CME credit, relicensure (revalidation) and recertification are linked to the abilities of physician to assess their own needs and select learning activities to meet those needs.
In a literature search of comparisons between self and external assessment, 13 of 20 studies demonstrated little, no or an inverse relationship; 7 a positive association.
A number of studies found the worst accuracy in self-assessment among those who were the least skilled.
Conclusion: The preponderance of evidence suggests that physicians have a limited ability to accurately self-assess.
Kevin Eva PhD, of the program for Educational Research and Development at McMaster University, echoed these findings, based on an article that he and an associate wrote in Academic Medicine (October 2005 Supplement):
The archetype of the self-regulating professional will reflect regularly on practice, self-assess gaps, seek to redress these, and incorporate new knowledge and skills in practice.
All but the very highest performers tend to overestimate their ability.
Those most in need of improvement are those least likely to know.
Conclusion: A critical premise (self-assessment) underlying the concept of self-regulation is unsupportable.
Eva then listed some specific implications for physicians based on a search of related literature in self-efficacy and self-concept, cognitive theory, social cognition, expert performance and reflective practice. Here are some of his findings:
We can never create a good "self-assessor" -- and probably shouldn't try.
Learners rarely spontaneously face the failures that enable better judgements of learning.
We know little about the extent to which physicians intentionally seek external assessments.
Doctors need coaches to motivate them and to help them understand the boundaries of their abilities.
Reflection in practice is highly important for ensuring safe and effective practice.
Once attendees at the conference recovered from the shock of discovering that self-assessment in itself is not a desirable goal, they focused on two cardinal rules for directed self- assessment:
Determine how to combine self and external assessment into a working system that truly will improve physician competence.
Convince physicians and educators that external assessments are legitimate and should be sought.
Robert Galbraith MD, director of the Center for Innovation of the National Board of Medical Examiners (U.S.), offered his approach to these principles, based on development of practice/work profiles for individual physicians, linking these to multiple-choice questions to test knowledge, and in turn adding external assessment in the forms of comparison to practice norms and mentoring. These steps, he suggested, can assist the physician in closing the gaps in knowledge and skills in a process of continuous improvement. And continuous improvement requires continuous monitoring of performance.
There are parallels here to the new system of revalidation in the UK, though this was not mentioned at the summit. Whether the UK system is working or not is another question. Here is a recent e-mail query to members of the TUFH (Towards Unity for Health) Network: "We are looking for any published evidence on the impact of CPD/revalidation on the performance of (health) professionals."
On a macro basis, there are many knowledge self- assessment exams available, primarily through specialty organizations such as the American College of Physicians, American Society of Clinical Oncology, American Psychiatric Association, and others. These are based on the most up-to-date evidence- based guidelines. But the problem is linking these to an individual's practice profile, which is not readily available in most countries.
The American Board of Medical Specialties is struggling with this problem as it pursues a goal of maintenance of certification based on self-evaluation every 1-3 years and an exam only every 10 years. One element is a practice improvement module based on chart review, a patient survey and a practice survey. Some specialty societies have begun to implement this on an experimental basis.
Then there is the question of what governments will require. As noted, the UK has imposed a mandatory revalidation system combining self-assessment with practice profiling, aided by a mentor. Canada is moving in a similar direction. The U.S. Federation of State Medical Boards is seeking to move from a mandatory credit-hour basis in most states to measurement of the ongoing competence of a physician -- one that the medical community, legislators and voters can accept. But many countries still have no relicensure requirements in place.
And we haven't even mentioned the role of hospitals in requiring evidence of competence and monitoring performance.
The lesson from the CME Summit is clear: We can no longer rely on the individual physician to structure his/her own approach to CME based on self-assessment. There needs to be another component, however crudely designed, to provide some outside direction to identifying individual needs based on a practice profile.
How well do you know yourself?
That's the question we discuss this month -- in relation to doctors -- but it applies to educators as well. Then we examine the coming crisis in managing health care, and the role CME leaders can play.
Global health care headed for trouble
A new IBM study concludes that many healthcare systems around the world will become unsustainable by 2015, unless changes are made in how health care is funded, delivered and evaluated.
What are the major problems? The IBM experts point to rising health care costs, inconsistent quality, focus on episodic acute care, lack of emphasis on products/services that improve outcomes at lower cost, and lack of society and government will to make rational decisions.
The report says that these factors are on a collision course with a fundamentally new environment driven by globalization, consumerism, demographic shifts, the increased burden of disease and expensive new technologies and treatments. Healthcare systems that fail to address this new environment, the report says, will "hit the wall or collapse."
What is the answer? The IBM study says there must be a focus on value, in which consumers, payers and providers agree upon the measures of healthcare value and restructure the system of service delivery and reimbursement accordingly. Consumers need to make sound lifestyle choices (easier said than done!), say the authors, "and become astute purchasers of healthcare services".
CME providers can be part of the restructuring, by emphasizing in their offerings to physicians:
Management of chronic diseases
Prevention of illness
Patient empowerment
Cost-related outcomes management
Teamwork within the healthcare system
Ensuring the quality of care in Europe
The European Union of Medical Specialists (UEMS) is discussing a new policy document -- not yet posted on its website -- to define the means by which the safety and quality of care provided by doctors is ensured through regulation.
In the report, UEMS calls on all groups involved to respect the "primacy of the medical profession in regulating medical care", yet also to recognize that any regulatory system must reflect the expectations of society and the resources available. The areas in which regulation is achieved are described as:
The setting of standards and ethics for medical practice
The basic, specialist and continuing education of doctors
The accreditation and registration of practitioners
Intervention when practice standards are not met
In relation to education, the report emphasizes that every doctor has a responsibility "to ensure that they are appropriately trained for the care they provide and that they incorporate into their practice effective and proven new developments in their field".
Other key recommendations include the use of health professional teams learning together, joint practice audits, adequate funding by employers, the setting and monitoring of standards by national regulatory bodies, and the further development of the European Accreditation Council for CME (EACCME) in order to ensure "a robust regulatory basis for the free movement of patients and doctors".
The report on regulation is the final paper in a UEMS trilogy relating to quality. The first two, which appear on the UEMS web site, are "The Basel Declaration" (2001) on continuing professional development and "Promoting Good Medical Care" (2004) on quality assurance.
Effects of professional isolation in New Zealand
"Professional isolation is importantly associated with substandard clinical performance," says Dr. Ian M. St. George, medical adviser to the Medical Council of New Zealand, in an article in the Journal of Continuing Education in the Health Professions.
In his research, Dr. St. George called on 16 members of the Council's Competency Advisory Team to define and weight the markers of professional isolation. In order, they are:
Personality
Solo practice
Poor colleague relationships
Outlier practice
CPD failure
Specialist in only private practice (in New Zealand, most also work in public practice)
Stress, no relief, complaints, job satisfaction
Locum, itinerant or part-timer
Cultural barrier
Male gender
Geographic isolation is not necessarily a criterion, the author states. Many rural physicians find ways to bond with others, while some town physicians who choose solo practice and lack personal insight and/or humility may be professionally isolated. And the isolated physician often fails to keep up with CPD requirements, and is never seen at local conferences.
The internet provides useful learning, but doctors also need social interaction to reduce professional isolation and to improve performance, Dr. St. George suggests. Early recognition of a colleague's isolation may lead to interventions to prevent or rehabilitate underperformance.
European respiratory specialists differ on internet CME preferences
The learning preferences of 160 respiratory specialists from 4 European countries were studied by Prof. C. M. Roberts of St. Bartholomew's and the London School of Medicine and colleagues. They had participated in 10 internet-based learning modules, and generally were enthusiastic about the process, according to his article in Medical Teacher.
The modules were designed to test internet delivery of self-directed learning, social or group learning and use of multi-media. Clinical questions could be sent to a tertiary care specialist; there were case- based quizzes, journal club discussions, audio and video presentations, and Powerpoint lectures. However, there were some technical difficulties reported by the study participants, not all of whom had capability for high- speed internet, video or audio cards, etc.
