When we started in this field of continuing medical education, we believed that its primary purpose was to improve the physician's ability to care for his/her patients. We still hold that belief.
But it appears that more and more bureaucrats in government and some CME organizations are so focused on physician and hospital performance that the patient is no longer a factor.
What about the patient's contribution to performance improvement? Lowering blood pressure, achieving stability in blood sugar, successful post-operative care -- all depend on the patient's participation. That means that patient education needs to be part of CME.
The Chinese government started by asking the people what they saw as problems in the health care system. Their responses triggered its current approach to develop a community health center/family medicine system of care financed publicly.
We hope as a result there will be true partnership between health care providers and their patients. Perhaps some of the proposed 600 hours of CME can be devoted to patient education -- including the patient's family!
**************** WentzMiller & Associates are available to assist your organization in planning for the future, particularly as you strategize on how to expand to other countries and CME media. Call Lew Miller at 203 662-9690 or Dennis Wentz at 970 845-9910.
****************
Dear CME colleague,
Major changes in CME are ahead in 2 of the world's major societies -- the US and China. While we lack details about what will happen in China, it appears a big push will be forthcoming to upgrade the community health system and its providers. In the US. the shift to performance improvement as a key measure of CME is moving ahead rapidly. Your comments are welcome. Speaking of which, one reader, John Wright, wrote us: "I very much like your new layout and succinct report. One irresistible page, with the promise of updates to come."
Huge CME effort is contemplated to reform the Chinese health system
China has had a 3-tiered hospital system to provide care in neighborhoods, districts and cities. But, says a recent Family Medicine article, Chinese people have 2 major complaints: The system is "expensive to receive health care and inconvenient to access". The Chinese government is planning a switch to a two-tiered public health system, with community health centers as its base, to provide:
Prevention
Health education and promotion
Birth control
Outpatient evaluation and management of illness
Case management of chronic disease
Rehabilitation
The new system, the authors say, will use family physicians as gatekeepers, and will be piloted in cities that already have community health infrastructures. By 2010. there will be a network of such centers in most Chinese municipalities.
Now for the CME challenge: "The emphasis will be on continuing education and certification programs for the community health center physicians rather than on full-time residency programs in family medicine," the article states. "It has been suggested that 600 hours of training would be sufficient to ensure the competency" of these physicians.
We hope to update progress toward this ambitious target in coming months. Any contacts in China would be welcome.
The future of CME: Will it be performance improvement?
That is the implication of remarks at a recent CME Summit in Chicago by Barry Straube MD (right), acting director of the Office of Clinical Standard and Quality of the US Center for Medicare/Medicaid Services (CMS). The Center pays for more than 50% of all US health care, and, Dr. Straube says, must work to improve quality and reduce costs. The US cannot compare with most developed countries in delivery of high quality care at reasonable cost, he adds.
CMS is moving rapidly in the direction of linking reimbursement to performance improvement, based on performance measures developed by the American Medical Assn. convened Consortium for Performance Improvement. Hospitals have been first, and according to Dr. Straube, have responded positively to financial incentives linked to both cost and quality. The pressure is going to build on physicians to do likewise. The CMS progress to date is summarized in a recent report to Congress.
At the same meeting, Norman Kahn MD, new executive of the Council of Medical Specialties (sponsor of the Summit), reported on a new performance improvement program of the American Board of Medical Specialties. Two pilots are underway -- in North Carolina and Colorado. Varying incentives are being used with physician practices to bring about systems-based change as a result of education and data sharing. Physician coaches are assisting the effort.
Can performance improvement be the only basis for continuing medical education? Not in the opinion of some leading academic CME leaders. Dr. Barbara Barnes, speaking at the Summit, noted that the vast majority of medical practice is carried on in a state of "ambiguity", in which it is difficult to set performance measures. In an earlier conference, Dr. Van Harrison noted that relatively few such measures were widely accepted, and that most quality problems are system problems, not deficiencies of individual providers. CME, he says, must focus on both knowledge dissemination activities and knowledge implementation activities.
And where do you stand on this issue? If you are from outside the US, are you encountering pressure to reimburse doctors by performance improvement? If so, how does this relate to CME?
The hot topic in global CME is to build toward harmonization. As the Latin American survey points out in the adjoining column, there are many obstacles, chief among them: autonomy.
No group wants to give up the right to make unilateral decisions, whether a specialty board or society, a national authority or a medical school.
In the US, the American Academy of Family Physicians insists on its own credit system, rather than that of the Accreditation Council for CME. In Europe, EACCME, the national authorities and the specialty accreditation boards can't get together.
In individual countries, more of the same. In Italy, regions have trouble reaching consensus. In Canada, there are 5 boards or more involved in CME accreditation.
Unless there are collaborative structures for these bodies, how can we ever agree on the essentials of CME, its value, and its application to the practice of medicine?
We encourage CME organizations to form coalitions with the responsibility to define territory and common standards, subject to final approval of the bodies they represent.
Maybe one day, harmonization of CME around the world can become a reality.
Dear CME colleague.
We offer you a new format for the WentzMiller Global CME Newsletter - cleaner, shorter and easier to read. We hope you like it!
This issue focuses on CME surveys, covering both physician attitudes toward CME as learners and educators, and some major regional differences around the world.
CME, emerging in the emerging world -- Africa, Asia and Latin America
CME in these regions is on the move, reports Dr. Honorio Silva, board member of the Global Alliance for Medical Education (GAME). With the assistance of Pfizer country managers, local experts in CME provided these data:
Africa/Mideast Accreditation initiatives are underway in Israel, Nigeria, Saudi Arabia*, South Africa*, Turkey and UAE*.
Asia/Australia Accreditation is established in Australia*, HongKong, Japan**, Malaysia*, Pakistan, Philippines, Singapore* and Thailand.
Latin America Accreditation is established in Argentina**, Brazil**, Costa Rica, Mexico** and Peru**.
* Mandatory ** Semi-mandatory
Most CME is the emerging world is -- no surprise -- conducted by medical societies and academic institutions, and is funded by pharmaceutical companies, Dr. Silva noted. While web-based learning exists, it is not very popular. Live meetings are favored.
Latin American educators were also polled on obstacles they perceived to harmonization of CME in their region. Most were concerned about the autonomy of professional organizations, lack of government support, and lack of agreement on standards. Some also felt medical schools had enough problems educating students -- and were not prepared to take on the challenge of CME.
What doctors think of pharma funding
Do physicians view pharma-funded CME with suspicion? In part. A survey of practicing doctors conducted by the Annenberg Center for Health Sciences found that 75% of respondents said that a CME activity can be fair-balanced only occasionally or seldom when the primary focus is a therapeutic category in which the grantor has a vested interest. The study was funded by Procter and Gamble.
Nonetheless, physicians overwhelmingly felt that commercial funding was no deterrent to attending a CME program, and might have a positive influence on attendance. They weren't happy, however, about restrictions on meals for spouses!
The study reiterated that live meetings are "the gold standard" for physicians. Another survey, by Pri-Med, a global CME provider, found that while online CME has increased dramatically, live meetings are still preferred. Online learners earn an average of 34 credit hours per year, the study showed, but spent an average of 38 hours at live meetings as well.
Spain's accreditation system is reaffirmed
The Spanish government has issued a new decree restructuring and reorienting the competences of the Spanish Commission of Continuing Education of Health Professions, reports Dr. Helios Pardell, director of the Spanish Accreditation Commision for CME (SACCME) and a WentzMiller associate. But "nothing has changed," he says.
SACCME is under the supervision of the commission, which includes representatives of the ministries of health and education, universities and the 17 health regions in the country. The Spanish Medical Association is a controlling factor in SACCME. CME remains voluntary in Spain.
CME mandatory in Iran At least for doctors in private clinics
All health professionals in Iran now participate in a government-approved program of continuing education, calling for 125 credit points every 5 years. This is now mandatory for health professionals who have a private clinic, reports Mandana Shirazi, an Iranian PhD student at Karolinska Institute, Stockholm.
Credits may be earned in seminars, self-directed learning and congresses; however, 40% of points must be in planned programs focusing on "must knows" in the doctor's area of specialty. Programs are provided by universities and scientific societies.
