Since the European Accreditation Council for CME (EACCME) decided only last April to accredit e- Learning, there has been a rapid increase in the number of programs, Dr. Edwin Borman of the UK reported at the recent European CME Forum in London. What's more, he said, "the system for e- learning accreditation appears to have the most rigorous criteria of any of which I am aware."
So far, 68 applications for eCME have been received by EACCME, 6 accredited, 4 refused and 58 in review. "Rather than rejecting applications that almost fulfill the essential criteria," Dr. Borman, who wrote the original policy document, noted, "EACCME provides formative feedback and permits a short time in which the applicant can address the problems." Among the criteria:
Material must be evidence based, encourage active learning and free of bias
The provider must use an independent assessor of the quality of content and declare any conflict of interest
There must be confirmation of the achievement of learning objectives
Supporting these essentials is a study by Gensichen et al in the European Journal of General Practice, reporting on the responses of 60 primary care experts who are also e-Learning experts. While there was a positive attitude toward GP e-learning, there was concern about the lack of orientation toward users' needs and poor development of innovative didactic concepts.
More US CME providers and funders are leaning toward a new model of industry support, based on a survey at the 20th Annual National Task Force on CME/Provider/Industry Collaboration held last month in Baltimore MD. The new model: directed pooled funding, in which industry funds would be sent to a central pool (management not yet determined) but could be designated to meet a specific need.
The online report indicated that 58% of those voting prefer the current model of direct grants to providers, 25% prefer directed pooled funding; 12% nondirected pooled funding, and 5% elimination of industry funding. Panelists discussing the idea were from a cross-section of providers and industry; all were intrigued by the directed pool concept, which has been in use by the Medical Association of Georgia and related states for years.
Meantime, in a separate meeting, the American Medical Association rejected for a third time a proposal by its Council on Ethical & Judicial Affairs to limit or eliminate industry funding of CME. This proposal suggested that it would be preferable that CME providers accept funding only from sources that have no direct financial interest in a physician's clinical recommendations, but said it would be permissible to accept such funding if educational needs were determined in advance before funds were solicited.
Since 1996, when CME was mandated in France, at least 4 plans have been launched -- and still nothing is functioning. Herve Maisonneuve MD reports that the July 2009 lawnow puts the emphasis on continuing professional development (CPD) and in particular on performance improvement (PI). "The politicians," he says, "want to oblige doctors to do one PI activity per year, but they don't know how to evaluate these activities."
What about the current system that has accredited 500 providers for CME and 120 for PI? IT has never been implemented, and the 2009 law takes power away from the current national CME committees and makes them simply advisory to the health minister, who must set up a new scientific commission to direct PI activities -- probably through the specialty colleges. It appears that the entire credit system will disappear, Dr. Maisonneuve suggests. Financing the system has never been discussed. Vive la France?
As we go to press, the US Senate is beginning debate on Health Care Reform (HCR). There is no doubt the changes will have a major impact on CME in the US and our doctor's approaches to their professional development. This was made clear at the recent Society for Academic CME (SACME) meeting where the group was challenged to find new partners and get involved with "translational research", to move from the current paradigm of "mind the gaps" education to getting new evidence-based knowledge adopted into practice.
That same week the New York Times Magazine devoted its cover story to Dr. Brent James of Intermountain Health in Utah who has pioneered helping the health system use evidence-based knowledge, track outcomes, and adjust care based on feedback, approaches that may become mandatory as a result of HCR.
The first article in this issue offers important news about EACCME's system to accredit E-learning materials in Europe. Will this step eventually meet AMA's 2004 recognition of "Point of Care" E-learning, a concept which makes sense but is only being adopted at a slow pace? Finally, what can CME globally learn from industry's changing approach to marketing? Newspapers and trade publications are replete with stories of E-delivery of information via Twitter, Facebook, YouTube and other social networking connections. It's a new era for CME!
Responding to reader comments, we are bringing a changed format in this issue, easier to read at a glance, shorter, and with quick links to supporting articles when available. Let us know what you think by writinglew@wentzmiller.org.
"We are on a countdown for a provider accreditation system and e-learning in Italy," reports WentzMiller associate Alfonso Negri MD. The Italian Health Ministry introduced the new system at a recent continuing medical education (CME) conference in Cernobbio.
Italy will start a process of accrediting public and private providers, says Dr. Negri, instead of accrediting programs -- a move that is yet to be supported by the European Accreditation Council for CME (EACCME), There will be national and regional programs,including distance learning, which until now has been accredited only in Lombardia. The system, which is set to start in 2010, after a joint effort including to old accreditation process, will also include continuing professional development (CPD), an expansion of CME, and will require transparency of commercial sponsorship and clear identification of conflict of interest, if any. The number of events and providers should decrease with more attention to quality standards and controls, says Dr. Negri.