Were there country differences? A few: UK respondents were less likely to find references helpful and thought learning from the lung-sounds audio module was poor. Both UK and German specialists were less likely to want to participate in discussion than Italian and French doctors. The French were impatient to get answers quickly and were not accustomed to journal club discussions. Italians were generally satisfied! The author concluded that while internet learning was generally accepted, more incentives are needed to get full participation.
Call for practice guidelines abstracts
The Guidelines International Network (G-I-N) has announced a conference on "Collaboration in Clinical Practice Guidelines" to be held August 22-25, 2007, in Toronto, Canada. The goals are to learn from each other's progress and challenges, to exchange concrete products and to undertake concerted action in developing and updating guidelines. Abstracts are being sought.
Need help in developing a CME strategy?
WentzMiller & Associates has the expertise to assist in your efforts, whether global or regional. Through its staff of consultants in the U.S., Europe, Latin America and Asia, WM&A has worked with clients in the CME and pharmaceutical fields to improve approaches to accreditation and needs assessment techniques, to help plan online CME, and to create learning systems for developing countries. Contact Lew Miller at 203 662-9690 or lew@wentzmiller.org.
The "new CME" is focused not only education but also on practice improvement by the physician and to an extent by the system in which the physician works. The CME provider must "utilize non-education strategies to enhance change" and "identify factors outside the provider's control that impact on patient outcomes". These are no small tasks!
Who will pay for the "new CME" in America? Currently the pharmaceutical industry is funding more than 50% of the cost. But as noted in previous issues of this newsletter, there may be a reduction in pharma funding because of the reorganization of the CME grant-making process.
Primarily because of Federal government intervention to force separation of education from marketing, companies have shifted control of CME funding from marketing managers to medical education managers reporting to the scientific divisions of their organizations. This new breed of funders is expected to function independently of marketing objectives. Marketing managers, however, still control the bulk of the funds -- within their product categories -- and are reluctant to relinquish control when they are measured by increased sales, not performance improvement of physicians.
What's more, the distribution of CME funding in each company is now concentrated in the hands of a few medical education managers reporting to a single manager or "czar", who (a) is inundated with grant requests that used to be spread across scores of marketing managers and (b) is moving to limit access to grants to a comparatively small number of accredited providers who are academic institutions or specialty societies. Recently, medical education and communications companies (MECCs) have been receiving about half of all pharma grant funding.
That may not continue. One pharma medical education manager told us at a recent national meeting, "MECCs can no longer consider pharma companies as clients; academic medical centers are now their clients." Another manager will no longer accept any grant application from a MECC, whether that organization has been accredited by ACCME or not. And a third concluded that "MECCs in general are mediocre at CME; maybe they can function as meeting planners for medical schools or societies." This despite 2005 grants of $595 million to MECCs (mostly by marketing managers)!
Is the "new CME" in America going in the right direction? For those of you who might be tempted to emulate America's "new CME", here are some questions to consider:
Who is responsible for improving physician performance? Government? Employers? Health care systems? CME providers?
Are educators qualified to measure performance improvement?
If not, who will train them and how?
Are the data sets available, particularly in ambulatory care, to measure competence or performance?
Is there clear evidence that competence leads to improved patient outcomes?
Are academic medical centers and specialty societies capable, and motivated, to carry out the innovation necessary to implement the new requirements?
How will the funding changes within pharma impact the system?
Are pharma companies willing to support performance improvement, regardless of the impact on their sales?
We note that in the UK, performance improvement falls within the National Health Service's program of revalidation of physicians, and that CME is simply one part of the process. Which is a better model to emulate -- or avoid? We encourage your comments (to lew@wentzmiller.org).
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America and Europe: new directions
We follow last month's discussion of performance- based vs. traditional CME with confirmation that in America, CME is now required to focus on performance improvement. And we revisit efforts to harmonize CME accreditation systems in Europe. Isn't global CME an exciting field?
Robin Stevenson, president of the European Board for Accreditation in Pneumology (EBAP), speaking at the meeting of the Association for Medical Education (AMEE) in Europe in Genoa last month, identified the players in the system:
CME providers
National Accreditation Authorities
EACCME and its parent, Union of European Medical Specialties (UEMS)
The main problems with harmonization, Dr. Stevenson said, are these:
The NAAs are jealous of their independence and unwilling to recognize a European body;
There is a different system in each country;
The governance of EACCME is restricted to the Management Council of UEMS;
The ESABs are recognized by their specialties but often not by EACCME or NAAs.
What is the solution? Dr. Stevenson proposed the establishment of "a reformed EACCME comprising major stakeholders with executive powers, and including UEMS, NAAs, ESABs (and their UEMS sections), CME providers and postgraduate medical schools.
The reformed EACCME, he said, would carry out these responsibilities:
Define accreditation standards
Accredit ESABs for international CME
Accredit NAAs for national CME
Regularly review performance of ESABs and NAAs
Review critically current practice vs. alternative models
Remit an appropriate fee to UEMS
Christina Fabian, president of UEMO, reported that UEMO is seeking to become a legal body under Belgian law (as is UEMS). Once that occurs, probably in 2007, discussions will continue about creation of an accreditation council. Dr, Mateja Bulc of Slovenia is responsible for the UEMO process.
Coincidentally, the current president of UEMS, Zlatko Fras, is also from Slovenia. UEMO and UEMS have had some discussion about UEMO working through EACCME.
Will the French ever get there?
"It could take 20 years," said Hervé Maisonneuve, CME manager at Pfizer, Paris, in a presentation at AMEE in Genoa. The effort began in 1996, and attempts to organize a CME system have been unsuccessful ever since.
There has been some progress, Dr. Maisonneuve reported. A new law, passed in 2004, requires CME, including clinical audits. Committees to design the system have been set up for hospital physicians, community physicians in private practice and for doctors working in other settings. There is also a coordinating committee including representatives of these bodies and the Health Ministry. Unfortunately, the committees have never received the public funds that were allocated for their work, which must include:
Listing the national CME objectives
Publishing rules to accredit providers
Accrediting providers for 5 years
Evaluating providers' annual reports
Accrediting bodies to do external audits of providers
Providers of clinical audits will be accredited separately, Dr. Maisonneuve noted, and 23 have already been accredited and started to propose activities.
He is pessimistic about resolving the problems that are delaying the implementation of the system:
Funding is key, and unclear
Medical unions are battling
Incentives have to be defined
Doctors have other priorities, given a major shortage of physicians
The political agenda may change tomorrow
Why does society ignore CPD?
"Society in general fails to provide meaningful support to the field of continuing professional development (CPD)," Dennis Wentz said in a talk at the 2006 AMEE meeting in Genoa. Using a phrase from a 2006 Lancet commentary, “Knowledge is the Enemy of Disease” as his centerpiece, he gave specific instances of substantial gaps in the application of important medical knowledge to front- line practice and patient care. Except for professional medical associations and medical specialty societies, few societal organizations provide any resources or time for quality continuing medical education.
Although the World Federation for Medical Education (WFME) has called for CPD “to be recognized as an integral part of medical practice reflected in budgets, resource allocations, and time planning”, this is clearly not the case. Of particular concern to Dr. Wentz is that major foundations have not provided any funding for the education of primary care practitioners or their health care teams, while they spend hundreds of millions of dollars focusing on vaccine development and eradication of specific diseases.
Most national medical systems consider CME a doctor’s issue, not a health system problem. Only 5 countries or health ministries provide funding or financial incentives. Dr. Wentz concluded that the field of CPD must become energized to be a better advocate for its key role and importance in the lives of doctors and the betterment of care for patients.
How will the code affect continuing medical education? Very little, in those parts of the world in which the pharmaceutical industry already has strong guidelines, such as US and Europe. But since most countries and pharmaceutical companies around the world are signatories, CME sponsorship and other practices will be more tightly regulated in those regions where controls have been lax.
Here are some of the elements in the new code:
All events for physicians must have a clear educational purpose -- either to inform about products or provide scientific information.
No sponsorship permitted for individuals attending an event outside the country unless it is an international scientific congress or symposium.
Companies must avoid using renowned or extravagant venues for educational events.
Companies may not pay more for meals than physicians would normally "be prepared to pay for themselves."
No personal gifts are allowed; promotional gifts must be of minimal value and relevant to practice.