The Ministry of Health has now formed a CME accreditation board to improve the quality of the CME process.
Let us know what you think of the revamped newsletter. And if we and our associates around the world can help you be more effective in CME, send us an email (lew@wentzmiller.org) or call us at 888 239-9194. Lew Miller and Dennis Wentz MD WentzMiller & Associates LLC
Medical associations in India have been campaigning for a formal CME program for almost 10 years. In 2001, the MCI and Indian Medical Association (IMA) asked the government to prepare a CME curriculum and MCI proposed an accreditation system for medical institutes as providers. While some local medical councils, including that in Delhi, mandated 100 CME hours every 5 years as a requirement for re- registration, the mandate has been difficult to enforce without legislative support.
Last year, Anbumani Ramdoss, Indian Health and Family Welfare minister, announced that the government would soon make such a 5-year re- registration compulsory, following a CME program. Initially only those in government-owned institutions would be affected, but the program would later roll out to all doctors in the country. However, as of now, no progress has been made.
India has more than 600,000 qualified doctors. Our rough estimate, says Saurabh Jain, is that existing spending on CME is in excess of US$100 million, in the following categories:
Pharma company sponsored medical lectures
Medical association regional and national conferences
Symposia and workshops held by hospitals and teaching institutions
Distribution of CME material by commercial sponsors
Subscriptions to medical journals containing CME
India must mandate a CME regimen similar to that in most developed nations, as we become more integrated in the global economy. The model must incorporate:
Guidelines for development of programs and content
Administrative backbone to monitor compliance
Guidelines for import of CME from respected foreign organizations
Harmonization between Indian and other national CME credit systems
An atmosphere that incentivizes thought leaders and medical organizations to develop high-quality CME
This must be a public-private endeavor, with guidelines from the government, and implementation by the private sector. The time-tested model of the US Accreditation Council for CME (ACCME) can be adopted as a starting point, and adapted to local needs. We also need to increase the quantity of excellent CME by importing CME material from foreign providers.
***************************************** More on CME funding
Responding to an article on pharma funding of CME in the July 2007 edition of this newsletter, Jacqueline Parochka EdD, president of Excellence in Continuing Education, writes: "I bring to the attention of your readers an article by Van Harrison in the Journal of Continuing Education in the Health Professions, in which he offers a continuum of funding possibilities ranging from leaving everything as it is to allowing no commercial funds to support CME."
World Forum CPD starts up in Europe
A new nonprofit organization is launching an ambitious program of online CME in Europe next month. The World Forum CPD in Medicine, based in Switzerland, will offer a 3-month pilot program to selected groups of GPs, neurologists and surgeons in Germany. If successful, the World Forum expects to expand its offerings into the rest of Europe and North and South America, in German, English, Spanish and French.
The World Forum plans to offer a monthly program in each specialty that includes one clinical case online or offline; an online lecture and a virtual classroom, or chat room, in which learners interact with each other and the speaker. Each unit would be accompanied by a CME test. The programs will carry 10 credits per month in Germany.
The mission of the World Forum is to "support initiatives that take quality management and quality assurance as a central process of CPD in medicine", to do so through courses, workshops and conferences "that make interdisciplinary cooperation and communication possible", and to "exchange ideas on a national and international level".
President of the organization is Ulrich Weigeldt MD, former head of the German Association of General Practitioners. Deutsche Telekom is providing the technical support for the website and communications. The website and content is being managed by QUAIME (Quality in Medical Education), a Swiss company headed by Dr. Peter Posel.
Italy changing its CME system
Italy is moving to update its CME system, started in 1999 and implemented four years ago. The Permanent National Commission for State/Regions and Autonomous Provinces of Trento and Bolzano has approved a 24-page document titled "Reorganization of the CME-Continuing Education System", calling for a shift from individual event accreditation, as has been done in the past, to independent provider accreditation.
The report also proposes a new governance for CME, moving from rule by the Italian Health Ministry to a new national Agency for Regional Health Services (ASSR), in which would be located a CME Commission. Also proposed are new rules for pharmaceutical company sponsors (which may not be providers) and for disclosure of conflicts of interest on the part of providers, speakers and learners. The credit system would parallel that of the U.S. and the Union of European Medical Specialties (UEMS), that is, 50 credits required per year, and 150 in 3 years, starting in 2008. These and other changes would be finalized by the CME Commission of ASSR, and would apply to 1 million health professionals, including physicians.
"Timing is important," says Alfonso Negri MD of Milan (and a WentzMiller associate). "In a perfect world, we should have the system set up for new providers, including a decision on which organizations will be accredited, by December 31, 2007, so we can start a trial of the new system next January," he notes. "But to do so would be a feat of super bureaucratic effort, not often seen in Italy."
Recruiting CME speakers: Is it getting harder?
Yes, says a recent article in Teaching and Learning in Medicine (2007, 19(2):115-9). The authors, Doug Klein and Michael Allan at the University of Alberta, Canada, set out to quantify the difficulty in recruiting speakers for CME. Their findings, after a review of planning documents from 3 programs for family physicians:
Over 3 years, it took 32% more requests than before to obtain a speaker.
Finding speakers for rural programs is more challenging than for other settings.
University faculty represent 45% of CME speakers.
The changes put new burdens on CME offices.
CME Congress 2008 seeking abstracts
The CME Congress, held every 4 years, is a major international meeting for researchers and practitioners concerned with CPD and CME. The next session will be held May 29-31, 2008, in Vancouver, BC, Canada. Themes include:
Interprofessional learning
Education physicians for systems-based practice
Physician competence assessment
Learning theory
Advancing the global CME/CPD agenda: a consortium approach
The organizers have issued a call for abstracts, due by September 30, 2007. The Congress will include symposia, workshops, research papers, reports on demonstration projects and poster presentations.
The assumptions that elected officials make when they mandate CME are that the process will ensure the competence of physicians and thereby will improve health care. Both assumptions are clearly not true.
First, there are no requirements in most mandatory systems to link the CME to the physician's identified needs and type of practice. Theoretically, an orthopedic surgeon can satisfy the credit requirements with courses only in psychiatry! And there are no requirements to link the CME process to evidence of a physician's competence in his/her field of practice.
Second, as Dr. Janet Grant of Open University, London, pointed out at the European Congress, "there is no consistent correlation between CME/CPD (continuing professional development) activity and patient outcomes." Measuring a doctor's increased knowledge or skills is no guarantee that this change will permeate into practice, she adds.
Unfortunately, medical organizations, including accrediting bodies, have been trying to demonstrate that the legislators' assumptions are valid through myriad and confusing systems of credit that can be reported to the bureaucrats who equate hours with better patient care. One exception is the UK's General Medical Council, which has moved away from required CME/CPD credits to a system of physician revalidation based on appraisal, with these key elements:
Defining personal and professional development needs;
Agreeing with a same-specialty mentor on plans for the needs to be met;
Reviewing the doctor's performance periodically; and
Considering the doctor's contribution to the quality and improvement of health care services.
Will the UK system work? The jury is still out. In the U.S., the Federation of State Medical Boards (these administer the state requirements) is discussing ways to modify the credit system to relate more effectively to competence and practice setting. But change is still years off. France's new law, still not fully in effect, includes a requirement for a practice audit as well as for CME credits.
Given the billions of dollars, Euros and other currencies spent annually on CME, is there any incentive for CME professionals to educate legislators to rethink the assumptions behind mandated CME? Do you think that is possible -- or will it open a Pandora's box? Can we ever return to a voluntary system, still supported by the Union of European Medical Specialties (UEMS), Spain and a number of other countries?
******************************** Need help understanding global CME requirements?
The consulting group at WentzMiller & Associates is ready to help -- whether you simply want to determine where eCME is acceptable for credit, or whether you are developing a global strategy for CME in your organization. Contact either Dennis Wentz, principal, dkwentz@aol.com, or Lew Miller, principal, lew@wentzmiller.org. We will be glad to match our capabilities to your needs.
