Ghana
Thanks to Sue Pelletier of Medical Meetings, who called our attention to an article in the Accra Daily Mail reporting on the third conference on Advances in CME in Kumasi.
At the conference, Dr. George Bedu-Addo, head of the Department of Medicine at a Kumasi teaching hospital, called for establishment of regional offices of the Ghana College of Physicians and Surgeons to enable doctors to have easier access to CME. He said that the present arrangement provided courses only in Accra, which carried high costs and travel risks.
The conference was attended by about 150 doctors from Ghana, Nigeria, Cote d'Ivoire, USA and Burkina Faso. The aim is to focus on keeping physicians current with advances in medicine.
It's one thing to measure performance in clinical topics such as management of hypertension, where there are evidence based guidelines to work from. It's another in surgery, where randomized double blind clinical trials are few and far between. Yet the American Board of Medical Specialties has been pushing all specialty certification boards to move to "maintenance of certification" (MOC) programs that go beyond traditional periodic examinations and required hours of CME to also evaluate performance in practice.
Progress has been slow in most specialties, whose boards are grappling with what to measure and how. (See Mark Cheren's adjacent letter.) Yet one board, the American Board of Neurological Surgery (ABNS), has forged ahead.
The ABNS components of MOC, to be implemented this year, are:
A 10-year cycle
150 hours of specific neurosurgical CME every 3 years
Web-based self assessment program developed by the Congress of Neurological Surgeons
Submission and evaluation every 3 years of 10 consecutive "key cases" selected from a list of neurosurgery procedures
Once in 10 years, submission of a surgical case log, in which 6 months of practice data are entered in ABNS' Internet based NeuroLog
Use of a communications assessment tool to measure patient perceptions of performance in interpersonal communications skills
The other 9 surgical specialty boards are still wrestling with what to do. In the words of the American Board of Ophthalmology, "the broad national consensus is that no valid and reliable tools are available" to measure performance. "The most practical approach," says the Board, "is the use of nonpunitive self-learning models that would encourage improvement in practice."
There will be an inevitable link between effective CME and performance evaluation, and in turn between performance and outcomes, and eventually between outcomes and physician compensation. (CMS, the federal agency that pays providers is already moving in this direction.) CME leaders who recognize this progression have an opportunity to provide valuable innovations to their constituents.
************************* WentzMiller & Associates is available to help you develop global or regional CME strategies, solve problems in CME delivery around the world, or improve what your organization is now doing in the field. Contact lew@wentzmiller.org.
********* Back Issues Now Available! You can access past issues of the WM&A newsletter at www.wentzmiller.org.
Katrina sufferers need your help!
WentzMiller has joined forces with Mediworld USA, Healthways and the Global Alliance for Medical Education to publish more than 1 million guides to prevent infection from contamination for the victims of Hurricane Katrina. State Health Departments in Lousiana, Mississippi and Alabama will distribute these to doctors, paaramedics and the general public We need your (tax deductible) contribution. Send check made out to GAME to Fred Clarke, Dowden Health Media, 110 Summit Ave., Montvale NJ 07645. Thanks!
Mandatory CME? Germany vs Sweden
Mandatory CME, while viewed as "an attempt to regulate an autonomous profession," received generally favorable support in a poll of 500 ambulatory care physicians conducted in Gemany by the University of Witten/Herdecke and the Bertelsmann Foundation. Daniela Kempkens MD of the university reported these survey results at the 2005 GAME meeting: Mandatory CME ...
can only work if the content is of high quality -- 84%
supports doctors in their efforts to keep up to date with new medical knowledge -- 73%
provides access to new medical knowledge -- 60%
takes up valuable time that could be better used for patient care -- 34%
usually teaches contents which are irrelevant for medical practice -- 20%
On the issue of funding, 55% of respondents said health insurance funds should pay, 49% physicians, 44% government and 43% medical associations. CME spending per physician in 2003-4 averaged about $1,000 US per year.
Ambulatory care physicians in Germany have been subject to mandatory CME since January, 2004, and hospital based physicians must comply starting in 2006.
The situation is quite different in Sweden. "We're still in the pre-CME era," reported Richard Bergstrom of the Swedish Association of the Pharmaceutical Industry. But there is growing interest in voluntary Continuing Professional Development (CPD).
The Institute for Professional Develment of Physicians in Sweden (IPULS) has been established, and the pharma industry has agreed that any CPD funded by companies must be reviewed by IPULS, Bergstrom said. In addition, industry has agreed to ban social activities, to invite doctors only through their employers and to pay only course fees and 50% of travel and lodging.
Changing CME Rules in Italy
The huge CME enterprise in Italy, mandated by national law, is likely to change significantly by the end of the year, said Dr. Alfonso Negri, secretary of the Italian Society for CME Accreditation in Pneumology, at GAME.