But sponsorship payment is still permitted for travel, meals, accommodations and registration fees.
Educational efforts have been launched in some countries regarding the new code. For example, pharma companies in Mexico have been informed of the code, and may restrict to some extent their investment in educational events starting in 2007.
There may also be some changes in Australia. A recent survey of medical specialists showed that a high percentage were offered meals, personal gifts, items for the office, and travel to conferences. Among the gifts were tickets to sporting events, entertainment and travel expenses for spouses. In Britain, where pharma guidance is more restrictive, business travel for physicians is no longer acceptable.
Medical schools in the US are going even further in limiting the activities of pharma companies. Stanford University just announced that it will bar physicians working at its two hospitals from accepting even the smallest gifts from drug sales representatives. "Gift giving creates a reciprocal obligation that is a powerful force," says David Magnus, director of the Stanford Center for Biomedical Ethics. Yale University and the University of Pennsylvania have announced similar policies, in part as a response to an article in the Journal of the American Medical Association last January, which said that current relations with pharmaceutical representatives created conflicts of interest in academic medical centers.
In the U.S. Senate, an investigation has started into the use of educational grants by pharma companies. The concern is that grants are awarded to medical specialty groups to promote products, especially for off label use.
To counteract this concern, there are proposals that pharma grants be channeled into one or more not-for- profit organizations, which would dispense grants to educational organizations according to identified needs, without regard for product category.
It appeared this might be happening when Wyeth Pharmaceuticals recently awarded the first “block grant” to a coalition of five state medical societies. However, the grant will be used to fund outcomes- based CME activities focusing on the treatment and diagnosis of depression and anxiety. Each activity will include an evaluation component to measure changes in physician practice. Grants to state medical society accredited CME providers will be awarded by a special committee within each participating society – Colorado, Georgia, Florida, Massachusetts, and Oklahoma. For more information contact Robert L. Addleton, EdD, Director of Education, Medical Association of Georgia, bob@mag.org.
, adopted by the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA). The code will go into effect in January 2007.
Changes in the wind!
Two critical trends are emerging, and reported here: First, the effort by the pharmaceutical industry, often under pressure, to separate marketing from education. Second, the move away from traditional CME to performance-based CME. Both have long- term implications for those of us in the field.
Will CME stay traditional or become performance based?
Hospital doctors in Wales prefer traditional forms of continuing education (reading, lectures and meetings) and have not yet accepted newer clinical governance frameworks that encourage doctors to focus on professional and healthcare outcomes when determining personal learning objectives. These are results of a survey recently reported in Medical Teacher.
"Learning around clinical topics from colleagues and experts continue to be central," the authors said. "While doctors continue to assume that CPD is simply a matter of updating clinical knowledge and skills and that this can be relied on to produce changes in clinical practice, the individualized model will continue unchallenged."
Despite mandatory credit requirements, many physicians share the feeling that CME is simply their professional responsibility -- as it was for many years. Now pressures are building to make doctors responsible to the public, through government agencies, for proving their competence in practice.
The UK is ahead of most countries in implementing a system of clinical governance designed to improve patient care, of which CME is simply one part. In the US, a push is on to emphasize performance improvement as the principal measure of the effectiveness of CME.
Here is a summary of three such efforts:
The National Alliance for Physician Competence, a multi-sponsor organization formed by the Federation of State Medical Boards, is seeking to define a new system for determining, measuring and assuring physician competence. A Good Medical Practice document is in preparation, and another summit meeting will be held within the next few months.
The AMA has convened the Physician Consortium for Performance Improvement to develop and test evidence-based clinical performance measures and outcome reporting tools. More than 100 organizations are involved. Almost 100 measures on 17 clinical topics have been defined.
The AMA is also moving ahead with its Initiative to Transform Medical Education, to change the entire continuum of medical education, including CME. Point-of-care learning and quality improvement activities are being emphasized.
A new way to keep up in the developing world
A joint initiative between WHO and about 90 scientific publishers has transformed patient care at a university hospital in Kenya, where students and their teachers have Internet access to the latest research findings. So reports the Bulletin of the World Health Organization.
The Health InterNetwork Access Research Initiative is a gift by WHO to academic institutions in developing countries, providing them with free online access to 3300 scientific journals. "My colleagues and I are able to provide the latest medical care for our patients here in Nairobi," says Dr. Hilary Rono of Kenya, "instead of having them taken to the developed world for treatment."
What's ahead in international meetings
As this issue goes to press, Lew Miller and Dennis Wentz are headed to Genoa, Italy, to participate in the annual meeting of the Association of Medical Education in Europe (AMEE) September 16-18. Both will be speaking on CME. Other CME-related sessions coming up:
The field of CME is changing rapidly around the world, as this issue of the newsletter indicates. You can help your staff and your CME clients keep up to date through the resources of WentzMiller & Associates. We have conducted research and education programs on the separation of pharma marketing from CME, new directions in e-CME, and integrating US and international approaches to CME. Contact Lew Miller, lew@wentzmiller.org, 203 662-9690, or Dennis Wentz, dkwentz@aol.com, 970 845-9910.
The latest report from the US Accreditation Council for Continuing Medical Education (ACCME) presents these findings:
The number of CME activities in 2005 -- 19,107 -- is up 19% from 2004 and over 1000% from 2000.
In 2005, e-CME comprised 24% of all CME activities, up from 21% in 2004 and 3% in 2000.
The number of e-CME credit hours in 2005 -- 37,000 -- is up 32% from 2004 and 520% from 2000.
The total of physician e-CME participants (includes multiple visits) was up 53% in 2005 over 2004, and more than 1000% over 2000.
Internet-based learning also takes place at non- accredited sites, such as through searches of literature databases, pharmaceutical company sites and medical society sites. In the US, there are a few accredited providers offering specially designed "search and learn" activities for which credit can now be given.
Outside the US, more and more physicians are also turning to the Web for e-learning, though in many countries, accreditation of e-CME has been opposed because of fear of the difficulty of controlling content and the learning process. In Europe, Spain has been accrediting e-CME for some time, and Germany is starting to do the same. It won't be long before the rest of Europe follows suit.
At the GAME meeting, Dr. Bernard Maillet, secretary general of the Union of European Medical Specialists (UEMS) and head of the European Accreditation Council for CME (EACCME), predicted that EACCME would start accepting Web-based applications for credit by September. In Italy, Dr. Alfonso Negri, a leading CME accreditor, suggested his country might take similar action by year-end. In answer to the question, "Why the lag in accrediting distance learning?", Dr. Maillet replied: "We have to convince 25 national authorities to accept it. This is not easy; they think we are the devil!"
Malaysia has accredited e-CME since 2002, said Dr. P. Krishnan, chairman of CPD, Malaysian Medical Association. "But a doctor must get 6 of 10 answers correct on a post-test to earn a credit," he commented, "and only 158 did so last year."
Is e-CME as effective as live learning? It depends on how well each delivery method is used -- if there is adequate needs assessment, use of interactive modules, and good outcomes measures. At GAME, Dr. Michael Fordis of Baylor College of Medicine presented results of a major study comparing efficacy of e-CME and live workshops, which demonstrated that e-CME had an edge in obtaining behavior change.
Clearly, Internet-based learning is on a rapid rise, and offers many benefits to physicians. Low-paid doctors who can neither afford the time off nor the cost of live courses can access e-CME at any time and at their own pace. The cost is nominal, except for a few high-priced courses. Top global experts are often the presenters. And case-based learning can involve the learner in a private environment where he/she can compare responses with those of the experts as well as with those of their peers.
What's missing is satisfying the very human need to interact in person with your peers. And there are still too few experts in constructing effective e- CME; many courses are simply talking heads. Nonetheless, the benefits of e-CME outweigh the drawbacks. It is the CME of the future. Do you agree? Let us have your opinion. Send to lew@wentzmiller.org.
from the US Accreditation Council for Continuing Medical Education (ACCME) presents these findings:
E-CME and other surprising trends
In this issue, we report the rapid growth of e-CME in the latest US statistics, and the changing climate for acceptance in Europe. We also examine trends in pharma spending for CME, and changing perceptions of CME's role in the world around us. You can access reports or more data by clicking on any word(s) underlined.