More on separation between CME and pharma
In the June issue of this Newsletter, we discussed some steps to change public perception of CME as a tool of the pharmaceutical industry. Two actions have now occurred in the U.S.:
The Accreditation Council for CME (ACCME), in a letter to the Senate Finance Committee, has indicated that its board will enhance its standards and processes to maintain freedom from commercial bias and will consider alternative funding models.
Eli Lilly now posts online all educational grants to U.S. organizations and its guidelines for these "to assure no inappropriate influence on content or balance"; Pfizer and other companies may follow suit.
In the June article, we recommended other strategies to clearly separate pharmaceutical industry support from any influence on content or presentation, and encouraged the Global Alliance for Medical Education (GAME) to take the lead in doing so. In response, Honorio Silva M.D., a member of GAME's Board and a vice-president at Pfizer, wrote:
"You overlooked the fact that 3 of GAME's board members work for pharmaceuticals. Yet we work for GAME to achieve its mission, a true example of collaboration rather than a demonstration of separation.
"I am not sure whether the U.S.standards [of ACCME] for commercial support should be the model to replicate. GAME should gather representatives from pharmaceuticals, CME providers, academia, medical societies and government to work on a set of guidelines in the planning, sponsoring, conduct and assessment of international CME activities. And the pharmaceutical industry cannot be regarded as the only source of funding."
Another of our suggestions was that "CME providers, not programs, should be accredited, in order to better review activities." Dr. Norman Kahn of the American Academy of Family Physicians disagrees: "As an accreditor which reviews programs rather than accredits providers, we review each and every activity prospectively," he wrote. "To 'better review activities' would seem to favor an accreditor that is set up to do just that."
Of course, the problem of changing perceptions remains difficult when the pharma industry continues to finance the majority of accredited or certified CME. ACCME recently reported that total revenue of U.S. accredited CME providers rose to $2.384 billion in 2006, an increase of 6% over 2005. Commercial support in 2006 totaled $1.2 billion, up 7% from the year before. Predictions for a drop in pharma's share proved to be wrong; we note that the same predictions are being made for 2007. What is your forecast?
Hematologists in Europe now have their own CME system
Hematology is not among the specialties included in the Union of European Medical Specialties (UEMS), the parent of the European Accreditation Council for CME (EACCME). So the European Hematology Association (EHA) created its own system, with these objectives:
Improve and harmonize the knowledge and skills of European hematologists
Facilitate access to peer-reviewed CME
Ensure scientific independence and objectivity
Improve the quality of patient care
Didi Jasmin, based at Hospital Saint-Louis in Paris and past education director of the program, reported on the system at the recent European CME Congress in London. Using a needs assessment survey of hematologists in 29 European countries, EHA obtained major European Commission support through a 3-year grant. The result: a self-sustaining, non-profit CME system consisting of live events and self-learning tools, including e-learning.
Academics, academic organizations and institutions can apply for accreditation for their CME events, Ms. Jasmin said. Administration is online, covering applications, review procedures, commercial disclosures, participant evaluations and credit certificates. By June 2007, there were about 20,000 hematologists with CME accounts, she reported.
To control quality, there is peer review of planned events by an EHA CME board, and random onsite quality control visits. E-learning programs are also visited for the same reason. Biggest need now: To integrate the EHA CME system with requirements of national accreditation authorities and other specialty systems.
How good are your needs assessment techniques?
CME professionals in the past have relied heavily on demographic data and the medical literature to determine topics and content for CME programs. To supplement this approach, there should be a focus on the specific needs of an identified physician audience. In turn, this can allow better evaluation of the quality of programming to determine how well the needs are met.
At the European CME Congress in London, Lew Miller of WentzMiller & Associates and Thomas Kellner of MSD, Germany, presented an outline of "Techniques for Successful Needs Assessment".
Kellner discussed sources of epidemiologic data -- global, national and local, and the types of data that can trigger successful programs, e.g., discovering that of 1000 patients with diabetes, only 250 receive the right diagnosis quickly, half of those the right treatment, and many fewer remain adherent to their drug regimen. He also discussed the use of data to determine the right format for the audience -- live, print or online. The latter is growing in popularity, he noted, according to available surveys in Europe.
Miller then offered a review of approaches to identifying specific audience needs:
Self-assessment through questionnaires, focus groups, interviews
Chart audit and feedback
Mentor analysis
Peer review of performance
Standardized patients
He noted that several studies have shown that doctors have a limited ability to accurately self-assess their strengths and weaknesses in patient care. Therefore, self-assessment should be combined with one or more external evaluation techniques to identify both perceived and actual needs. For a copy of the presentation, contact lew@wentzmiller.org.
Build a global organization to work together on this and related issues
Develop a set of strategies to clearly separate pharmaceutical industry support from any influence on the content and presentation of CME
Develop an advocacy program to promote the effectiveness of this separation to physicians and government bodies
There is currently a global organization -- the Global Alliance for Medical Education (GAME) -- that could develop the capability to deal with the issues. As noted in the next column, GAME's recent meeting on harmonization was an excellent start. One of the world's major accrediting bodies, the European Accreditation Council for CME (EACCME), was a major supporter, and its chief executive, Dr. Bernard Maillet, is on the GAME board.
Also on the board are Dr. Alejandro Aparicio, head of the American Medical Assn. division of CPPD, and Maureen Doyle-Scharff, a member of the board of the Alliance for CME, North America's largest group of CME professionals. Participants included R. Bernard Marlow of the College of Physicians of Canada and Dr. Michael Zarski of the American Osteopathic Information Assn. More official representation from all these groups, as well as from the Society for Academic CME and the Accreditation Council for CME, would strengthen GAME. Another board member, Dr. Honorio Silva, proposed creation of a Latin American Accreditation Council, working through the PanAmerican Federation of Medical Schools (PAFAMS). But no one from Latin America was present. Nor were there representatives from Australasia or Africa. So there is work to be done.
Developing the separation strategies will not be easy. Detailed standards for commercial support -- requiring fair balance, no pharma content control and resolution of any conflicts of interest -- have been in place in the U.S. for years. These have been applied to accredited providers only retrospectively, based on data generated by the providers themselves. Much more limited standards exist in Europe, Latin America, Asia and Australia, with no enforcement mechanism.
The International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) recently adopted a strong set of guidelines for member associations and companies around the world, including limitations on meeting locations and travel costs. It remains to be seen whether this code of ethics can and will be enforced. But at least it represents global agreement on a set of standards.
What might a similar set of standards look like in CME? Here are some possibilities:
Educational grants from pharma may specify a broad therapeutic area (e.g., cardiovascular disease) but not a specific diagnosis (e.g., heart failure)
Pharma educational grant-making should be completely separate from marketing within each company
Pharma grant application reviews should include at least 2 independent physician reviewers paid by accrediting authorities
CME providers, not programs, should be accredited, in order to better review activities
Each accredited provider should have 5% of its programs -- live, internet, print or otherwise -- randomly selected and audited in real time by the accrediting authorities
The standards for review such include fair balance, evidence based CME and identification and resolution of conflicts of interest on the part of faculty and organizers
Pharma companies should be asked to contribute 5% of CME expenditures to an independently controlled fund to support CME in underfunded areas such as prevention and wellchild care
We realize that the adoption of standards such as these will take at least 2-5 years. But if we don't get started, we run the risk that governments will set up their own regulations -- which may be harmful to the end value of CME for improving patient care. This is the reason to start an advocacy program as well, making physicians, politicians and the general public aware that the CME field is working hard to stay true to its mission. At the same time, we must recognize the legitimate role of the pharmaceutical industry to support -- not control -- the CME enterprise.
We need your opinion. Write lew@wentzmiller.org.
*****************************
Need direction in global CME?
WentzMiller & Associates is a group of experienced CME professionals in the U.S., Europe, Latin America and Asia. If your organization needs help in strategy, accreditation specifics or cultural issues, we are ready to help. You can learn more about us at www. wentzmiller.org.
GAME promotes global harmonization of CME
In its most successful meeting in a 12-year history, the Global Alliance for CME (GAME), set a record attendance of 170 CME professionals from North America and Europe, and focused on a topic of growing importance: Harmonization of CME Systems Around the World.