Dutch GPs don't regularly adhere to published practice guidelines, a recent study published in Implementation Science demonstrates. The most perceived barriers, say the authors, are lack of agreement with the recommendations due to lack of applicability or lack of evidence.
Other barriers included environmental factors such as organizational constraints, lack of knowledge regarding the guideline recommendations and concerns about the unclear or ambiguous nature of the guidelines. The authors suggest that implementation strategies would help, along with focus groups in CME as a means of bolstering implementation.
Should European countries come together to have a quality assurance model for physicians -- one that includes CME and CPD, but also includes assessment of fitness to practice? These issues are explored in a review paper published recently by the European Observatory on Health Systems and Policies. The authors note that few countries require demonstration of fitness to practice, though that is the direction the UK is headed toward with its revalidation scheme.
The problem with CME/CPD, the authors note, is that this learning model seeks to improve clinical competence but lacks formal external assessment, and evidence of improving health outcomes. Assessment tools, however, are not well proven either, and are often costly. Screening assessments are being used to some extent in Austria, France, Hungary Ireland, the Netherlands, Slovenia and UK. But none has been discovered that with reliably indicate poor performance, the authors add. "There is an unmet need for a forum on the regulation of the medical profession," they conclude.
The PanAmerican Federation of Associations of Medical Schools will include a discussion of harmonizing CME systems at its meeting in Buenos Aires October 21-23.
The European Institute for Medical & Scientific Education (EIMSED) presented its first "educational signature concept" program on Type 2 diabetes last month in Vienna.
The Cochrane Collaboration has published an update of its systematic review of CME effectiveness, concluding that "educational meetings alone or combined with other interventions can improve professional practice and the achievement of treatment goals by patients".
Did GSK raise the bar, or not? Sondra Moylan, president American Academy of CME, writes re last month's issue, "I am very upset by the heading, 'Glaxo raises the bar on CME it will fund". This gives the distinct impression that by not providing grants to [other than institutions], and selecting only 20 providers, it somehow raises the bar. It doesn't; it simply takes away the intent of independence within CME."
Arrogant protesters? Bruce Bellande, of CME Enterprise, feels that "the major problem with commercial support is not with CME but with physicians such as Drs. Carlat and Nissen who seemed almost arrogant as they boasted about their violations at Sen. Kohl's hearings. It is essential that we emphasize that CME providers are educators. We depend on the integrity and ethics of faculty to comply with our standards. We do not need to continue to castigate our system but rather correct the problem. I request we form a united voice."
Can the CME community change from reactive to pro-active?
Lew Miller's commentary
The news items in the adjacent column remind us that despite continuing efforts to demonstrate CME effectiveness, we have failed to make our case for value in the eyes of politicians, the public and even the academicians in our medical schools.
The situations is aggravated by the fact that around the world a majority of funding for CME comes from the pharmaceutical industry -- and that can be, and sometimes is, a cause for conflict of interest.
To date, those of us who believe that CME does has a value, and that it is possible to reduce or eliminate conflict of interest between providers and funders, have failed to make the case effectively. As is often the case, headlines go to the critics, not the defenders.
Can we turn that around? Can the CME community move from defense to offense? Saving lives seems to be less exciting than losing lives. Improving patients' ability to function sounds dull compared to reporting on the debilitating side-effects of a potent drug.
I'm beginning to think we need to take a lesson from the Nissens (see article on More assaults...) of this world. Let's go on the attack, for example:
Let's throw out all the state and national laws requiring physicians to record hours of CME in order to continue medical practice. These laws fool the public into believing that hours of CME safeguard their health. What nonsense! They should be replaced with something that specifies measures of clinical competence.
That leads to the opportunity to show what the CME community is doing effectively:
New studies show that patients with bipolar depression do better when their family doctor takes a refresher course. Now a major global pharmaceutical company (see Glaxo ... below) is promoting the value of patient-health-oriented CME in its new policy that all CME it funds must lead to optimal performance of physicians. Et cetera.
We have plenty to be proud of as CME professionals, whether we work in academia, medical societies, medical education companies or the pharmaceutical industry. We have been making dramatic changes in the past decade in the way in which we provide education that leads to performance improvement and improved patient outcomes. We have strengthened the rules to reduce bias and conflict of interest, and have responded to government guidelines in the US to separate marketing from medical education.