Can CME aid in peacebuilding?
Yes, say the organizers of the Canada International Scientific Exchange Program (CISEPO), organized 10 years ago to bring together Israeli, Jordanian and Palestinian health care professionals through continuing education initiatives designed to build collaborative partnerships and to contribute to peacebuilding.
In May 1998, CISEPO brokered the formation of the Middle East Association for the Management of Hearing Loss (MEHA). A research study reported on recently by Abi Sriharan of the Silverman Centre for International Health, Mount Sinai Hospital, Toronto, identified why health professionals participate and how and why this model of cross-border CME has been successful.
CME: One underutilized tool to stop the "brain drain"
Innovative approaches to teaching and innovative uses of information technology for continuing education are critical to maintaining and increasing the supply of qualified health care workers in developing countries. So says a report from the 59th World Health Assembly held last spring under WHO auspices.
The Assembly recognized that health-worker shortages are interfering with efforts to achieve international health care goals, particularly in developing countries. The best doctors and nurses often migrate to developed countries, and their native lands lack the financial means, facilities and educators to build a trained healthcare force that will remain to take care of their own populations.
The Assembly seeks to promote partnerships between medical schools in industrialized and in less developed countries, based on human resources development. A part of the program includes promotion of innovative methods of continuing education through technology.
Surprise: Sustained strength of US CME financing by pharma
There were dire predictions in the past year that pharmaceutical company funding of certified CME in the US would fall dramatically because of increased federal regulation of the pharma industry's promotion and education practices.
This did not happen, according to the 2005 annual report of the Accreditation Council for CME (ACCME), released in July.
The overall expenditure for support of certified CME activities rose to an alltime high of US$2.25 billion in 2005, up 9% from the year before, and up 77% from the year 2000. The amount attributable to commercial support, mostly from the pharmaceutical industry, rose to US$1.1 billion, up 8% from a year ago, and up 139% from 2000. There had been fears among CME providers that this amount would decline between 10- 20%. Some providers believe that a decline will surface this year as a result of structural changes in pharmaceutical companies that clearly separate educational support from marketing and promotion.
What else did the report disclose? Here are some critical findings:
Government/military organizations increased their CME income by more than 300% to $72 million, and almost broke even, compared to a loss of $55 million a year ago.
Physician membership organizations went up only 5% to $704 million in income, about half of which came from commercial support and advertising/exhibit income; they showed a "profit" of $256 million.
Medical schools lagged behind, with only a 2% increase in income to $398 million (63% from pharma) and a "profit" of $65 million.
Publishing and education companies became the #1 category of provider, up 12% to $781 million (78% from pharma) and a "profit" of $182 million.
The data on income and expense (defined above as "profit") may not be an accurate reflection of expenditures by the 716 accredited CME providers, who must submit an annual report to ACCME each spring. What is apparent, besides the continued increase in pharma support, is that medical schools and physician membership organizations are losing ground compared to for-profit companies in the CME business. Is this a phenomenon of the US CME field, or will it become a pattern in other countries -- particularly where government support may predominate?
Educate your associates in global CME
The field of CME is changing rapidly around the world, as the excerpts from the GAME meeting indicate. You can help your staff and your CME clients keep up to date through the resources of WentzMiller & Associates. We have conducted research and education programs on the separation of pharma marketing from CME, new directions in e-CME, and integrating US and international approaches to CME. Contact Lew Miller, lew@wentzmiller.org, 203 662-9690, or Dennis Wentz, dkwentz@aol.com, 970 845-9910.
In this issue, we report on the formation of the Project Globe Consortium to bring CME to developing countries, and offer highlights and sound bites from the 11th Annual Meeting of the Global Alliance for Medical Education (GAME) just concluded in Rome.
Project GLOBE is now official!
In the making for almost 2 years, Project GLOBE is now a not-for-profit corporation with the mission of improving health care in developing countries through continuing education of primary health care professionals. Its official name: Project GLOBE Consortium for Continuing Professional Development.
The idea for GLOBE was hatched at the 1994 meeting of GAME in New York, in conversations among Lew Miller of WentzMiller & Associates; Dr. Pablo Pulido, head of the PanAmerican Federation of Medical Schools (PAFAMS), and Dr. Honorio Silva, vice president of Pfizer Medical Humanities Initiative. A trial balloon for the concept was rolled out at a meeting of world medical education leaders in Edinburgh in September 2004. A Steering Committee was formed in March 2005, addressing issues of needs assessment, content acquisition and delivery, and pilot country selection. Dr. Dennis Wentz joined the 3 founders on the executive committee, and in April 2006 the legal entity was set up to move ahead with a 3-year business plan.
Directors elected at the Organization Meeting: Drs. Alberto Oriol Bosch, Medical Education Foundation, Spain; Dave Davis, former dean of CME, University of Toronto, Canada; Hans Karle, World Federation of Medical Education, Denmark; Michael Kidd, Wonca, Australia; Pablo Pulido, Venezuela; Roy Schwarz, China Medical Board, US; Honorio Silva, US; Bruce Sparks, Wonca, South Africa, and Dennis Wentz, WentzMiller & Associates, US. Officers are: Dr. Pulido, president (pablopulido@cantv.net); Dr. Wentz, vice-president, and Dr. Schwarz, treasurer.
GLOBE's next step is to identify 2-4 pilot countries in which to test the concept, eventually one each in Latin America, Africa, Asia and Eastern Europe. What's needed for success in each country is a local leadership team which can carry out needs assessment, content delivery and outcomes measurement with front-line GPs; can work with national health authorities, and can cooperate with a local funding source. GLOBE will serve as the resource and technical assistance center. For 2006, funding has been assured by Pfizer Medical Humanities Initiative. Other funders will also be sought. Headquarters will be in New York City.
More from the GAME World Cup! (continued from Column 1)
Commercial support
"From country to country in Europe, there's a great difference in the role of pharmaceutical companies in CME." --Pardell
The pharma industry is not evil. We need a realistic, pragmatic approach, not as in Norway: "No Support". --Maillet
"The tougher standards in the US, including separation of education and marketing functions in pharma companies, will spread to the rest of the world." --Dennis Wheatley, IPCAA, UK
"In the UK, if an organization or any speakers have a conflict of interest, it must be declared." -- Starke
"In the US, any conflict of interest must be resolved!" --Lewis Miller, WM&A, US
"In Europe, we need clear guidelines on pharma paying for individuals to attend CME." --Dr. Wolfgang Grisold, Austria
"Physicians from Europe are sponsored to attend US meetings, but it's not permitted for US physicians." --Svetlana Lisanti, Belgium
"In Sweden, pharma must give the support money to the organization, not the individual; in the Netherlands, the physician must pay 50%." -- Wheatley
"In Malaysia, 25% of a CME program supported by pharma may be promotion; the balance must be unbiased." --Krishnan
GAME elects three, honors two
Three new members were elected to the GAME Board of Directors: Alejandro Aparicio MD, director, division of continuing physician professional development, American Medical Association; Helios Pardell MD, director, Spanish Accreditation Council for CME, and Paul PichôUpresident, Health Information Technologies, Montreal.
A highlight of the meeting was the presentation of 2 awards by Jim Arnott, president of GAME, and Maureen Doyle-Scharff, chair of the Awards Committee.
Cees Leibbrandt MD of the Netherlands received the Precepts of Hippocrates Award for outstanding service to the global field of CME/CPD as executive of the UEMS and first head of the European Accreditation Council for CME (EACCME). HE also pioneered the reciprocal EACCME-AMA credit recognition program with Dr. Wentz, then head of AMA's CPPD division.
Abi Sriharan, working toward her PhD in CME at University of Oxford, was the first recipient of the Innovation in Global CME/CPD Award. She conducted a multistage program evaluation of the World Federation of Neurology CME program in 36 low and middle-income countries.
Watch for the next issue of the WM&A Newsletter to read more highlights from GAME in Rome!