Despite some skepticism, participants agreed that the objective is a laudable one, if difficult to accomplish. Speakers and breakout sessions were seeking points of commonality that might lead to harmonization (not standardization, said many!), for example:
Systems for uniform exchange of credits
Acceptance of credits for a range of CME activities, including internet as well as live programs
Systems for accrediting providers and events
Guidelines for commercial support of CME
Content based on best available evidence
Systems of needs assessment
Systems of outcomes measurement
Methods of determining quality
There was plenty of evidence of current contradictions in CME systems, both in North America and Europe. Dr. Helios Pardell, head of the Spanish Accreditation Council for CME, called attention to the tug of war among government, professional organizations and physicians' desire for professional competency. "We may be reducing the value of the health system to patients," he said.
Dr. Bernard Marlow, education director for the College of Family Physicians of Canada, noted that there are 5 accreditation systems in his small country alone! Europe has national accreditation systems, specialty board accreditation systems and the European Accreditation Council for CME (EACCME). Dr. Honorio Silva, a Pfizer vice-president, reported that six countries in Latin America have accreditation systems, but do not integrate these in any way.
Nonetheless, participants were optimistic that something could be done, if all could agree on a common starting point. Small groups addressed GAME's role for the future, some recommending that GAME serve as the leading organization that encourages international cooperation in CME. First steps might include:
Building a database of CME opinion leaders around the world
Developing representation from all 5 continents
Creating regional chapters and meetings
Creating a spreadsheet database of current accreditation systems
Developing a system for credit exchange around the world
Gaining support for research on CME effectiveness
The board of GAME, chaired by Dr. Hervé Maisonneuve of France, will be addressing its future role at a strategic planning meeting in October in Arlington VA. Meantime, Dr. Maisonneuve (Herve.Maisonneuve@pfizer.com) will welcome any comments.
More details of presentations will appear in future issues of this newsletter, and most presentations will eventually be available online at GAME's website.
Specific search engines for physicians
If you or the physicians you serve become overwhelmed in a search for evidence-based clinical information on Google or Yahoo, then try SearchMedica.com, a service from CMP Media. SearchMedica currently offers 3 free search engines -- in primary care, psychiatry and oncology.
Each search engine narrows the results, for example from 10 million Google hits on "melanoma" to 75,000 on SearchMedica. Adding qualifying terms will reduce that number substantially. There's a breakdown of evidence-based articles and metanalyses, of practical articles, and of practice guidelines, to help further.
Search engines are available in American English, English English, French and Spanish. The company expects to add additional specialty-specific engines in the future.
New head for pharma's medical congress group
Dr.h.c. Keith B. Spencer has recently taken over the position of Executive Director of the International Pharmaceutical Advisory Association (IPCAA), based in Switzerland. He has more than 35 years experience of working in the healthcare industry, including responsibility for organization of corporate participation in international medical and surgical congresses.
Working out of Germany and the UK, Spencer succeeds Dennis Wheatley. "CME is a tremendously important topic for IPCAA", Spencer says, "and it is a major priority of the Association, to monitor latest trends and review and update appropriate global information on the subject for its members, since ongoing closer involvement of the medical industry with CME issues is inevitable".
Founded almost 20 years ago, IPCAA's stated mission is to "ensure the most beneficial outcome for all parties involved in medical congresses, through the development of common and consistent congress policies and through recognized partnerships with medical societies". The Association membership currently accounts for more than 70% of the sponsorship of global medical congresses.
IT: Best tool for CME -- and patient care?
More and more, there is evidence that information technology -- properly used -- can make a difference in improving health care. It can also make a difference in CME, bringing together the processes of needs assessment and outcomes measures on a variety of levels: by physician, by practice, by region, by nation.
The latest evidence comes from a report from the Australian Centre for Health Research, which focuses on the value of sharing chronically ill patients' information via the Internet. The report noted that Australian physicians are working in "disconnected silos" ( a common problem around the world) and fail to communicate effectively among primary care physicians, specialists and hospitals. This results in lower quality care and increased cost. Such a shared system could save up to $1.25 billion (Australian) annually, as well as improve care, the report says. Further, Dr. Michael Georgeff, the author, says:
"More than 50% of doctors do not follow best practice guidelines. Between 30-50% of patients with chronic disease are hospitalized because of inadequate care management. Less than 1% are tracked to see if they adhere to care plans."
By inference, it is clear that some of these failures could be remedied through CME as well as by system changes.
Last month, the U.S. Senate Committee on Finance released a report stating that drug companies have used educational grants to help increase the market for their products, especially favoring newer and more lucrative products. Furthermore:
New products tend to be more expensive than older products, thereby increasing [government] spending.
New products may expose patients to greater risk than older products with better established safety and efficacy.
Despite guidelines from the Accreditation Council for CME (ACCME), which accredits providers, and efforts by pharma companies to separate education grant-making from marketing, a "significant gray area" continues to exist in the use of grants to serve marketing purposes.
There is no proactive or real-time oversight of CME programs by the U.S. Food & Drug Administration (FDA) or ACCME; they do not routinely place monitors in CME audiences to see what is presented.
Even when violations of regulations or guidelines are identified after the fact, it can take years to impose penalties.
Drug makers pay doctors who prescribe and recommend drugs, teach about underlying diseases, perform studies and write guidelines that other doctors often feel bound to follow.
In one state, Minnesota, pharmaceutical companies paid individual psychiatrists a median of $1,750 from 2000- 2005 [reasons not stated]. Such payments could encourage psychiatrists to use drugs in ways that endanger patient health, said a former director of the National Institute of Mental Health.
The chief of psychiatry at the University of Minnesota helped conduct a study of Concerta, a Johnson & Johnson drug for attention deficit disorder. In 2003 he earned $5,000 from the company for giving 3 talks about Concerta; he conceded that his relationship might prompt him to try a drug, but continued use would depend on results.
It is illegal for drug makers to pay doctors directly to prescribe specific products or to promote unapproved uses. But they can pay doctors to give lectures; if asked, they can discuss unapproved uses. The industry says these are invaluable education; critics say the events, often at expensive restaurants, are disguised kickbacks that encourage potentially dangerous drug uses, particularly in children.
There are distortions and overstatements in these reports, which tend to ignore the values of CME that is both balanced and evidence-based, encouraging changes in practice that benefit patients or reinforcing existing valid practices. It is, however, a fact that pharma companies fund much of the CME that is offered around the world. Can sponsoring organizations, lecturers and attending physicians be trusted to present and use information in a balanced manner for the benefit of patient care? Or must an alternative source of funding be found?
In some countries government underwrites the majority of CME. Are these programs always free of bias or might there be a tendency to stress clinical practices that save money?
In some countries, including the U.S., proposals have been made that academia control the allocation of CME funding (from pharma and the government). Are professors, who usually are paid to conduct drug studies, less likely to reflect bias if the CME portion of their funding comes through a medical school?
The Senate Finance Committee proposes to monitor CME courses to identify infractions. Who will be the monitors? What constitutes infractions? Who will be punished and how?
In the end, it seems to us, the practicing physician has the ethical and professional responsibility to evaluate the evidence from CME programs, discuss it with colleagues, and apply what works best with in patient care. And organizers of CME programs have a similar responsibility to present balanced and evidence- based content. For the most part, the medical and CME professions live up to these responsibilities. In a future issue, we will explore ideas for more self-regulation.
Meanwhile, what is your solution to this CME dilemma?
Health care in 6 countries: Which has the best?
Surveys of patients and primary care physicians in Australia, Canada, Germany, New Zealand, U.K. and U.S. show no clear winner -- but one clear loser: The U.S. ranks last or next to last on five dimensions of a high performance health system, reports the Commonwealth Fund. These are quality, access, efficiency, equity and healthy lives. The results parallel those of similar studies in 2006 and 2004.
"The most notable way the U.S. differs from the other countries is the absence of universal health insurance coverage," the report states. "Other nations ensure the accessibility of care through universal health insurance systems and through better ties between patients and the physician practices that serve as their long-term medical 'home'."