Under the current system, more than 200,000 requests for accreditation have funneled through the Ministry of Health. Each program is evaluated by 3 referees, who through a scoring method evaluating both time and quality, determine the final amount of credits. The whole system is Internet driven.
The new system, to be introduced soon, will accredit institutional and society providers on a national and regional basis, each to be audited on a 1-year and 5- year basis. Providers will award credit hours. In addition, distance learning activities will be included, and may be carried out by private firms, if validated by institutions, Dr. Negri said. Mandatory requirements are for 150 hours in 5 years, to be shortened to 3 years.
In Board Certification, Are Guidelines a Bad End or a Good Beginning?
In Dec. ‘04, Lew Miller asked in these pages, “Is it too late to be asking: What has happened to the joy of learning when the physician is handed today's evidence-based guideline and told to follow it? What has happened to the sense of professional responsibility for keeping up when the physician has to be led to the water and told to wash?”
These questions, and more recent discussion of pay for performance, convey understandable ambivalence. We all know what we have been trying to leave behind: the valuing of inputs over outcomes and the valuing of hours over improvements. But is counting how many times specific aspects within an evidence-based, discipline approved guideline are followed really what the medical education leaders and specialty boards had in mind when they identified “practice-based learning and improvement” as one of six areas of competence that would significantly raise the quality of healthcare in the new century? Probably not.
Counting compliance with guidelines is but a stepping stone from counting hours to practice improvement -- a bad end in itself but a good beginning. We in CME must devote our best efforts to the true end point: helping healthcare professionals define practice- based learning and improvement in terms of quality improvement methodologies and systems thinking.
For example, we can help them learn to work together in small or large teams to understand why it's difficult to achieve compliance with a guiideline in a local setting. This is part of the process that will enable physicians to apply systems thinking to create or help create entirely new procedures, processes, systems or even guidelines that enhance if not raise the standard of care. Mark Cheren, Improvement LE
"When Europe presents itself to the world as one economic whole, it is perhaps not surprising that many global marketers regard it as one cohesive 'region'. But any marketer who regards Europe -- from the Baltic to the Mediteranean, from the Atlantic to the Black Sea -- as one ... is heading for marketing oblivion."
Newman goes on to note the diversity of healthcare systems. Take prescribing, for example. In France, patients expect all medications to be prescribed. In Eastern Europe many treatments are available without an Rx. In Southern Europe, the rules are widely flouted and drugs can be bought without a prescription.
In many European countries, doctors are dependent on government paychecks. In others, private practice still flourishes. Ambulatory care doctors are often treated differently from specialists by their health care systems. Accreditation by the European Accreditation Council for CME is only good for specialists and only good if the national health authority says OK.
All is not bleak, however. Newman points out that the mobility of labor, including physicians, will help break down cultural barriers. Diseases don't differ much across borders. CME, while it can have a pan-European strategy behind it, can be adapted to fit political, cultural and economic differences on a local level.
Here's another example of how European physicians -- in this case, GPs -- view the concept of one Europe: A German professor put out a call (via an e-mail list serve) for assistance in depression research in Germany, England, the Netherlands, Finland, Estonia and Canada.
Roars -- or at least mumurs -- of protest immediately arose from the South of Europe: "I feel left out of such all too common Northern European initiatives." "Northern countries dominate .. Italy is not considered." And from a Nordic country: "This is not a North South problem. The question is if each country has developed a strong infrastucture for research and development."
And the final insightful comment: "Do we have a lack of development of academic family medicine in the South and East of Europe due to the lack of individual GP initiatives, or is it a system problem that requires a system solution -- an EU systems solution?" What do you think?
************************* WentzMiller & Associates is available to help you develop global or regional CME strategies, solve problems in CME delivery around the world, or improve what your organization is now doing in the field. Contact lew@wentzmiller.org.
********* Back Issues Now Available! You can access past issues of the WM&A newsletter at www.wentzmiller.o rg.
Summer Fun and GAME
This is a combined Summer issue, written from vacation headquarters in Vermont. Let us know where you are on holiday! Meantime, here are more highlights from the 10th Anniversary Meeting of the Global Alliance for Medical Education (GAME) held June 19-21 in New York City. We'll cover more in our next issue.
CME in the Emerging World
"CME/CPD is developing steadily in the emerging world," Honorio Silva MD (hsilva@pfizer.com), of Pfizer's Medical Humanities Initiative, told the audience at GAME. He reported on the results of a survey conducted by Pfizer country medical directors from Latin America, Asia and the Middle East/Africa regions.
In the Middle East/Africa region, Dr. Silva, said, the following have CME accreditation initiatives: Nigeria, Saudi Arabia, South Africa, Turkey, Israel and the UAE. Across these and other countries in the region, CME is provided primarily by medical societies and academic institutions. In most countries the pharmaceutical industry plays a provider role, except in Saudi Arabia where the health ministry does most of the programs, although with substantial pharma support, as is the case in most countries.