Educate your associates in global CME
The field of CME is changing rapidly around the world, as the excerpts from the GAME meeting indicate. You can help your staff and your CME clients keep up to date through the resources of WentzMiller & Associates. We have conducted research and education programs on the separation of pharma marketing from CME, new directions in e-CME, and integrating US and international approaches to CME. Contact Lew Miller, lew@wentzmiller.org, 203 662-9690, or Dennis Wentz, dkwentz@aol.com, 970 845-9910.
As more continuing medical education goes global, will it be as effective in the UK as in Brazil? In the U.S. as in Japan? How does culture affect our ability to communicate? These questions were addressed in recent talks to pharmaceutical and CME meeting planners by Carol Krugman, president/CEO of Krugman Group International, and Dean Foster, president DFA.
"If you enter a region, ask what its prohibitions are; if you visit a country, ask what its customs are; if you cross a family's threshold, ask what its taboos are." So wrote Li Ji in one of the Confucian classics in 500 BC. The rules haven't changed, said Foster.
Foster encourages us to look at three values when we enter another culture:
How do we relate to each other? Is the individual or group more important? Is the task or the relationship more important? Is status or rank more important than being of equal rank?
How do we view time? Is doing or being more important? Are we future or past-oriented? Are we risk-taking or risk-avoiding? Does the clock or do the people determine action?
How do we communicate with others? Is harmony more important than confrontation? Is it better to be direct or indirect? Are we outcome- oriented, process-oriented or holistic?
Understanding these factors is crucial both to negotiating CME relationships and to presenting effective programs. For example, in the U.S., a speaker may be effective striding up and down amid the audience, addressing questions to individuals at random, and gaining responses. In China, no one will respond to the speaker; senior professors only must be addressed in public.
A complicating factor, says Krugman, is determining levels of understanding. You may have failed to communicate if listeners ask no questions, nod and smile, say, "I think I understand".Krugman also raises the question of ethics. How are right and wrong defined? Behaviors that are condoned in some cultures are unethical -- and often illegal -- in others. Finally, she offered these quick and dirty classifications of cultural differences by region:
Germans, Scandinavians, Australians and North Americans conduct their activities by these principles:
What you do is more important than who you are
The individual is more important than the group
"Time is money"
Asians, Southern Europeans, Arabs and Latin Americans follow these behaviors:
Who you are is more important than what you do
The group is more important than the individual
Time is relative
In many cultures, particularly those in the "who you are" regions, Krugman adds, formality is very important. Better to hand out business cards early, to use last names and titles rather than first names. In advance, determine when to bow or shake hands, when to avoid eye contact, who in a group to greet first, whether gift giving and receiving is appropriate.
Krugman conducted a couple of "totally unscientific" studies of Europeans and Latin Americans vs. North Americans. Here's what she found: What bothers North Americans about non-North Americans?
Why can't they all speak English?
Why don't they loosen up?
What don't they just say what they mean, and mean what they say?
Why do they go at such a slow pace?
And what bothers the others about North Americans?
Why do they always act superior?
Why do they think they know all the answers?
Why don't they respect our customs and culture?
Why do they say they are flexible -- but don't compromise?
/why are they always in a hurry?
Krugman summarizes: "The Golden Rule says to treat people the way you want to be treated. Instead, follow the Platinum Rule: Treat people the way they want to be treated." If you have some cross-cultural lessons to share, please write to Lew@wentzmiller.org.
************************************* We welcome a new WentzMiller associate: Professor William J. Hall MD of the University of Rochester (NY). Dr. Hall, a graduate of the University of Michigan medical school, is certified in internal medicine and pulmonary disease with added qualifications in geriatrics. He is part president of the American College of Physicians, on the executive committee of the International Society of Internal Medicine and a fellow of of colleges of physicians in the U.S. Scotland, Malaysia and Panama. He has been a frequent speaker on geriatrics and pulmonary disease at congresses around the world.
Culture shock and credit shock!
In this issue, we discuss the kinds of cultural differences that can make or break CME programs around the world. And we take up the perennial issue of whether CME really makes a difference in competency and patient outcomes -- and whether it should be a mandatory basis for licensing of physicians.
·Do CME credits assure quality care?
That's the question raised (once again!) in a recent article in The Health Care Manager by authors who reviewed the literature on mandatory continuing education (MCE) of health professionals in an effort to find evidence that MCE affects clinical competency and patient outcomes. Their conclusion: It doesn't.
"CE programs have had little or no effect on performance-based outcomes. Evidence collected suggested few observable improvements by professionals in their practice following CE programs," the authors state. Further, they believe that CE "has digressed from the mission of helping health care professionals stay on top of their field to becoming a profitable business opportunity."
MCE is an accepted measure of professional competence required for relicensure not only in the U.S. but also in France, Italy, Germany and a number of other countries. Why? Because legislators and some professional societies perceived that health care professionals need to be committed to lifelong learning to retain and improve their competence. Requiring hours of CE credit appeared to be an easy way to accomplish the purpose.
But, as the authors of this review point out, there is no evidence linking CE credit hours to competence. One of the authors of this newsletter, Lewis A. Miller, suggests that legislators are providing their citizens with a false sense of security by mandating CE credits. He believes that it will be difficult to change the laws, but there is a way to reform the system: "Change the measure of CE credits from time to performance." Nancy Davis and Charles Willis have recently written in the J ournal of Continuing Education for Health Professionals about the need to change our accreditation systems from hour-based measures of “butts in seats” to systems that award credits based on improved healthcare outcomes.
Efforts are already underway in the UK, the U.S. and Canada (see below) to do just that. The U.K. has no required credit hours. CME is part of the individual's professional responsibility to maintain knowledge and skills in his/her areas of practice. It becomes part of a total portfolio of practice improvement that leads to revalidation of license. In the U.S., the American Medical Association has signed a pact with the Congress to develop more than 100 standard measures of performance. By 2007, doctors may voluntarily report on 3-5 quality measures in their practices to the federal government. Five other U.S. medical groups have banded together on an initiative titled Improving Performance in Practice. These can become the first steps in reforming the credit system.
·Re MCE, most doctors in Jamaica are practicing illegally
An article in the Jamaica Observer newspaper recently stated that 60% of doctors in the country are "unlicensed and practicing illegally" because they have failed to complete the mandatory hours of CME.
The law requires that all 1,577 Jamaican doctors must re-register by January 31 of each year. To qualify, each must show completion of 10 hours of CME. In 2006, a month after the deadline, only 30% had complied. The Medical Council registrar believes that many doctors have not participated in CME. The president of the medical association claims that doctors are often so busy they don't have time to re- register. The penalty: Double the renewal fee after one year, and after that, a doctor may be stricken from the register, and lose the right to practice.
·Canadian CME is also evolving
Accreditation systems in Canada also are evolving to accommodate new forms of learning, technology and practice. The College of Family Physicians of Canada (CFPC) has been awarding credits for over 50 years. The present system, Mainpro, was introduced in 1998. Its first evolution went from credits for CME (M1) to a higher level of credits for CPD (Mainpro C) that is based on self-assessed needs, evidence- based resources and self-reflection. The menu of activities accredited rapidly expanded from traditional topics covering medical knowledge to a broader range that included skills such as teaching, research and communication.
Recently CFPC has introduced credits for point of care learning and standards for online-line CME are changing as physicians learn more about this form of learning. Some predict that in the near future we will not have a need for CME credits, as learning will become a continuous process involving audit and feedback facilitated by the electyonic medical record (EMR). There is an old adage that “learning occurs best in the environment in which it is used” and education will move from the lecture hall and classroom to the clinic and bedside.
At present, CE credits are mandatory for College members, but membership is voluntary. There is ongoing discussion with the licensing bodies to make participation in College accredited programs mandatory for all GPs and FPs in Canada. -- Bernard Marlow MD, Director of CME/CPD, CFPC
·Health care in Bhutan: Dalai Lama's perception
When Dennis Wentz MD visited Bhutan last year, he encountered this sage quote from the Dalai Lama: "Tibetan medicine views health as a question of balance. A variety of circumstances such as diet, lifestyle, seasonal and mental conditions can disturb this natural balance, which gives rise to different kinds of disorders.