The U.K. ranks first overall in the study, scoring highest on quality, efficiency and equity. Germany ranks second, scoring best on access. Australia ranks highest on healthy lives. Canada and the U.S. rank fifth and sixth respectively. Some detailed findings:
Quality The four indicators in this dimension are effective care, safe care, coordinated care and patient-centered care. The U.S. ranks highest on effective care, Germany on safe care, U.K. on coordinated care and New Zealand on patient- centered care. "Information systems in countries like Germany, New Zealand and U.K. enhance ability of physicians to identify and monitor patients with chronic conditions," the report says. Nurses also help coordinate care as part of a team.
Access Given the absence of universal coverage, Americans go without needed health care because of cost more often than elsewhere. If insured, Americans have rapid access to specialized care, whereas in the U.K. and Canada, waits are long. Germany scores well on access to care at night and weekends, and even when offices are closed.
Efficiency On measures of health care expenditures and administrative costs, U.K. and New Zealand come out ahead. IT and teamwork also add to efficiency, compared to U.S. -- at bottom.
Equity Low-income patients fare well in the U.K., Australia and New Zealand, much less so in the U.S., Canada and Germany. The indicators here were lack of physician visits when sick, failing to fill a prescription, not getting followup care.
Healthy lives Surprisingly, the U.K. and New Zealand rank near the U.S. at the bottom, with death rates in 1998 from conditions amenable to care 25-50% higher than Canada or Australia.
Is there a lesson for CME professionals? Yes, to identify best practices in each of these countries, and find a way to include these in future course content -- whether clinical or management.
The U.K.'s different perspectives on pharma and CME
"CME is one of the key ways of establishing leadership [by a pharma company], because it is so effective in building both long-term relationships as well as establishing a presence," says Weber Shandwick director Sam Barnes of the U.K. in a Pharmafocus article entitled "Med Ed comes of age".
Another U.K. communications expert, Tim Mustill of Fishawack, adds, "Despite strict controls, there is still massive scope to influence opinion and create brand receptivity pre-launch." This thinking would certainly demand the attention of the U.S. Senate Finance Committee (see adjacent article).
The article notes that CME comes into its own at an international level, gathering world-leading physicians to discuss their practices and guidelines. Such meetings can position the sponsoring company as a leader in the field. Accreditation is becoming streamlined at the European and national level.
There is, however, a growing concern with the definition of "med ed". Will Hind, chairman of Alpharmaxim, says the term should apply to CME, as in the U.S., with a very specific set of criteria, entirely set aside from marketing.
CME activity in Finland on the increase
Legislation passed in Finland in 2004 obliges community health centers and hospitals to offer their health professionals "sufficient" CME opportunities. The Finnish Medical Association (FMA), based on a 2006 survey, reports that there has been a slight increase in the average days that doctors participate in external CME/CPD activities since the law was passed.
But there is room for improvement. The FMA and the National Evaluation Council for CME/CPD have both recommended a minimum of 10 days of CME per physician per year. The current average is close to 8 days. Hospital doctors (47%) participated for 2 more days than primary care physicians. The proportion of all doctors participating has risen to 89%. CME is not mandated, nor is recertification. For more information contact fma@fimnet.fi.
A new institute to link QI and CME
Nancy Davis, former director of CME at the American Academy of Family Physicians and past president of the Society for Academic CME, has been appointed executive director of the new National Institute for Quality Improvement and Education, based in Homestead, PA, U.S.
Davis says the new institute will create strategies and support research to help CME evolve towards quality and physician performance improvement. As of the moment, quality improvement functions in U.S. hospitals tend to be quite separate from medical education.
Course in CME research
The Society for Academic CME will hold the SACME Summer Research Institute, a short CME research methods course, at the University of Toronto Conference Centre June 16-20, 2007. The course is limited to 30 participants. Both those new to research and those more seasoned are welcome.
This is the question that participants will address at the 12th Annual Meeting of the Global Alliance for Medical Education (GAME) in New York City June 10-12. As a preview to that meeting, we will review some of the critical issues underlying the question.
Do doctors' learning styles vary widely based on geography, culture and training? There have been few studies specific to physicians, but there have been studies of substantial variations in how people perceive others and how they interact by geography and culture. In the May 2006 issue of this Newsletter, Carol Krugman, a global medical meetings expert, identified differences that may apply to doctors' learning styles:
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
Is there common ground for content development regarding diagnosis, therapy and patient management? In certain disease categories the answer is probably yes. In others, probably no. What makes the difference? First, the frequency of a disease category. Second, the weight of evidence favoring specific diagnostic and/or therapeutic approaches. Third, the degree of control the national/regional health care system exerts over medical practice. Fourth, the cultural differences. Fifth, the availability of diagnostic and therapeutic modalities. For example, diagnosis and treatment of myocardial infarction in the developed world has become relatively standardized. In contrast, diagnosis and treatment of bipolar disorder may vary considerably because of the lack of sufficient evidence-based guidelines.
How comparable are educational delivery methods? In some countries, in part because of culture, lectures are the gold standard, delivered by professors with little or no interaction with the audience. In others, interactive workshops are welcomed. Web-based learning, including point-of- care CME, is growing rapidly in the U.S. In Europe, the European Accreditation Council for CME has yet to accept this learning modality.
Are there comparable standards for commercial support of CME? Worldwide, the pharmaceutical industry is the major supporter of CME. In the U.S., relatively new rules emphasize the separation of control of content and speakers from the drug company sponsor. In others, the pharma company may be given a chance to promote its products as part of the CME program. In general, physicians attending are expected to distinguish what is biased and what is not.
How consistent are CME accreditation systems? There are two major methods of accreditation -- by provider or by program. Each has its advantages and disadvantages. Provider accreditation reduces the number of accreditation efforts substantially, and gives the accredited provider the freedom to produce programs within certain guidelines, including outcomes measures -- but allows opportunities for a few biased or inaccurate programs to slip through. Program accreditation monitors the objectives of every presentation and may or may not examine effectiveness. But this is highly time-consuming and leads to superficial review in some cases. Finally, accreditation of medical education companies is accepted in some countries, not in others.
Can credit systems be equated? Within the European Union, the EACCME has sought a common currency for credits among member countries, though every country appears to have a somewhat unique approach to awarding points or credits. The EACCME and the AMA in the U.S. have a reciprocal arrangement. Is there a difference in credits in countries that have voluntary CME vs those with mandatory CME? To what extent do the rules for accreditation of provider or program affect the true value of a CME credit? Should effectiveness of CME -- by some measure -- be considered as a global standard?
These and other questions will be debated vigorously during the GAME meeting. There are no easy answers. Come to GAME to share your thoughts. And send us an email (lew@wentzmiller.org) with your response: Can CME be harmonized globally?
·Update: CME in Germany is moving forward
German physicians now have a wide variety of CME available, and the compulsory system -- in effect since 2004 for office-based physicians and since 2006 for hospital-based physicians -- appears to be working well. Most doctors seem to have little trouble moving toward the required 250 points or credits in a 5-year period. What will happen to those who miss the mark by 2009 is still not clear.
Initially each of the 16 chambers of physicians was allowed to accredit CME activities by its own guidelines, but efforts are now being made to streamline the guidelines on a national level. The model regulations of the German Medical Association state that the objective of CME is to enable physicians to maintain and constantly update their professional competence. Content, says the association, should not only cover clinical knowledge and skills but also improvement of communication and social skills, methods of quality assurance and evidence-based medicine.
Who can provide CME? An organizer recognized by one of the state chambers -- usually a scientific society, a medical school or a quality circle. The organizer can be accredited for a 12-month period in most cases, after signing a contract to abide by the chamber's requirements. These include a written declaration of compliance with the German Medical Association's perquisites, such as having a physician responsible for scientific content, disclosing economic ties to industry and following a basic set of categories for certified CME. The state chamber may supplement these requirements.
The German Medical Association's credit categories cover lectures and discussions, both one day and multi-day, at home or abroad; workshops and similar small group learning, interactive CME via print, online or audiovisual media; personal study; scientific publications and presentations; time as a visiting doctor, and curriculum based content, such as that prescribed for specialist qualification.