In Latin America, CME accreditation is underway or starting in Argentina, Brazil, Costa Rica, Mexico and Peru, Dr. Silva noted. Governments play a limited role as providers, which are divided between medical organizations and the industry, which also does most of the financing, except in Mexico, where the government plays a significant role.
Asia and Australia have a high rate of CME accreditation -- in Australia, HongKong, Japan, Malaysia, Pakistan, Philippines, Singapore and Thailand. There's a somewhat higher level of government involvement in both providing and financing CME than in other regions.
Dr. Silva reported on three other key indicators:
Is distance learning accredited? Yes, in 2/3rds of the countries with credit systems.
Are CME credits used for recertification? Yes, but only in 40% of those with credit systems.
Are there any standards for commercial support? In Latin America, almost none. In Australia/Asia and Middle East/Africa, about half of those with credit systems also have standards.
Neurology CME in Developing Countries
In a GAME poster exhibit, Abi Sriharan of the World Federation of Neurology (WFN) described the federation's program to improve knowledge, skills and self-perceived competency of neurologists in 33 countries around the woirld, ranging from Bangladesh to Russia to Cuba.
Course materials are developed by the American Academy of Neurology, coordinated through WFN and delivered in 6 units per year by national coordinators, adapted to local needs. "Global CME initiatives provide an effective method for knowledge translation," says Ms. Sriharan.
Promotional Education vs CME in US vs Europe
Marty Cearnal of Thomson Medical Education, US, and his associate, Edgar Ingold, of Thomson Europe, Germany, vigorously debated at GAME the differences between the 2 regions in medical education.
A highlight of the discussion dealt with promotional education vs CME. In the US, there is clear differentiation: certified CME must be independent of influence from the commercial supporter, noted Cearnal. New rules from the Accreditation Council for DME (ACCME) and the Federal government are quite strict to eliminate any possibility of bias.
In Europe, Ingold said, "there is a large gray zone". Companies try to use CME to do product placement, he went on, and prefer to be sponsors rather than grantors who provide funds on an unrestricted basis. Quality assurance is still a problem. Several Europeans in the GAME audience responded by citing specific moves to maintain quality and reduce bias.
Here are some of the highlights from the 10th Anniversary Meeting of the Global Alliance for Medical Education (GAME) held June 19-21 in New York City. We'll cover more in our next issue.
India Struggling to Create CME Structure
The vast subcontinent of India has plenty of CME programs, said Dr. Sanjiv Malik, president-elect of the India Medical Association (IMA), but no statuatory requirements, nor structure nor certification for CME.
IMA adopted a resolution a year ago calling for a voluntary system of CME for all doctors, but the health ministry has not yet gone along with the proposal, he said. "Patient pressure and consumer activism" are among the reasons for moving ahead with certification of print, video, web based and live CME content.
Meantime, the IMA and its local organizations conduct thousands of program a year for India's more than 500,000 physicians. Once a doctor, always a doctor, Malik said, since there is no reregistration requirement. There is little health insurance in the country, he noted, so "people pay through the nose for quality services."
Germany Implements a New System
CME bcame mandatory for ambulatory care physicians in Germany in 2004, and will become mandatory for hospital based physicians in 2006. Dr. Daniela Kempkens of the University of Witten/Herdecke, outlined the requirements of the new system, which calls for 250 CME points in 5 years.
Points may be acquired in 8 categories:
Lectures and discussions
National and international conferences
Active participation in a learning experience
Structured interactive CME in print, online
Self-study: journals, texts, etc. (limited to maximum 50 points)
Scientific publications and lectures
Observational practice visits
Other CME with structured curricula
What happens to a doctor who doesn't earn 250 points by July 1, 2009? Step 1, Dr. Kempkens said, is less reimbursement, and Step 2, loss of license.
How do German physicians feel about the new requirements? A national survey of ambulatory care physicians conducted by the university and Bertelsmann Foundation showed:
System can only work if the content is of high quality
It's an attempt to regulate an autonomous profession
Health insurance funds, physicians and government should pay (now pharma is #1 payer)
Currently scientific journals, conversations with colleagues and talks with pharma reps are the major non-meeting sources of CME
Time for a Change in Italy!
Italy, which mandated CME for all health professionals in 1999, is rethinking its system, said Alfonso Negri MD, scientific secretary of the Italian Council for Accreditation in Pneumonology. Until now, the Italian Ministry of Health, through various organizations, has accredited programs, but is now moving toward accreditation of providers.