There is plenty more we can do, of course. We need, for example, to pay serious attention to those critics who want to get rid of pharma funding entirely. Suggestions that pharma fund a general CME grant resource have met with little enthusiasm. Should the industry consider shifting its internal funding channel from brand marketing managers to medical/scientific departments? Or would that still come under fire?
Are you ready to be pro-active? Write me (lew@wentzmiller.org) with your ideas to share with our readers.
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Glaxo raises the bar on CME it will fund
In a memo sent to many CME providers Sept. 18, GlaxoSmithKline (GSK) announced that starting in 2010 it will fund only "independent medical education programs clearly designed to close gaps in patient care by supporting the optimal performance of healthcare professionals". GSK will fund fewer programs but will support those "with the greatest potential to improve patient health". Like Pfizer, GSK will no longer fund CME by medical education companies, accredited or not.
Dear CME colleague,
We are making great strides in CME -- and in documenting our work, as some of the studies below indicate. But we are not doing so well in making the case for our effectiveness and our ability to deal with conflict of interest. The commentary offers some thoughts on possible next steps.
CME does work: 3 studies of effectiveness with varying results
New evidence of the value of continuing medical education appears in three studies published in recent months. The first and most significant is a Cochrane Review of randomized controlled trials of educational meetings that reported an objective measure of professional practice or health outcomes. The second examines what physicians learned from 3 accredited CME courses at the annual meeting of the Society of General Medicine. And the third reports on the efficacy of a newsletter in long-term retention of information and of the case-based method for collecting survey data.
Cochrane Review: Authors from Norway, Iran, Canada and the US updated a previous review to cover 81 trials. The authors concluded that:
"Educational meetings alone or combined with other interventions, can improve professional practice and health outcomes for patients. The effect is most likely to be small and similar to other types of [CME] such as audits and feedback. Strategies to increase attendance ..., using mixed interactive and didactic formats, and focusing on outcomes that are ... perceived as serious may increase the effectiveness... Meetings alone are not likely to be effective for changing complex behaviors."
Internal Medicine Courses: Saul J.Weiner MD et al examined results from an 80-hour course and 2 90-minute workshops at a meeting of the Society of General Internal Medicine to determine knowledge acquisition, knowledge sustainment and changes in comfort.
The results, published in the May 2009 issue of Journal of General Internal Medicine (subscription only access), showed modest to moderate gains in knowledge in the workshops and large gains from the longer course. However, participants from one workshop had a large knowledge gain after 9 months, compared to a small to modest decay in the other two groups. In the workshop with the knowledge gain, the comfort level decreased! The authors didn't identify the reasons for the differences.
Newsletter Effectiveness:The University of Cincinnati College of Medicine reported on a study of the value of a newsletter, "Treating Bipolar Depression in Family Practice," in assisting participants to make clinical decisions consistent with evidence-based recommendations. The survey was conducted with case vignettes. Compared with nonparticipants, participants were 35% more likely to make appropriate decisions. Overall, however, physician confidence for managing bipolar depression was not high, indicating a need for further CME.
The study also supported the use of case vignettes as a valid method to measure a physician's process of care in actual practice.
More assaults on pharma-funded CME: A prominent cardiologist and a Pfizer settlement
Dr. Steven Nissen, top cardiologist at the Cleveland Clinic and long a lover of attacks on the establishment, took aim at the Accreditation Council for CME (ACCME) at a recent US Senate committee hearing on conflicts of interest in medical education. "Whatever ACCME is doing" to eliminate bias "is ineffective," he said. "We need ACCME to go away and replace it with something else." Further, he estimated that the US government could save $900 billion over 10 years on unnecessary prescribing of branded drugs -- in part through curbing bias in CME. A defense of ACCME by its chief Dr. Murray Kopelow got little attention.
Nissen's comments dovetailed with those of the hearing chair Sen. Herb Kohl, who said that corporations wouldn't spend large sums on CME "unless they think they can get something out of it." He wanted to know whether industry-funded programs "stay true to their mission of providing unbiased education" or instead use the programs "to market the latest products."
Just this month, Pfizer agreed with the US Department of Justice to pay a $2.3 billion fine (double the total annual investment in US CME by industry!) for the way it promoted its painkiller Bextra for off-label uses. The agreement requires Pfizer to put procedures in place to avoid a repetition, including closer monitoring of consulting arrangements, publication activities and medical education grants.
A related postscript: Reporting on a recent Pharmaceutical Alliance for CME Summit in the Alliance Almanac, Pesha Rubinstein noted the need for pharma marketing departments to be as well versed as medical education departments in how promotional material differs from CME. It is corporate, not department, integrity that counts.