The requirements of one state chamber (Westfalen-Lippe) go into more detail, to include, for example:
A participant may not be charged more than the actual costs of the CME activity.
The CME credits are to be communicated to the Medical Chamber. The Medical Chamber is the only organization authorized to award CME certificates to doctors.
Commercial sponsors are allowed to exhibit their products, for which they have to pay an appropriate fee.
If products have to be mentioned in presentations this has to be objective and limited.
If the CME activity falls short of the required standards [of accuracy and objectivity], the Medical Chamber is authorized to cancel the accreditation of the CME activity immediately.
A list of all 16 state chambers and their contact information appears on the the site of the German Medical Association. Application forms for providers appear on the chamber sites.
·CME academicians examine the latest trends
The Society for Academic CME (SACME), an association of U.S. and Canadian CME professionals with scholarly interests from medical schools and specialty societies, recently celebrated its 30th anniversary at a meeting at Copper MountainCO. The program focused on CME as a bridge to quality, and emphasized practical strategies for evaluating change. Trends and directions from the Canadian government on assessment of physician performance and competence were included.
More on CME effectiveness from a SACME leader: The president-elect of SACME is Dr. Jocelyn Lockyer, associate dean, CME and CPD, University of Calgary, Canada. She and a colleague published a worthwhile meta-analysis of CME effectiveness in the Winter 2007 issue of the Journal of Continuing Education in the Health Professions. The study produced similar results to that reported in this newsletter last month, generated by the U.S. Agency for Healthcare Research and Quality. Findings of the new meta-analysis:
There is a medium effect of CME on physician knowledge.
There is only a small effect on physician performance and patient outcomes.
Interactive interventions improve the effect.
Multiple methods also enhance results.
Focusing on a small group of physicians from a single discipline also improves the effect.
·Spanish CME/CPD Bulletin is launched
A new online newsletter bringing Spanish- speaking CME professionals together has been launched by the Spanish Medical Education Foundation under the sponsorship of Wolters Kluwer Health. Boletín DPC-FMC is edited by WentzMiller associate Dr. Helios Pardell of Barcelona, and includes international as well as Spanish CME leaders on its editorial board.
Dr. Pardell expects that the new publication will be a way for relevant experts and institutions in Latin America and Spain to exchange knowledge, experience and events.
·Dave Davis takes on new responsibilities
Dave Davis MD, longtime head of CME at University of Toronto, Canada, and a pioneer in CME and its effectiveness (undoubtedly the most quoted in the field), has been appointed vice-president for continuing health education and physician performance improvement at the Association of American Medical Colleges. This new position recognizes the growing importance of CME in the academic world.
·Latest WentzMiller accomplishments
In recent weeks, WentzMiller & Associates has (1) completed an assessment of healthcare information needs in the U.S. for a European-owned company; (2) advised a non-U.S. CME provider on design and completion of a CME grant application in the U.S.; (3) counseled a U.S. MECC on ways to extend their existing programming to other countries in Europe and Latin America, and (4) advised a medical publisher on strategies to improve readership. IF you are interested in learning more about our capabilities, contact Lew Miller (lew@wentzmiller.org) or Dr. Dennis Wentz (dkwentz@aol.com).
Unfortunately, the authors found that the heterogeneous nature of the studies made it difficult to draw further clear conclusions regarding effectiveness of specific educational interventions. They also noted "a lack of standardization of the definition of CME or associated performance improvement". Nevertheless, the following observations were made:
Print media seem to be less effective than live media.
Only 3 studies utilized the internet, and all demonstrated some knowledge improvement.
Only 13 percent of trials were rated as “good” in enabling learners to be active contributors.
Multimedia seem generally more effective than single media.
Interactive techniques seem more effective than non-interactive ones.
Multiple exposures to the CME activity seem to be more effective than single exposure.
Simulation training improved psychomotor skills but there were no outcomes reviewed in these studies.
The authors used the verb "seem" rather than drawing firm conclusions because of the limitations of the studies they reviewed. They found only 136 articles and 9 systematic reviews, out of 8,000 citations, that met their criteria -- and these seldom used the same methodology, much less explaining a methodology. And they reviewed only studies in the English language. If you know of non-English language well- done randomized studies of CME effectiveness, please send the references to lew@wentzmiller.org).
The authors conclude with strong recommendations to educators to strengthen a research agenda on CME effectiveness by:
Standardizing definitions of CME, interventions, media, techniques and outcomes to be measured
Creating a sound conceptual model of what influences the effectiveness of CME
Setting up a national consensus conference to lay the foundation for a comprehensive CME research agenda
Funding educational researchers to design higher quality studies and outcome measures
In the U.S. alone, more than US$2 billion is spent annually on certified CME; around the world the number must be well in excess of US$3 billion. With that level of investment, it should be clear that CME professionals and their organizations need to devote substantial resources to determining what works with whom and why. Do you agree?
++++++++++++++++++++++++++++++++ Check Out G-I-N, the Meeting Not the Drink!
There are literally thousands of clinical guidelines in existence around the world. For CME professionals and faculty seeking to select the best evidence for a program, the process is daunting. Help may now be on the way. The Guidelines International Network (G-I- N) is holding its 4th annual conference in Toronto August 22-25, and invites all CME professionals not only to attend but also to submit an abstract. Your challenge to the group may improve the selection process!
++++++++++++++++++++++++++++++++ Honors to 2 from WentzMiller
Dr. Beverley Rowley, a WentzMiller associate, was recently honored by the University of Nevada School of Medicine, along with her longtime colleague Dr. DeWitt Baldwin Jr., for their founding 30 years ago of Nevada's Office of Rural Health, through which they recruited new or replacement health professionals for 38 rural communities in the state.
Lew Miller, principal, was inducted last month into the Medical Advertising Hall of Fame in New York. He was recognized for his leadership in the fields of medical publishing and continuing medical education over the past 45 years.
The face of European CME is changing
European governments are moving more rapidly to regulate the growing CME sector, say three leaders in medical communications, as quoted in a new publication, Pharmafocus Europe. They differ on the effect of this trend, however.
Says Max Jackson, president of emerging markets and businesses, Publicis Healthcare Communications Group: "My feeling is that growth in medical education has slowed down ... because it built from a small base, but also because we are running into some significant governmental legislation pressures, as well as time pressures on doctors." Another factor, he notes, is the lack of a unifying certifying body for CME in Europe.
"At one extreme," Jackson says, "in Italy there are more than 5,000 CME accrediting bodies ... so it is absolute chaos in terms of predicting the quality of the programs." The UK government, he continues, "has been content to let the pharmaceutical industry run CME for them -- because it was cheap -- but I think the government will now want to control what information is provided to its doctors." Jackson expects CME to make the most sense in Germany and France, where "governments take CME very seriously."
Finally, he sees the US trend towards separating promotional and nonpromotional CME taking root in Europe. "Pharmaceutical companies are starting to get very nervous about having the same agency working on their promotional and nonpromotional" education, Jackson concludes.
Chris Gray, managing director, Adelphi Group, says "Europe med ed ... is in a healthy state of change. The sector is struggling to become more creative in a bid to respond to regulatory scrutiny ... and the need to provide learning that is measurably effective." This is challenging because "European markets are much more conservative than in the US."
Gray suggests that as pharma clients develop new interventions, these will require a fundamental change in practice. "Effective education with measurable impact is increasingly seen as the most beneficial way" to achieve such change. Nonetheless, Gray concludes, delivery of European accredited programs will "remain very different to implementation in the USA".
William Hind, managing director, AlphaRmaxim Healthcare Communications, harks back to Jackson's comments re separating types of medical education. "With true med ed becoming subject to increasing regulation, it is important to clearly define broader programs -- possibly mistakenly called 'med ed' at present -- as marketing communications. These may embrace elements of medical education, but they will have marketing objectives at their core."
A new approach to designing CME interventions?
Most CME interventions are based on disease models. A group of researchers from the University of Toronto, in an article in the Journal of Continuing Education in the Health Professions, are now suggesting that performance measurements of CME effectiveness "have failed to fully account for the multidimensional nature of physician performance", especially in general and family practice.