Negri himself has reviewed for accreditation over 3,000 programs in his field since the inception of mandatory CME -- quite a burden for a specialty society leader. He has been one of three referees who review every single application, determine a score and set the final number of credits. Organizers register programs at the ministry web site (ecm.sanita.it). If a meeting has fewer participants, e.g., 20 vs 500, it will be eligible for a higher score and more credits.
The changes involve:
Moving from 150 credits in 5 to 3 years
Providers will be accredited based on rules from the Ministry of Health CME Commission
Providers must (initially) be institutions -- universities, hospitals and scientific societies, though private firms may be accredited for distance learning if validated by an institution
Providers will be audited after one year, and then every 5 years
State/regional conferences will be responsible for approving implementation
Credits obtained by Italian doctors in the European Union, USA or Canada will receive 50% credit
While Italy, Spain and Germany recognize distance learning as a source of credit, the European Accreditation Council for CME has not yet done so.
Miller Honored by GAME
Lewis A. Miller, principal of WentzMiller & Associates, a consulting firm specializing in global continuing medical education (CME), received the Precepts of Hippocrates Award in recognition of his international achievements in CME at the 10th Annual Meeting of GAME. The conference included attendees from 14 countries.
In presenting the award, Mark Evans, president of GAME and director of healthcare education at the American Medical Association (AMA), stated: "It is only fitting and proper on this 10th anniversary of GAME that we honor our founder, Lewis Miller. Through his vision and commitment, the international community has been strengthened, healers educated and patients' lives improved."
Another JCEHP article in the same issue reported that journal-based CME activities "may be educational at all stages of the learning process, and journal-based learning episodes may result in commitments to change practice." The statement resulted from a self- reported survey of 138 journal CME participants. Those who made a commitment to change on the CME evaluation form were more likely than others to report progress in learning.
Questions have frequently been raised about the value of distance learning. Three recent reports attest that a variety of distance learning approaches can be effective.
A study in Medical Teacher (Vol. 26, No.6, pp. 559 - 564) reported on a distance learning course in therapeutics for GPs. The course, developed by the Irish College of GPs, was completed by 100 GPs from Ireland, Malta, HongKong and Saudi Arabia. Modules were supplied both in print and on the college website. Each of 30 modules was assessed individually through a combination of essay questions and multiple choice questions. Particiants responding to a mail survey indicated they were more confident and more selective in prescribing.
Some 4,000 U.S. doctors participated in a pilot to determine the usefulness of looking up answers to clinical questions on handheld computers. (Both AMA and American Academy of Family Physicians award CME credits for this activity.) In the pilot, doctors used performance measures to track the success of their care in 3 areas -- diabetes management, breast cancer screening and flu immunizations. The final report of a random survey of participants indicated not only their satisfaction with the program but also resulting improvement in patient care.
A Canadian study sought to compare physician perceptions of interactive on-line CME with face-to-face CME. As expected, some physicians preferred the discipline of structured face-to-face learning to self pacing on the Internet, and also the sharing of ideas in person. On the other side, many physicians preferred the leisure of self pacing and the opportunity to reflect on each segment of a program. Issues of access and technical competency were important, although the latter disappeared with experience. A key issue was the capacity of on-line CME to meet personal learning preferences.
Since the use of multiple choice questions (MCQs) is so common in pre and post-testing of CME, there have been continuing arguments about the validity of such tests and their correlation to competence and performance. A literature review in Medical Teacher (Vol. 26, No. 8, pp. 709 - 712) concludes that "MCQ testing is ... both reliable and valid, ... and predicts and correlates well with overall competence and performance." However, the author states, there are validity problems concerning fairness and alignment with learning. "There is a wealth of evidence," he says, that extended- matching questions (EMQs) are the fairest format. In this format, there may be 20 or more branches from which the physician must select one or more correct answers.
Have you tested any CME learning methods lately?
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Don't Miss the GAME!
If you want to improve your perspective on international CME/CPD, make sure to attend the 10th Anniversary Meeting of the Global Alliance for Medical Education (GAME) June 19-21 in New York City. Mike Magee MD, senior fellow in Humanities to the World Medical Assn., will deliver the keynote: "Globalization: Curse or Cure?". You will get a taste of CME in Europe and Africa, and a debate on differences in medical education companies in the U.S. and Europe. Speakers from North America, South America and Europe will discuss ethical issues, and a final segment of the program will cover e-learning. Go to www.game- cme.org for registration information.
How much luxury CME travel should pharma pay for?
"When Dr. Enrico Benedetti (chief of transplantaion at University of Illinois, Chicago) decided to hold a medical symposium in his hometown of Gubbio, Italy, he faced a daunting challenge: finding money to pay for the event." That was the lead of a recent article in the Chicago Tribune.