Does Britain need testing (and CME) for doctors from other EU states?
The Sunday Telegraph questions the lack of safety checks on foreign doctors coming to work in the UK. More than 5000 are from former Eastern bloc countries, Laura Donnelly reports, and under a European Union directive "doctors who qualify in any EU state can work in any other member state without tests on language skills and clinical competence". Further, there is no way to determine if any of these doctors had had disciplinary action taken against them in their home countries. Meantime there has been "a doubling in cases of serious disciplinary action taken against doctors from other EU states" in the UK.
Britain's General Medical Council has pleaded with the UK government and the EU to re-examine the rules. Is there any way to require CME for such doctors, as an element of the revalidation procedure being adopted?
Progress in Bulgaria's CME battle
At the recent annual meeting of the Assn. for Medical Education in Europe (AMEE), Dr. T. A. Popov of the Union of the Bulgarian Medical Societies (USMSB) described the struggle of his organization to rebuild a measurable CME system in the face of conflict with the Bulgarian Medical Assn. He indicated optimism as a result of a meeting with the Rome CME/CPD Group, an informal alliance of CME leaders from Europe and North America. A "Sofia Declaration" was issued calling for the Bulgarian Ministry of Health to set up an independent body to agree on "educational quality criteria and evaluate CME/CPD activities against these," and to gradually introduce a mandatory system. It is not known if this will be successful.
The top leaders of the US Senate Finance Committee -- two of the major critics of pharmaceutical company funding of CME -- received more than $5 million in contributions from health companies in recent years, reports Kaiser Health News. Naturally, they aren't influenced by these gifts!
Senators Max Baucus (D-Montana) chair of the committee, received $3 million from 2003-2008; Senator Charles Grassley (R-Iowa), the former chair, received more than $2 million. Perhaps to show their resentment at the size of these gifts, they have focused strong criticism on how pharma "influences" CME, and have demanded transparency, by requiring all gifts to physicians over a small amount be reported on a public web site.
Senator Chris Dodd, acting chair of the Senate Health Education and Labor Committee, accepted 32 contributions from lobbyists representing healthcare interests between April-June 2009, Kaiser Health News says. But his spokesperson says he hasn't let this influence his policy making.
"How can the public and the profession be certain that a professional medical association (PMA) dependent on industry for support is being faithful to its mission of conducting educational programs and setting practice guidelines that reflect only the best scientific knowledge?"
The JAMA authors -- a mix of PMA officers, academics and editors -- go on to recommend a "complete ban on pharmaceutical and medical device industry funding ($0), except for income from journal advertising and exhibit fees."
This goes further than a report from the US Institute of Medicine (IOM), a governmental agency, issued around the same time, designed to control conflict of interest (COI) by recommending more transparency and a new system of funding CME that is "free from industry influence".
No one has yet suggested that senators be banned from receiving gifts that might cause a conflict of interest, though the law does require disclosure of gift sources to elected officials. Not so with the IOM, whose mission is to serve the nation. Its report on COI was funded in part by the Macy Foundation, according to a National Review article, "in hopes of realizing its dream of ending private funding of CME". IOM, the article continues, "has no public reporting structure in place to disclose" where its money comes from.
We are not recommending that senators and government agencies excuse themselves from policy making because of apparent conflicts of interest over funding. But we believe that these same senators and agencies should not single out doctors and pharma as guilty of the sin of conflict of interest, without recognizing that they can manage such conflicts as effectively as the senators can!
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Newsletter survey results
We recently surveyed readers of this newsletter, and were pleased to receive high marks for its content and relevance. Readers in particular valued articles about European CME; second was US coverage, and third these commentaries.
What can we do to improve? The most common answer was "more case studies" of best practices. We'll do our best. And thanks to those who took time to complete the survey. If it's still in your inbox from June, it's not too late to complete it.
Dear CME colleague,
The trend toward more internet CME reported globally at the GAME meeting is echoed in the 2008 data from from the US, as reported by ACCME. While there have been a couple of small studies re the effectiveness of internet CME for small groups, we still do not know whether widely disseminated CME on the Web makes a difference in the delivery of patient care.
GAME highlights: mandatory CME, who pays, internet use, learning styles
As we reported in the previous issue. attendees from 22 countries participated enthusiastically at the 14th Annual Meeting of the Global Alliance for Medical Education (GAME) in Lyon, France, June 7-9, 2009. CME around the world is changing rapidly: more mandated programs without teeth, more reach through web-based education despite reluctance of some doctors and administrators to shift from didactic sessions; more awareness of local needs, including cultural differences. What hasn't changed: pharma still pays, and outside the US, little desire among CME providers to be independent of its influence. Nor is there much interest in measuring CME effectiveness. If you are a GAME member, you can find most presentations at www.game-cme.org.