Here are the dimensions Dr. Elizabeth F. Wenghofer and colleagues identified:
Managing patient with acute condition or new presentation
Managing patient with chronic conditions
Providing patient with continuity of care and referrals
Providing patient with well care and health maintenance
Providing patient with psychosocial care
Managing patient records and recording skills
Using these dimensions, the authors suggest, can improve both needs assessment and performance evaluation, so that CME can be structured to the context in which each physician treats his/her patients.
ACCME now ready to recognize other accreditors around the world
The Accreditation Council for CME in the US has announced that it is now implementing a system for the recognition of non-US CME accreditors, based on "substantial equivalency" of accreditors. That means, says the ACCME, that "the program is comparable in educational outcomes, but may differ in format or method of delivery".
The system is based on documents based through collaborations with other CME accreditors, specifically, the framework developed in 2002 with the Association of Faculties of Medicine in Canada, and the consensus on basic values, developed with North American and European CME leaders in 2004.
The ACCME is "looking forward ... to establish or renew the substantial equivalency of the following ... if requested to do so":
Committee on Accreditation of Canadian Medical Schools
Royal College of Physicians and Surgeons of Canada
European Accreditation Council for CME
And the ACCME is further offering a service to other emerging, developing or established accreditation systems to assist in self-assessment and peer review. Eligibility will be determined on a case-by- case basis. Enquire of Dr. Murray Kopelow, CEO (mkopelow@accme.org).
The Physician Executive, the journal of the American College of Physician Executives recently published the responses of 1205 of their members regarding the physicians they work with. Rated on a scale from 1- 10, 59% of the execs rated the morale of physicians they work with at a level of 5 or less, with only 23% rating the morale as 7 or higher. In their view, the top reasons were:
Low reimbursement rates 22%
Loss of autonomy 21%
Bureaucratic red tape 17%
Patient overload 12%
Medical malpractice environment 11%
Loss of respect 11%
The physician executives themselves indicated these personal problems: Fatigue (77%), Emotional burnout (67%), Marital/family discord (34%), Depression (32%), and Suicidal thoughts (4.4%). An analysis of the data that revealed that 60 per cent of doctors said they had thought about getting out of medicine; over 70% knew of at least one doctor who had quit practice due to low morale.
Two researchers from the University of Edinburgh looked at GP satisfaction in their work in the UK, in an article in Annals of Family Medicine. The major influences on satisfaction in consultations "were the perceived outcome for the ... patient, the interpersonal relationship ... and the impact ... on the doctor's identity."
Dissatisfaction resulted when doctor-patient interactions were not successful in their minds -- more in terms of relationship than clinical outcome. This affected the doctors' sense of self, the authors said, after interviews in depth with 19 GPs. But the doctors often blamed more surface reasons, such as negative moral evaluation of a patient, or lack of time.
Current proposals to reform the primary care system in the UK by emphasizing standardized clinical care rather than individual health "threaten to undermine" the doctor-patient relationship, the authors concluded, and thus may well exacerbate GP dissatisfaction.
A recently published study in the New England Journal of Medicine by University of Chicago researchers indicated that a small minority of doctors feel no responsibility to inform patients of treatments they deem immoral, nor do they refer them to other doctors.
Of 1144 respondents to a mail survey, 52% opposed abortion for failed contraception, 42% objected to prescribing birth control for adolescents without parental approval, and 17% opposed terminal sedation for dying patients. Most doctors felt obligated to inform patients of all the options or refer to another physician despite their moral or religious objections. But 8% felt no obligation to inform, and 18% no obligation to refer to another doctor. Said the New York Times in an editorial: "Any doctors who cannot talk to patients about legally permitted care because it conflicts with their values should give up the practice of medicine."
Should CME/CPD professionals be thinking about how to assist doctors in analyzing their ethical behavior, and how to make life in medical practice more rewarding? If so, how? In our experience, these are topics better addressed in the context of courses on clinical care topics than presented directly. For example, a CME activity on care of the pregnant adolescent could well include discussion of how to communicate in a balanced way on birth control and abortion issues.
What's your opinion? Have you dealt with topics of morale and self-respect, or ethical dilemmas in CME/CPD activities? Have you been successful? We would like to share your experiences. Write lew@wentzmiller.org or dkwentz@aol.com.
European physician portals growing as a source of CME
Physician portals are rapidly becoming a primary source of information for a new generation of physicians in Europe, says Mark Bard, president of Manhattan Research. These are sites such as Univadis that bring together CME, news, drug reference and patient education in one destination. "Time spent reading textbooks, searching journals in the hospital and attending congresses for education is being transitioned to the online channel," Bard says. And he encouraged pharmaceutical company supporters to contribute to the online infrastructures. More at Taking the Pulse Europe.
Another site, newly launched in the UK by Haymarket, goes even further, adding an "off-duty" section on topics such as gardening, food and cars. The site, HealthcareRepublic.com, provides news, CME, clinical articles, help with the business side of practice, and links to an online prescribing and guidelines database.
In a related web development, the tedious process of searching for evidence based and relevant clinical content is being made easier by a new care-centric search tool, SearchMedica .com. A Google search for a specific disease or syndrome may turn up 500,000 possibilities, many of which are off target or of dubious value. SearchMedica narrows the entries by value to specialties. Search engines for primary care and psychiatry are already available; oncology will soon be launched. The tool is available in the UK, the US, France and soon in Spain.
And the European Accreditation Council for CME will once again consider this year issuing credits for long- distance learning, a decision that so far has been deferred.
Netherlands CME process is streamlined
The Netherlands has had an integrated system of CME credits for several years, thanks to the efforts of the Royal Dutch Medical Association (KNMG) to bring together the 28 clinical specialties, the GP group and social medicine specialties. Now the system is going digital.
An electronic application form is available on the KNMG website in Dutch and English. The professional societies with still do the accreditation and awarding of credits. Their websites all have links to KNMG. A system for accounting of doctor credits will be operational this year, using the doctors' registration numbers, and the data will go to the Registration Colleges in the 3 groups mentioned above. Requirements for reregistration in a 5-year cycle are:
40 hours of CME yearly on average
16 hours of patient related work per week
Participation in the visitation programs of the professional societies
Says Dr. C. C. Leibbrandt, a WentzMiller associate and former director of the EACCME: "A weak point is that CME activities abroad and participating doctors from outside the Netherlands do not fit into this system easily. Paperwork will remain!"
CME rebellion in Italy -- by pharma
The Italian government announced a 5% price decrease on drugs before the start of the year, says WentzMiller associate Alfonso Negri MD. In retaliation, the industry organization, Farmindustria, set up a 3-month ban on travel, room and meals for Italian doctors for both Italian and international education events.
Then, in late January Farmindustria extended the ban until the end of June, due to a further possible price reduction, according to Dr. Negri. This suggests that most CME events will suffer greatly, since it is a common practice for pharma to pay expenses for doctors attending such congresses. It may result in postponing many events until the second half of the year. "One-day events will also be affected, with no food, or even coffee!," says Dr. Negri.
There is discussion of a joint meeting of pharma, the ministry and scientific societies to negotiate a truce.
Clarification re "promotional education"
Last month we referred to non-certified CME programs in the US as "promotional" medical education. Pam Mason, head of the medical education office at AstraZeneca, took issue as follows:
"This is not a true statement for all companies. Promotional programs are heavily regulated and the company has full control. Independent programs can be either certified CME or non-certified. Examples of the latter are fellows or investigator programs and small scientific conferences. The key word is "independent". All requests for such programs must be submitted to our grants office."
Check your calendars for June CME events
Lew Miller, principal, and Alfonso Negri MD of Italy and Helios Pardell MD of Spain, both associates, of WentzMiller will be playing active roles in 2 forthcoming international CME conferences:
CBI's 2nd Annual European Congress of CME, June 27-28, 2007, in London, on the theme "Complying With Evolving Regulations to Maximize the Value of CME Activities" (A discount coupon is available from lew@wentzmiller.org)
How can we help you?