Dr. Benedetti "knew what to do," the article continued. He raised $174,000 from drug companies like Fujisawa Healthcare, Novartis and Abbott for his first meeting in 2002 and another $185,000 for a second, last June in Sicily. Both meetings focused on living donor transplants, and were conducted under the auspices of UIC and University of Minnesota. Speakers and special guests received business class air tickets and luxury hotel accomodations. Other attendees paid a fee of $450
Voluntary guidelines from the Pharmaceutical Research and Manufacturers Assn. (PhRMA) in the U.S. clearly limit expenditures to reasonable travel. But do the same guidelines apply to activities conducted outside the U.S.? In many non-North American countries, it appears to be acceptable to have travel expenses of attendees as well as speakers paid for by pharma companies -- sometimes at a level of luxury.
In the Tribune article, Dr. Arnold Relman, former editor of the New England Journal of Medicine, was quoted, "There is a conflict of interest here; ... pharmaceutical companies ... have exceed their proper bounds." Dr. Benedetti's response: By accepting contributions from several companies, "there's no way you can be influenced. And in fact, we are not."
The Tribune reporters then noted that Fujisawa (now known as Astellas) markets Prograf, a drug to prevent rejection in transplant patients. "Should a physician choose Prograf over a rival drug, it could mean $10,000 or more per year in revenue to the company per patient" for many years.
Clearly, this type of news article reduces the stature of doctors and the CME community as professionals. The AMA has spoken through its Ethical Opinion 8.061 on Gifts to Physicians from Industry (www.ama- assn.org) and the World Medical Assn. adopted a similar statement in 2004 (www.wma.net). The question for all of us in CME, regardless of voluntary guidelines or Standards for Commercial Support, is this: What is the ethically correct position -- for conference providers, for faculty, for attendees and for industry supporters?
Brazil starting mandatory CME for specialists
Effective in April 2005, all specialists in Brazil (about 35% of total doctors) are subject to mandatory revalidation every 5 years, through a resolution adopted by the Federal Medicine Council (CFM).
CFM and the Brazilian Medical Assn. (AMB) set up a joint commission to determine implementation. Their current proposal, open for public comment, calls for 100 CME credits over 5 years, of which 50% can be acquired through distance learning (but one hour of distance learning is worth only 0.5 credit).
AMB will be responsible for content of CME courses, through its 52 speclalty associations. A commission has been set up to approve educational programs. For those starting January 2006, submissions are required by September 5 2005. -- Raul Cruz Lima [raul@conexaomedica.com.br]
Netherlands finalizes its mandatory CME
As a requirement of registration and reregistration of 3 groups of Dutch physicians -- specialists, GPs and "social medicine" doctors -- each must record an average of 40 hours of CME yearly for 5 years, effective January 1 2005.
The Accreditation Consultation Body for CME met recently and agreed to set up a joined fully digital system for accreditation of CME activities and registration of credits for each doctor. The basis will be the existing voluntary systems of cardiologists, gynecologists and GPs. Accreditation will remain the responsibility of professional societies; there are no plans for a central CME authority.
The rules for awarding accreditation hours or points are clearly spelled out, and limit such credits to educational parts of a program involving transfer or exchange of knowledge, individual and group training during a program and supervised training in skills during a program. Professionl societies will have discretion in awarding credits for internet education, staff meetings and individual activities such as teaching, preparing and presenting a paper, etc. -- Dr. C. C. Leibbrandt [cc@leibbrandt.net]
Mexico's biggest CME events
The second International Medical Forum (FIM) was held in Mexico City March 4-5. It was a great success with more than 6,000 Primary Care physicians attending for two full days. Twenty one lectures were given by Harvard Medical School professors and Mexican opinion leaders. FIM also held several symposia sponsored by the pharmaceutical industry. In 2006, FIM is expected grow to 10,000 physicians, including this time lectures for specialists. FIM 2006 will be on July 28-29.
Continuing in the same line, the International Cardiology Forum (FIC) will take place on August 25- 26, 2005. Some 2,000 cardiologists are expected, to hear lectures by Cleveland Clinic faculty. -- Ing. Pedro Vera Cervera [pverac@intersistemas.com.mx]
More diligence -- physicians, nurses and others should not make mistakes
Physicians should be more careful
Physicians should follow protocols
The researchers found these suggestions to be "unhelpful expressions of the name, blame, shame culture." Truly helpful suggestions, offered less frequently, included:
Provide care differently. For example, have walkers beside the beds of frail elderly persons to help prevent falls; involve clinicians in the design of information management systems; avoid overuse of steroids; store medicines in different areas if they may have dangerous interactions.
Improve communication. Explain diagnoses and treatment options more clearly to patients; set up arrangements for transferring responsibility for patient care among health-care professionals.
Offer more education to health care professionals and patients. Provide more resources, namely, more time, physical resources, money and research.
"A culture of individual blame is more evident than recognized need for systems design," the researchers said. There were few specific suggestions for changing systems to protect the safety of patients. They recommended setting up error reporting systems as a practical way to generate solutions to potentially harmful problems.