"Health is not a matter of merely personal interest but a universal concern for which we all share responsibility. That is why the ideal physician is one who combines sound medical understanding with a strong realization of wisdom and compassion."
In this latest report, DCCP has analyzed the best and most cost-effective solutions for such countries. Most involve educating the public in developing nations; many require improved knowledge on the part of health care providers, including first-line physicians. Can a combination of continuing medical education and public education work to promote the following ideas? These were rated as the "10 best health buys that have proven to be highly cost- effective in a variety of settings.
Vaccinate children against major childhood killers, including measles, polio, tetanus, whooping cough and diphtheria
Monitor children’s health to prevent or, if necessary, treat childhood pneumonia, diarrhea and malaria
Tax tobacco products to increase consumers’ costs by at least one-third to curb smoking and reduce the prevalence of cardiovascular disease, cancer, and respiratory disease
Attack the spread of HIV through a coordinated approach that includes: promoting 100 percent condom use among populations at risk; treating other sexually transmitted infections; providing antiretroviral medications, especially for pregnant women; and offering voluntary HIV counseling and testing
Give children and pregnant women essential nutrients,including vitamin A, iron, and iodine, to prevent maternal anemia, infant deaths, and long- term health problems
Provide insecticide-treated bednets in malaria- endemic areas to drastically reduce malaria
Enforce traffic regulations and install speed bumps at dangerous intersections to reduce traffic- related injuries
Treat TB patients with short-course chemotherapy to cure infected people and prevent new infections
Teach mothers and train birth attendants to keep newborns warm and clean to reduce illness and death
Promote use of aspirin and other inexpensive drugs to treat and prevent heart attack and stroke
How were these best buys determined? Through calculation of disability-adjusted life-years (DALYs), which capture the years of life that an intervention saves and the state of health in which people live, or well-being. $1 million spent on vaccines in the developing countries, for example, can save between 50,000 and 500,000 DALYs depending on the cost of the vaccines, whereas the same amount spent on coronary bypass surgery will return only about 40 DALYs. Such an analysis doesn't mean that a country should only spend on the lowest cost interventions, but allows leaders to see the trade-offs. Because the calculation includes well-being, treatments for non- fatal diseases that are incapacitating such as river blindness may show up as a worthwhile intervention.
Among the groups examining the data is the Project Globe Consortium for Continuing Professional Development, a new nonprofit organization dedicated to improving health in developing countries through continuing medical education. (Contact pulido@globecpd.org for more information.)
If you know of other organizations interested in community or professional education in developing countries, we would like to share the information through this newsletter. Send a note to lew@wentzmiller.org.
*************************** Opportunities and challenges in China
China's healthcare system is undergoing major changes. New regulations will upgrade the levels of education and competence of millions of part-time doctors in village clinics across the country by 2010. And there will be increasing focus on chronic diseases such as hypertension and diabetes, which cause approximately 70% of total death each year. So reports Jennifer Goodwin of the Goodwin Group International in a recent issue of Medical Meetings magazine.
Ms. Goodwin worked with China Medical Tribune to organize a 2-day gastroenterology summit in Beijing. Some of the lessons she learned:
Business transactions are often viewed as an "exchange of favors"
Double your travel budget, and visit early in the planning process
Plan conference calls carefully, aware of time zones and language problems
Translate everything --either in Cantonese or Mandarin or both
Plan at least a year ahead to secure funding -- using global HQ to assist in getting local support
Don't go by Western accreditation standards; commercial supporters expect full control
(DCPP), a four-year effort supported by the U.S. National Institutes of Health, the World Bank, the World Health Organization, and the Population Reference Bureau, with funding from the Gates Foundation. The objective is to improve health of people in developing nations by fostering an environment that supports evidence based decision making. (DCPP), a four-year effort supported by the U.S. National Institutes of Health, the World Bank, the World Health Organization, and the Population Reference Bureau, with funding from the Gates Foundation. The objective is to improve health of people in developing nations by fostering an environment that supports evidence based decision making.
The gap between developed and developing countries
In this issue, we offer an exciting list of the 10 best health buys in developing countries, where pennies a day are spent on each resident's health care. CME is not on the list! At the same time, we look at sophisticated methods of improving care through CME in the developed world -- mentoring in Canada, e- learning in Europe and the U.S., and more.
Upgrading skills of rural physicians
Upgrading existing skills or developing new skills is often an issue for physicians practicing in rural or remote communities. Busy physicians often find these obstacles: distance from tertiary care centers or faculties of medicine, the lack of networking opportunities, difficulties finding locums, and complicated, confusing and intimidating processes to access training.
However, rural physicians in Alberta Canada can access an Enrichment Program run by The Alberta Rural Physician Action Plan (RPAP) which provides a simple, single point of entry to skills training that is based on their individual needs. The program enables physicians to upgrade their existing skills or to gain new skills to improve the level of health services in the rural community/region or to replace existing skills that will be lost due to retirement or other reasons.
Physicians interested in training consult one of RPAP’s two “skills brokers,” who are experienced rural physicians and “one of their own.” These brokers act as part-time advocates and work to satisfy the needs of the rural physician, the medical needs of the community and the province’s medical licensing body. Each applicant is assigned a preceptor who confirms the learning objectives with the trainee, provides the required training and ensures the trainee is evaluated at the end of the training. Procedural skills are learned typically at a medical school, 30 minutes to 5 hours distant. Cognitive topics are taught on the web or home study. Skill brokers communicate via phone or internet.
Since the program was launched in 1992-1993, in excess of 150 rural physicians have participated. RPAP pays for the program; participants receive an honorarium of $76,000 (Can.) per year pro-rated, and skills brokers $1,000 (Can.) per month. Now RPAP has launched a study to determine whether the trainees’ objectives, preceptors’ and communities’ needs, as well as the long-term goal of rural physician retention, have been met.
Scandal accelerates mandatory CME in Ireland
The Irish Medical Council has been discussing mandating its Competence Assurance Structures (CAS) for some time, but the process appears to be speeding up as a result of the the "Neary scandal".
Irish newspapers use that headline to describe a 2003-4 incident involving professional misconduct by an obstetrician, Dr. Michael Neary, accused of removing the wombs of some 60 women without their consent or knowledge during childbirth. Dr. Neary lost his license as a result.
Politicians refer to the case to justify mandating CAS- like activity, which has been voluntary to date. CAS includes participation in appropriate CME/CPD; in clinical audit and, for a few clinicians, in peer review performance assessment. Said Irish Minister Mary Harney recently: "There must be mandatory CPD and skills assessment at all levels of health care. Staff should be able to recognize that procedures change in accordance with evidence-based research."
It is expected that a new Medical Practitioners Act, mandating CAS, will pass in the Parliament this year. Would such a measure have prevented the "Neary scandal"? Some physicians doubt it!
Internet becomes a major learning source for European and U.S. physicians
European and U.S. physicians are increasingly reliant on the internet as a source of information and continuing medical education. What are the implications for your professional efforts in CME/CPD?
A Manhattan Research report indicates that 86% of European physicians access the internet in their offices, a majority by high speed connection. About 65% agree that access is essential to their practice of medicine. These are findings from a study conducted in France, Germany, Italy, Spain and the UK. Most doctors visit professional journals, their professional society sites and literature databases -- much of which might be considered "point-of-care" CME.
In the U.S., a study by Verispan found that 87% of physicians said they earned eCME credits in 2005, and 40% said they are earning more than 20% of their credits online. How much time do doctors spend on searching the Web? 44% said between 1-3 hours a week, and 84% said the internet has a positive impact on their knowledge of medical conditions and new products. Finally, the report said that pharmaceutical companies spent $280 million to reach doctors online in 2005!
Are CME providers meeting doctors' needs as well as they can? Columnist Joe DeBelle of Pharmaceutical Executive magazine doubts it. "While the interest in e-CME continues to grow," he says, "the quality of these programs, in some cases, has not kept pace."
DeBelle emphasizes that the following features are important to gain and hold physician attention:
Make e-CME available on demand, rather than just through live webcasts. MDs want access when they have time available.
Develop a high level of interactivity, including streaming video and audio, diagrams, 3-D animation, live chats, ability to send questions to presenters, and case-based learning.