The knowledgeable team at WentzMiller & Associates stand ready to help you solve problems in international CME, identify opportunities or develop a global strategy. Call Lew Miller at 203 662-9690, or by e-mail at lew@wentzmiller.org. We'll let you know if we can help, how, and at what cost.
Russia's level of 3% of GDP appears too far below what's necessary to maintain the health of its population. The lack of sufficient well-trained physicians seems to explain some of the gap between Russia and the developed nations. Dennis K. Wentz MD, a WentzMiller principal and vice- president of the Project Globe Consortium for CPD, recently met with leaders in Russian health care in Moscow. Key points from his report:
There is no private practice; state-employed doctors work in polyclinics or hospitals.
District doctors deliver outpatient care in 15,639 adult, 15,200 pediatric and 42,000 obstetric/gyn polyclinics; one polyclinic in Moscow serves 54,000 residents.
Family medicine or general practice as known in developed countries does not exist.
After 6 years of medical school, doctors choose either a one-year internship or two-year specialty training before starting practice.
The work load is intense: doctors are allotted only 12 minutes per patient in the polyclinic.
Equal time to polyclinic hours is allocated to home care and telephone visits.
Salaries are extremely low; a top-qualified district doctor earns about $1000 U.S. per month, specialists less than half that.
There is a critical shortage of doctors and diagnostic tools.
It appears that government leaders in Russia have not yet recognized the crisis in health care, and have failed to devote a larger share of the country's rapidly growing oil and gas revenues to reversing the downward trend in health outcomes.
Meanwhile, the Kaiser report encourages U.S. policymakers to look at the growing gap between its health spending and that of other developed countries: "What are people in the U.S. getting for their far higher and faster growing spending on health care?"
Certainly not better primary care! Findings of the Commonwealth Fund's 2006 International Health Policy Survey indicate that primary care doctors in the U.S. are less likely than those in other industrialized countries to have the tools and support needed to provide patients with the best care possible.
The survey notes that primary care doctors in Australia, Canada, Germany, the Netherlands, New Zealand and the U.K. are better equipped to offer patients access to care outside regular office hours and are much more likely to have clinical information systems in place to assist in treatment decisions and to alert them to potentially harmful drug interactions. Comments Fund senior vice president Cathy Schoen: U.S. primary care doctors "practice without basic decision supports that could improve health outcomes and reduce costs."
Is there any correlation between CME requirements, healthcare spending and health outcomes? Not that we can see. Russia and many developed countries, including most of the U.S., have mandatory CME linked to relicensure. Yet a few countries, notably Finland and Sweden, spend only 7-9% of GDP on healthcare, have among the best health outcomes and have no mandatory CME.
What the data suggest is that equivalent care is cheaper when health care costs are controlled by national governments. In addition, primary care is more effective -- and apparently no more costly -- when doctors are more available and are equipped with clinical information systems. We might hazard a guess that CME may be more effective when integrated with such systems -- but there's as yet no evidence to prove this. Your views?
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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.
We wish you a Joyful 2007
Yes, we face problems of war, religious and sectarian violence, poverty and disease as we enter this New Year. But we also have opportunities to make a difference in the delivery of better health care to people around the world. This issue discusses issues of cost:benefit in health care and CME trends in France, Canada and the U.S. in 2007.
Mandatory CME finally arrives in France
The first ordinance mandating CME in France was signed in April 1996. The year 2007 will finally mark its implementation, according to an announcement by the 3 presidents of the National Councils for Continuing Medical Education (CNFMC): Alain Beaupin for salaried doctors, Bernard Ortolan for private practitioners, and Dominique Bertrand for hospital doctors. "It will have taken 11 years and the efforts of more than 4 ministers to reach completion," they said.
French doctors must accumulate 250 credits during 5 years, regardless of type of practice. The objective is to enable them to improve knowledge, quality of care and well-being of their patients. A doctor who doesn't reach the 250 credits must work with the appropriate council to develop a remedial plan.
There are 4 categories of credits; 150 must be realized from the first 3, and 100 from the 4th category:
Attendance at live meetings -- 8 credits per day, 4 per 1/2 day or evening
Distance or individual learning -- including journal reading, print or electronic CME programs
Professional activities -- including quality improvement, research, publications in the doctor's healthcare field
Practice audit -- comparing the physician's performance to established guidelines, according to standards determined by the top health authority (not the National CME Councils)
The national committees will evaluate providers' dossiers early in 2007 to grant accreditation. Providers will then submit credits to Regional CME Councils, each of which will have 12 members named by the regional prefect, including 3 each from private practice, hospital practice and salaried doctors, plus 3 at-large physicians. These councils will be put in place in 2007.
CME in Canada: Moving to mandatory
Canada's CME is governed through provincial governments, the College of Family Physicians of Canada (CFPC) and the Royal College of Physicians and Surgeons of Canada (RCPSC). Until recently, provincial governments have left CME requirements to the professional associations. But now the provinces are beginning to require CME as part of the revalidation process.
Saskatchewan was the first province to implement the requirement, beginning this year. Ontario already has in place mandatory practice peer review, but not CME. Until now, most specialists, as fellows of their specialty colleges, have complied with the professional requirements, but almost 50% of GPs are not fellows of the CFPC and haven't been bound by any regulation. The implications of government intervention mean that these doctors will have to meet the college's 250-credit minimum over 5 years.
Canada is also shifting from CME to CPD (continuing professional development), focusing more on individual needs for improvement as identified in a physician's own written plan. CPD also emphasizes better outcomes measurement, more reflective learning (examining one's own behavior and results from patient to patient), and more practice audits.
Finally, funding of CME is beginning to shift. Some medical schools are limiting to 20% or less the percentage of funding they will accept from pharmaceutical supporters. Provincial governments are offering more support; for example in Quebec, doctors can get a $300 grant for attending a 1/2 day course. And some pharma companies are moving CME budgets from marketing managers to a professional education department.
EACCME has a busy year
Business is growing at the European Accreditation Council for CME (EACCME), which approved more than 7 00 programs for European physicians last year (through November 15, 2006). Programs must reach physicians beyond a single country's borders, and must be live. Internet programs are still under consideration for future accreditation.
The preferred country? Italy, with over 100 meetings; Milan was the top destination. Switzerland was a close second, with more than 90 approved programs; Tolochenaz was the favored venue. Other countries in the top 5: Germany, France and Spain.
But EACCME recognized a number of programs in locations outside Europe, ranging from Mexico and Brazil in Latin America, to China and Japan in Asia, to Canada and the U.S. in North America, and to India, Saudi Arabia and the UAE. As a result, European physicians attending those meetings were able to take credits back to their home countries.
Predictions for U.S. CME in 2007
Lew Miller of WentzMiller & Associates was asked by an editor of a pharma newsletter to forecast trends in U.S. CME in 2007. These are his predictions:
1. The shift from accredited or certified CME to non- certified or so-called “promotional” medical education will accelerate in 2007. Why? Managers of professional education departments in pharmaceutical companies:
Are limiting their grant-making activities more and more to accredited providers in academic medical centers and medical specialty societies.
Are forcing medical education companies, even those that are accredited, to run all their ideas through the academic centers and societies – or to develop these as non-certified CME activities funded with marketing dollars.
Are still dependent on marketing budgets in therapeutic areas most important to company sales, and for a variety of reasons it is likely those budgets will continue to decrease.
Are feeling increasing pressure from corporate legal departments to avoid any form of education for off-label uses that can lead to U.S. attorney action and major settlements.
2. There will be a decline in the number of accredited providers as smaller organizations – medical education companies, specialty societies and hospitals – find too onerous and too costly the new regulations of the Accreditation Council for CME to demonstrate outcomes in competency, performance or patient care.
3. Managers of professional education departments in several pharma companies will start planning individual or joint education efforts to improve the quality of grant submissions from accredited providers, many of whom fail to meet the higher standards for needs assessment and outcomes demanded by the company managers.
Declaration on quality of care in Europe available
In November, we described the new policy statement of the European Union of Medical Specialists, defining the way in which regulation can assist in ensuring safety and quality of patient care. The Budapest Declaration is accessible now on the UEMS site.