The conference of endocrinologists, held in Washington, DC, earlier this year, called for better information, education and a more coherent level of care in order to prevent medical errors. Dr. Richard Hellman of the American Society of Clinical Endocrinologists said that an estimated 50% of people with a chronic condition at some time experience a medical error in their care, or that of a family member.
He gave examples in the management of hospitalized diabetics: too much reliance on standard sliding scale doses of insulin; errors in sequencing tests; failure to deliver food on time after insulin is given. The specific recommendations from the conference included:
Create a culture of safety in which people work together, communicate and share information
Implement electronic patient records and information sharing systems
Reduce medication errors through use of computerized physician order entry
Improve coordination of care, focusing on teamwork among health professionals
Improved patient self-care through information and education
Where does continuing medical education fit into the strategies for correcting medical errors? Both reports described above emphasize development of teamwork, patient education and health information systems. Little emphasis is given to CME as a significant weapon in the battle to reduce medical errors. Is that because CME professionals have failed to utilize data of medical errors as a basis for educational programs? As CME becomes more outcomes based, there will be significant opportunities for programs based on the reduction of medical errors. Are providers and supporters of CME recognizing this need?
We'd like your opinion: What have you been doing along these lines? What other trends or opportunities do you see? Send an e-mail to dennis@wentzmiller.org, and we will share your thinking -- and doing -- with others around the world.
********* Back Issues Now Available! You can access past issues of the WM&A newsletter at www.wentzmiller.o rg.
Do you think it's feasible for continuing medical education to become truly global, as the following article suggests? Do you know of examples of CME programs that have been utilized by doctors around the world? We want to start a dialogue with readers on these questions. Send your comments to Lew@WentzMiller.org.
If pharma ad agencies are global, why not CME providers?
"The desire for cost savings, consistent branding and promotion, and quality control are driving [pharmaceutical] marketers to consolidate accounts with large global agency networks. The need to drive promotion beyond the commonly accepted markets of the United States, Europe and Japan comes as India and China have become more integrated in the international trade community."
So reads the opening paragraph of the lead article in the March 2005 issue of MedAd News. If consistency is important in pharmaceutical advertising around the world, should there be a similar consistency in continuing medical education around the world?
The answer from most agency heads would be yes. Ron Pantello, CEO of Euro RSCG Life, says that a network must have communication assets -- especially advertising, medical education, and public relations -- in the major countries that constitute 90% of the pharmaceutical industry's revenue. He notes that his agency has expanded its reach by adding medical education assets in key countries outside North America.
Publicis Healthcare Communications Group takes the same position. "You should have a medical education offering" to serve many markets, says its president, Nicholas Colucci. He and others point to a trend by some -- but not all -- major pharma companies to concentrate all their global advertising business in a single agency. A dissenting voice comes from Richard Daly, senior VP, Takeda Pharmaceuticals North America. He says, "I want the best people I can get for my CME. And sometimes they are not located in the same shop. So I'm not going to try to force an agency to have all those great things."
Are CME providers ready to work around the world? Remember, the emerging markets are becoming more and more important educationally. While some providers might be able to bridge from the US to Europe or Latin America, or vice versa, there will be a growing need to include not only India and China and Japan but also the Pacific Rim. At this time, there is a paucity of resources for CME in many of these countries.
Quality improvement in Denmark
Danish GPs are finding it much easier to quickly retrieve comprehensive and specific information on Internet databases during patient visits. This is being accomplished through Link Portal, a new service of the Danish Health Portal. The latter was launched in 2003 to share information among patients, GPs, pharmacies and hospitals through the Internet. Link Portal has been developed to ease the way of GPs to practice evidence based medicine.
Evaluation of this "point-of-care" system of CME is currently being evaluated as part of the Danish Primary Care Quality Project, a joint effort between the Danish General Practitioners Organization and the National Health Service of Denmark. The aim is to make quality development and integrated part of the primary health-care system, supported by financial objectives.
Other educational activities being carried out through groups of the Danish General Practitioners Organization include development of quality indicators for management of patients with diabetes, dementia and unspecific cough.
Don't miss GAME in June!
"Finally, Globalization of CME." That is the theme of the 10th Annual Meeting of the Global Alliance for Medical Education (GAME), June 19-21, 2005 in New York City. The keynote address will be given by Mike Magee, MD, senior fellow in humanities to the World Medical Assn. and vice president of Pfizer Medical Humanities Initiative.
Among the highlights of the program are:
What's happening to CME in Germany (recently mandated), Turkey and South Africa
Project Globe: a new initiative to improve the competence of generalists around the world
The contrasting world of medical education companies in the U.S. and Europe
Perspectives from 4 countries on managing commercial support of CME
An up-to-date look at e-CME and distance learning from experts in Canada, U.S. and Europe
GAME was organized to provide thought leaders in CME from around the world with an opportunity to learn and exchange ideas. Each annual meeting is organized to stimulate interchange. See www.game- cme.org for more information.