Make the experience easy and fun. Otherwise doctors will never come back. No one wants to download mountains of software.
Allow for easy navigation, with a self-directed syllabus or table of contents to guide participants, and a logical flow of screens.
Do advance qualification of potential participants, rather than mass e-mails inviting all doctors to an e- CME event. And make it easy to register and then return to the site.
Track and produce detailed activity reports, showing who and how many logged on, how long they stayed, pre and post-tests, etc. The data become the basis for future changes in programming.
What are the rules for e-CME in Europe?
If you need help clarifying whether and how to award credits for Web-based CME in Europe, WentzMiller & Associates can help. It's a complicated situation, our European associates tell us, but one that is manageable! Contact Principal Lew Miller for more information (lew@wentzmiller.org).
The European Commission released results of the first analysis of public perception of medical errors earlier this year. Citizens were surveyed in the 25 member states of the European Union and in candidate states as well -- and the results were alarming:
78% classify medical errors as an important problem in their country; in Italy the rate was 97%, in Denmark and Finland, half that.
Women are slightly more concerned than men; older people have a high level of concern, as do those with less education.
In comparison, only 40% of respondents were worried that they themselves would suffer a serious medical error, more in Greece and Italy and fewer in Sweden.
48% of citizens state that hospital patients should be worried about a serious error.
But only 23% say they have been directly affected by a medical error personally or in the family; 18% in hospital and 11% with a wrong prescription.
The countries in which errors were reported most frequently were Latvia (32%) and Denmark (29%).
Reported incidents of errors were uncommon in Austria, Germany and Hungary.
Despite their fears, most citizens (69%) trust their doctors not to make a harmful mistake; highest rates of trust are in Finland, France and Belgium, lowest in Poland and Lithuania.
And 51% believe that hospital patients would not be likely to have a say in avoiding a serious error.
As is common in such surveys, more people worry that the medical care system is prone to error than believe it will ever happen to them or their families. There is a relatively high level of confidence in their own physicians.
Nonetheless, one of four Europeans have experienced a serious medical mistake, and one of two think this is likely to happen to a hospital patient. What is the EU planning to do about these findings? The report says the Commission intends to "use the results as a starting point for a more profound approach", but fails to say what that will be.
The attitudes of the public might merit serious consideration by CME professionals as a form of needs assessment. The first step might be to examine how to create education in the field of patient communication, both for physicians and their staffs. A next step might include working with hospitals to determine the most common and the most life-threatening errors that have occurred in the past 3 years, in order to develop specific educational programs for the specialties in which those mistakes were committed.
Your suggestions and comments will be welcomed for publication in future issues of this newsletter. Write lew@wentzmiller.org.
Major CME successes in Mexico*********** LiveMed, a Mexican company, reports that in 2005 it conducted 125 programs in cities around the country, reaching 50,000 physicians, mostly in primary care. Many of the programs are based on the Pri-Med Update model in the U.S., and adapt material from these programs. LiveMed also conducted a program jointly with the Cleveland Clinic in Mexico City last summer which attracted more than 1,200 cardiologists. Plans are for 200 programs in 2006, plus an expansion of early efforts in Brazil and Spain. Contact angel.vazquez@livemed.org
********************************** GAME Goes to Europe in June The Global Alliance for Medical Education (GAME) will hold its annual meeting in Europe for the first time -- in Rome June 18-20, 2006. The keynote speaker will be Bruce Sparks MD, president of Wonca (the world organization of family doctors) and a leading South African medical educator. Save the dates and check the GAME website for more details.
of public perception of medical errors earlier this year. Citizens were surveyed in the 25 member states of the European Union and in candidate states as well -- and the results were alarming:
CME on the march in Europe
The landscape of European CME/CPD is changing, as France gears up to put its law on mandatory CME in effect, Italy and Spain are reviewing their systems after several years, and the GPs are trying to decide how to proceed with a more formal system of CME. Plus the challenge of dealing with medical errors in Europe.
The French CME system is finally underway
After many stalled attempts, the French are moving ahead to implement the continuing education system mandated for health professionals several years ago. National CME bodies created in 2004 have set some general rules, and 16 regional organizations will be created by the end of this year.
The medical unions have substantial impact on getting compensation for private practice doctors attending CME events. The Social Security system started to grant 300 EUR for a day of education, and in 2005 10,000 GPs were compensated for an average of 4 days each. There are 110,000 physicians who can claim such payments.
There is a great deal of competition to "run" the system. The medical association wants to be more involved. So does the "haute autorité de santé", which grants CME credits for clinical audits. And the national CME committees and pharmaceutical industry want to play key roles. Providers are not yet organized and pharma is supporting symposia at educational meetings, not yet subject to a future
The regional committees, when established, will start validating CME activities, and will submit the data to the French medical association. The national CME committees will publish the list of credits that are needed, and will start to accredit providers by the end of 2006 -- barring future impasses among government agencies and medical groups. -- Hervé Maisonneuve MD, Paris
CME in Spain and Italy revisited
Spain's system of voluntary CME has been working well in mostly regions of the country. In Italy, much progress has been made since its mandatory continuing education for professional system was started in 2002 -- also on a regional basis.
Now both countries are re-examining the process and considering changes. Among the key issues in both countries:
Distance learning, which has not been regularly accredited in Europe, partly because the European Accreditation Council for CME has not accepted the idea
Increased regulation of commercial support, which to date has simply indicated that programs should be free of bias
Accrediting providers instead of, or along with, accrediting programs, which has been the European standard
CME providers from outside those countries may be looking more carefully at distance learning opportunities. Even EACCME is seriously considering including these in the accreditation process. -- Helios Pardell MD and Alfonso Negri MD
What will Europe's GPs do to get CME credits?
General practitioners in Europe have generally been subject to national health authorities for CME credits, in some cases mandated, in others not. Now the Union of European Medical Omnipractitioners (UEMO) is looking at ways to establish a system that would cover the EU.
Dr. Bernard Maillet, head of the EACCME, recently reported that discussions were held with UEMO to consider involving GPs in European CME/CPD through EACCME, taking advantage of its know-how.
However, Dr. Christina Fabian of Sweden, current president of UEMO, says her organization is also considering developing its own CME system in collaboration with Wonca (World Organization of Family Doctors). UEMO has started the process of becoming a legal body under Belgian law. The topic will be discussed further at UEMO's June meeting in Ljubljana, Slovenia.
Dramatic changes in CME funding were unveiled at the annual meeting of the Alliance for CME in San Francisco last month. We discuss these and other ideas from that meeting. And thanks to Sue Pelletier of Medical Meetings magazine for excellent reporting that we accessed!
Outcome measurement: The other hot topic in the U.S.
The annual meeting of the Alliance for CME was studded with talks and workshops on how to measure outcomes of CME activities. Around the U.S., coalitions of health plans, doctors and hospitals are looking at physician performance, and informing patients as well.
As might be expected, money is a major motivating factor pushing the trend toward more sophisticated measurement of outcomes -- the cost:benefit ratio, whether it's the cost of CME or the cost of health care.
Let's examine the trend in CME outcomes first, as discussed at the January Alliance meeting. In this case, both the Accreditation Council for CME and pharmaceutical company funders are demanding better outcomes data, in the case of the latter, to justify continued support of educational programs, particularly in light of the restrictions reported in the article in the next column
In the old days, CME providers measured outcomes with a happiness index questionnaire: Were doctors satisfied with the quality of the lecture, the meeting room, the meals, etc.? Now there are additional levels of measurement:
Changes in knowledge, attitudes or skills,
As outcome measurements become more sophisticated, there's a greater emphasis on good needs assessment, so that the CME program can be designed to bring about desired outcomes. And it's important to design measurements that can clearly reflect the changes brought about by the CME itself and not other factors in the health care system.
Similar concerns apply to the efforts of health care coalitions to measure performance, and in many cases to reward improved performance with increased pay. There are more than 100 such programs across the US, according to a recent article in the San Jose (CA) Business Journal.
In California, 225 physician groups are participants in a program that rates doctors by patient satisfaction, adoption of technology and clinical behavior (based on 10 sets of disease management criteria). The scores are posted by the state Office of the Public
Can a CME program compete with strip club or Wimbledon entertainment? Some doctors in the UK apparently preferred the livelier activities -- and as a result, Abbott Laboratories has been suspended for at least 6 months by the Association of the British Pharmaceutical Industry for violating the ABPI Code of Practice.
Financial Times reported that in 2004 an Abbott manager paid for company representatives to take a doctor to a lap dancing club at the end of a medical workshop. Another Abbott manager invited senior London hospital consultants to centre court at
"The breaches are viewed in a very serious light," said Vincent Lawton, president of ABPI and head of Merck UK.
Postscript: At least 9 states in the U.S. are considering bills to make pharma companies publicly report how much they and their sales reps give to doctors, hospitals and pharmacists each year. And one proposal would ban all such gifts!
Rural healthcare CME in Uganda
A recent report in a Medical Meetings blog describes the efforts of Uganda Martyrs University to provide CME to rural health workers through information technology.
The project seeks to identify the needs of health workers, train them to use information communications technology and set up ICT resources in rural hospitals, so that the workers can access the information they need. Said one CME
New WentzMiller Associate: Alfonso Negri MD
WentzMiller & Associates is proud to announce that Alfonso Negri MD of Milan, Italy, has joined our consulting firm as an associate. Dr. Negri is a specialist in pneumology and allergy, is secretary general of the Italian Council for Accreditation in Pneumology and secretary of the accreditation committee of the European Academy of Allergology and Clinical Immunology.
Dr. Negri has been responsible for accreditation of over 500 educational events with the Italian Ministry of Health, and 150 events with the European Accreditation Council for CME. He can be reached at a.negri@pha-cme.org.
GAME Goes to Europe in June
The Global Alliance for Medical Education (GAME) will hold its annual meeting in Europe for the first time -- in Rome June 18-20, 2006. Save the dates and check the GAME website for more details.
The ESABs say they want to improve the quality of accreditation by using defined assessment criteria and employing expert specialists to evaluate the content of international meetings in their specialties, as well as distance learning activities, which to date the EACCME has not accepted for accreditation.
Their proposal was rejected by a majority of the advisory council, many of whom are representatives of the NAAs. One provocative issue appeared to be that EACCME and the NAAs would receive "notification" of any ESAB accredited activities. This, said one council member, “disregarded the duties of national authorities.” NAAs, said another, “should be at the front of information flow”.
Some ESAB representatives, fearing that NAA delegates were feeling "threatened", countered with a request that EACCME delegate some accrediting duties to their specialty boards, for instance, by issuing EACCME certificates to doctors attending international conferences. Other speakers were adamant that any change would interfere with the current process, in which NAAs accredit national events. And if the NAA has signed an agreement with EACCME, it will accept EACCME credits for doctors who have attended international events.
Underlying the battle are questions of money and power, since fees for accreditation are usually charged by only one body, but in the case of EACCME accreditation, are shared with the sections of its parent body, the European Union of Medical Specialists (UEMS). ESABs charge their own fees.
The debate is not over. Dr. Hannu Halila, retiring UEMS president, recommended further separate conversations between UEMS sections and ESABs with UEMS' and EACCME's executive director, Dr. Bernard Maillet. He encouraged ESABs to listen to the objections and come up with a new proposal by March. Subsequent to the meeting, he noted that ESABs, which are partly UEMS sections, can certainly request EACCME accreditation.
In other business, Dr. Halila reported that formal agreements on reciprocal accreditation have recently been signed by EACCME with three more NAAs, Royal College of Physicians of Ireland, Royal College of Surgeons of Ireland, and Malta. Agreements also exist with Spain, Cyprus and Greece, and negotiations are underway with Slovakia, Hungary, Slovenia, Belgium and Germany. Under these agreements, NAAs are certified as “the relevant authority guiding and controlling the accreditation of doctors and determining the number of [CME] credits required”.
Does EACCME-AMA reciprocity always apply?
During the EACCME meeting, a question was raised regarding accreditation of pharma-sponsored symposia held in conjunction with a European congress. Under guidelines of the European Board of Allergy/Immunologic Diseases, no credit can be granted. But the CME provider was accredited in the U.S., and under the reciprocal agreement with the
Finally, in a presentation by Dr. Halila, he indicated that EACCME was still studying how to handle accreditation of enduring materials, particularly Internet-based programs. He and Dr. Maillet agreed that this would happen in the near future -- but no timetable has been established.
of the Advisory Council of the European Accreditation for CME (EACCME).
REVISED issue has it all!
The earlier version of the January issue had several truncated paragraphs, thus this revised edition is complete! We feature the current maturation process of the European Accreditation Council for CME as well as issues surrounding the quality of health care in Western countries and the latest Cochrane evidence on CME effectiveness.
Health care problems in the world's top countries -- is CME helping?
Are those of us in continuing medical education really making a difference in patient care? It's somewhat hard to believe when you look at the results of a 2005 survey of sicker adults in Australia, Canada, Germany, New Zealand, the UK and the U.S.
"Overall, the findings reveal strikingly similar deficiencies" in both hospital and ambulatory care, the authors report. The survey, conducted through the Commonwealth Fund, interviewed adults in the 6 countries who had recently been hospitalized, had surgery or reported health problems. "The U.S. often stands out with high medical errors and inefficient care," the report continues.
What were the chief problems, in the eyes of patients? In hospital:
failure to explain risks completely
inadequate pain management
infections
failure to coordinate care during discharge.
In ambulatory care:
Incorrect or delayed results of diagnostic and lab tests
Medication errors
Failure by doctors to review all medications
Gaps in physicians' explanations of side effects
Failure to administer recommended batteries of screening tests, e.g., for diabetes, hypertension
Yes, there were variations by country, but no country was significantly better, in the opinion of those surveyed, on all indicators of care. Germany was at the bottom in evaluation for discharge coordination, the U.S. in medical errors outside the hospital, Canada in administering recommended screening tests for those with diabetes.
The array of problems discussed in this article offers a major opportunity for CME providers to develop new programs that can make a difference in the following areas:
Transitional care planning from hospital to home
Teamwork training, especially when multiple doctors are involved in a patient's care
Methods of reducing medication errors in hospital and office
Clear and candid patient communication skills
Improved chronic care management, involving self- management and guideline screening
Some would call these programs in continuing professional development (CPD). Whatever the framework, these necessary skills can help physicians and allied health personnel improve the quality of care before the next measurement of patent satisfaction. Are any readers now preparing such programs?
What works in CME: The results of 4 Cochrane Reviews
Evidence in CME methodology can help every professional in the field steer a clearer course. In the recent issue of the Cochrane Database of Systematic Reviews (2005 Issue 4), the following topics are covered:
Audit and feedback "can improve professional practice", but the effects are generally small to moderate.
CME meetings and workshops. Interactive workshops "could result in moderately large changes" in practice. Lectures alone were "unlikely to change" practice.
Educational outreach visits, sometimes known as academic detailing, "appear to be a promising approach to modifying" practice behavior, especially prescribing.
Local opinion leaders, often viewed as highly important in changing behavior, do not appear to be so significant, according to this review. Only a few trials "found any important impact on patients' outcome".
Who's buying lunch? Three answers
Gifts to physicians often raise questions about their effects on prescribing patterns --and sometimes may be a more powerful influence than CME! Here are 3 recent positions on gifts and hospitality from the pharmaceutical industry to doctors:
In the UK, the code of the Association of the British Pharmaceutical Industry limits the value of a promotional gift to 6 pounds ($10) unless it enhances patient care or benefits the National Health Service; meals must be secondary to the purpose of the meeting and "not out of proportion".
In Australia, apparently in response to physician complaints, Medicines Australia, the pharma body, is considering dropping language that limits food at events to "simple and modest". Too many sandwiches?
And in the U.S., authors in Thoracic Surgery Clinics (November 2005) suggest that physicians need ethical education so that some day "the popular choice will be to buy their own lunch".
**************************************** Need help understanding what is going on in CME around the world? WentzMiller & Associates is ready to provide advice and counsel. Call or e-mail Lew Miller, 203 662-9690, or lew@wentzmiller.org.