BUILD A STRONGER CME BUSINESS
If your organization needs help coping with the turmoil in U.S. CME, or in developing more international CME activities, the 9 associates and 2 principals of WentzMiller & Associates stand ready to come to your aid. Give us a call or send an e-mail to lew@wentzmiller.org.
Brazil, a country of 175 million people, has a National Health System which provides care to about 75% of the population, mainly through its Family Health System.
In many parts of the country, health teams consisting of a family doctor, nurse, nurse tech and community health agents, are each responsible for the health of 1500 families. They offer health promotion, disease prevention, clinical care and public health procedures. There have been "outstanding results" from this strategy, says Laura Feuerwerker of the Brazilian Ministry of Health.
There are problems, however. Ms. Feuerwerker notes the difficulty of expanding the strategy to big cities and linking the system to secondary level health units. Others have noted that many of the "family" doctors lack training as such, and may be specialists who couldn't find a position elsewhere.
Brazil has yet to create a continuing medication education system, though there are many CME programs in existence. But it is not clear that much is being done yet to systematically upgrade the competence of the family health professionals, despite a recent agreement between the Ministries of Health and Education to build initiatives in undergraduate, graduate and continuing education. There is also an effort by the Innovare Institute to develop and disseminate inovations and creative solutions for health professions education, health management and primary care.
A European Approach to e-CME
European Medical Network (EMN) has been launched with a 13- module program accredited by the European Board for Accreditation in Cardiology (EBC) on "Arterial Hypertension" (Course Director: Giuseppe Mancia, in cooperation with the European Society of Hypertension). A similar project on "Diabetes Management" is in development, plus clinical cases and further CME content.
EMN has developed and tested its concept in two field trials with 100 participants in six European countries, endorsed by the Union of European Medical Specialists (UEMS) and co-funded by the European Space Agency (ESA). Its main features, according to EMN CEO John Winistoerfer, are:
e-CME should be more than text-on-screen, hence the use of multimedia (audio, video, animations)
the lingua franca for the average European primary care provider, EMN's target participant, is his/her mother tongue, hence all EMN original contents are available either in English, German, French, Italian or Spanish (in preparation)
providing CME from the experts, i.e., from an internationally faculty of renowned opinion leaders
maintaining a fully independent status - as a Swiss private organization- providing original core content with full European accreditation
Scheduled for launch in April is a regular "General Practice Update" on a monthly disease area such as gynaecology, with distance-learning modules highlighting topics of current interest such as hormone replacement therapy and pre-natal screening, followed by a live virtual conference with the authors and chaired by EMN's Medical Director and WM&A Associate, Dr Leonard Harvey. (www.emn.net)
Don't miss GAME in June!
"Finally, Globalization of CME." That is the theme of the 10th Annual Meeting of the Global Alliance for Medical Education (GAME), June 19-21, 2005 in New York City. The keynote address will be given by Mike Magee, MD, senior fellow in humanities to the World Medical Assn. and vice president of Pfizer Medical Humanities Initiative.
Among the highlights of the program are:
What's happening to CME in Germany (recently mandated), Turkey and South Africa
Project Globe: a new initiative to improve the competence of generalists around the world
The contrasting world of medical education companies in the U.S. and Europe
Perspectives from 4 countries on managing commercial support of CME
An up-to-date look at e-CME and distance learning from experts in Canada, U.S. and Europe
GAME was organized to provide thought leaders in CME from around the world with an opportunity to learn and exchange ideas. Each annual meeting is organized to stimulate interchange. See www.game- cme.org for more information.
BUILD A STRONGER CME BUSINESS
If your organization needs help coping with the turmoil in U.S. CME, or in developing more international CME activities, the 9 associates and 2 principals of WentzMiller & Associates stand ready to come to your aid. Give us a call or send an e-mail to lew@wentzmiller.org.
In this Special Issue, we bring you the results of an important new survey of CME/CPPD in the major markets of Europe. This was conducted by WM&A Associate Dr. Helios Pardell, head of Spain's CME Accreditation Council, and presented first at the annual conference of the Alliance for CME in San Francisco January 29. Your comments and questions are welcome.
CME and CME Accreditation in 5 Major European Countries
The survey was based on responses from the following CME leaders for their countries:
FRANCE Hervé Maisonneuve, Yves Matillon GERMANY Martin Butzlaff ITALY Alfonso Negri, Riccardo Vigneri SPAIN Luis Pallarés, Helios Pardell UK Edwin Borman, Howard L. Young
The demography of each country follows:
FRANCE Pop:60 million #Drs: 190,000 50% GPs 50% specialists
GERMANY Pop:82.5 million #Drs: 381,000 26% GPs 74% specialists
ITALY Pop: 57 million #Drs: 330,000 40% GPs 60% specialists
GERMANY: Yes, at regional level; accredits providers & events
ITALY: Yes, national and regional; accredits events
SPAIN: Yes, national and regional; accredits events (also providers in Catalonia)
UK: Yes, national; accredits events, providers in some cases
In Spain and the UK, the national health authority is responsible for the accreditation system, working with the medical societies (and in Spain, with universities and the ministry of education). In Germany and Italy, medical associations are responsible for the system. All 4 countries accredit both on-site and distance learning, with credits based on hours and type of event.
Is CME mandatory? Yes, in Germany, Italy and Spain - - and by law in France, though not yet implemented. In the UK, CME is part of the revalidation requirement, as it also is in Germany (though not yet implemented). In Germany, Italy and the UK, physicians are compelled to collect a minimum number of credits; in Spain there is a recommendation but no requirement. Penalty in Germany is temporary license suspension.
Finally, is there regulation ofcommercial sponsorship of CME? The answer is Yes -- everywhere but France, although the regulation differs in strength. This survey did not address the requirements of the European Accreditation Council for CME, which also has restrictions.
Need a "Second Opinion" or strategy assistance about your organization's CME endeavors, in the U.S. or globally? Call WentzMiller & Associates! We'll quickly let you know if we can help, through our 5 principals and associates in the U.S., or through our 7 colleagues abroad.
As we start the second year of WentzMiller & Associates, we appreciate the support of our 2004 clients -- and hope to add your organization to the list:
Health Advances
Health Information Technologies
International Guidelines Center
Pfizer Medical Humanities Intiative
Veritas Institute of Medical Education
Australia's GP CPD Program Hailed as 'Model'
The Quality Assurance & Continuing Professional Development Program (QA&CPD) of the Royal Australian College of General Pracrtitioners (RACGP) has been given high marks by the Australian Medical Council in its recent Accreditation Report.
The report described the program as "well thought out," with an emphasis on activities "that demonstrated evidence of an influence on practitioner performance." The AMC team encouraged other specialist groups to consider the RACGP program as a model to consider.
Australia has some 20,000 GPs, 17,000 of which passed minimum participation levels in a recent 3- year period. Since 1989, the Commonwealth has required GPs to participate or have a reduction in payments for services.
During a 3-year cycle, a GP must accumulate 130 points, 30 of which must fall into Group 1 activities, which include clinical audit, supervised clinical attachment, learning plan development, and small group learning. Group 2 activities include seminars, multi-media CME and other courses. More than 2,000 providers are accredited to provide the programs -- and didactic programs are frowned upon! (www.racgp.org.au)
Dennis Wentz on the Road
Dennis Wentz made a late fall visit to the Himalayan kingdom of Bhutan, to experience high altitude trekking, but also to observe a productive blend of Western Medicine with traditional healing. The medical doctors, largely trained in India, are comfortable making rounds with traditional healers, and patients demand both. Bhutan is a 100% Buddhist community.
Dr. Wentz also spent time in Bangkok learning about the new Center for Continuing Medical Education (CCME) of the Medical Council of Thailand, as a guest of Professore Somkiat Wattanasirichaigoon, MD. The new mandatory system of CME reporting in Thailand uses a central repository of CME activity maintained in an individual physician transcript. The new system has been well received by the doctors of Thailand who no longer need to keep their own individual CME records.
WentzMiller was represented by Dennis Wentz at the special "Vision and Planning" meeting of the Pan- American Federation of Associations of Medical Schools in Caracas Venezuela in November. Attending the meeting were the Deans of medical schools in Latin and South America. David Hawkins, MD, Executive Director of the Association of Canadian Medical Colleges was a special guest.
Associate Helios Pardell in Latin America
Dr. Helios Pardell, a WentzMiller Associate and executive director of the Spanish Accreditation Council for CME, recently acted as international adviser to CME initiatives in Uruguay and Chile. "They are highly encouraging and could become the very first nationwide and comprehensive CME accreditation experiences in the Latin-American context," he comments.
In recent years, Uruguay has implemented a nationwide CME accreditation system, led by the Medical School of the "Universidad de la República" (Montevideo). It is based on accrediting provider institutions; in 2004, CME events accreditation has been introduced. Currently, a new regulation of the National Commission of Continuing Medical Education is under preparation, mainly aimed to externalise it from the University, incorporating new partners such as the Ministry of Health, the Medical Professional Associations and the Medical Societies.
In the same way, the Medical School of the University of Chile is now interested in promoting a nationwide CME accreditation system. This project could be strongly connected with the Uruguay experience, taking advantage of their similarities.