Mandatory CME: This is on the rise in Asia and elsewhere. Lisa Sullivan (left) of In Vivo Communications reported that CME is compulsory in Australia, Singapore, Taiwan and Korea. Dr. Wang Kun (right) of www.Haoyisheng.com China (HYS) indicated that Chinese physicians need 25 credit points a year as a criterion for promotion, though there is no national requirement. Moving westward,Dr. Saurabh Jain of Indegene Lifesystems said there is no CME regulation in India. In Russia, Dr. Felix Vartanian of the Academy for Advanced Medical Studies explained that every 5 years, the 615,000 doctors must take a CME exam. CME is required in Abu Dubai, said Sondra Moylan of the American Academy of CME and Lisa Stephens of IIR Middle East. Albania has just made CME mandatory. But there appears to be little if any penalty for doctors who fail to comply in any country! And Scandinavia, said Dr. Hannu Halila of Finland, remains with voluntary systems.
Who pays? For the most part, the pharmaceutical industry pays through brand promotion budgets outside the US. Without such support, CME offerings would diminish sharply, most speakers and participants agreed. Dr. Ina Weisshardt, White Cube Consultants, Germany, reported on a survey of European pharma managers who said CME programs take about 20-30% of marketing budgets and are mostly developed and implemented internally, though with external providers to get accreditation and build participation. Dr. Vartanian spoke up strongly for government payment. Dr. Wang noted that in China, doctors buy a prepaid card to log in at his company's CME site and participate at a low fee.
Internet use: This is growing by leaps and bounds around the globe. Dr. Jain (left) described his organization's approach, based on needs identification, learning objectives, local case studies for each market (India, Indonesia, Philippines and Malaysia) and a support system online, plus telephone and web chats with mentors. The HYS system has been licensed for national category CME in China since 2001, said Dr. Wang; in 2008, 900,000 students participated in 250 programs online! But in Italy, distance learning is accredited only in one state, Lombardia, Dr. Marco Cavallo (right) reported. Jann Balmer of the University of Virginia emphasized the need for web learning to be nonthreatening, delivered in small packets for those doctors who want to use smartphones, and connected to local environments through the use of local mentors.
Learning styles: It is hard to break the lecture habit in a number of countries, despite evidence that interactive, patient-centered learning is more effective. Dr. Sullivan noted that in Southeast Asia, there is little interest in case-based learning or interaction. The startup of organized CME in Albania faces similar challenges. Dr. Jain is moving into case simulations in India. Dr. Peter Posel of Quaime described the combination of clinical cases, lectures and interactive classroom discussions online in programs in Germany. EURACT, the European GP organization promoting quality education, favors CME based on the learner's experiences to improve knowledge, competence and performance -- a step ahead of most programs which emphasize knowledge retention. Dr. Pesach Shvartzman of Ben-Gurion University, discussed the need for cultural competency in Israel, and described efforts to educate physicians to deal with minorities such as the Bedouins, who are nomadic tent dwellers.
Pharma support drops 14% in US in 2008, but participant numbers grow by 23%
The Accreditation Council for CME (ACCME) in the US has just released 2008 annual report data, showing that total income for CME programs declined by 7%, from $2.5 to $2.4 billion in 2008. The principal cause was a drop in commercial support from drug and device makers of 14%, in line with predictions that pharma support is slowing -- and is doing so even more rapidly in 2009.
Among the causes: Manufacturers are trying to improve the bottom line by laying off employees and cutting budgets wherever possible. Brand managers are reluctant to lose control over funding to the medical education divisions of their companies when their budgets are reduced, and are putting more resources into promotional education where their control is greater.
Despite the drop in program income, CME activities drew more than 10.7 million participants in 2008, the ACCME reported, up 23%. In addition 6.6 million on-physician healthcare practitioners attended activities.
Internet enduring materials are now the #1 location for physician participants, attracting over 4 million physicians and 3.5 million non-physicians. Add in internet live events and searches, and the total well exceeds that of live courses and regularly scheduled series.
Medical schools are first in number of activities provided, followed by medical societies. Publishing and education companies are third, but attract more physician participants and more commercial support than any other category of provider.
Whose rules to follow for planning a meeting in Europe?
Planning a CME meeting in Europe can cause confusion for organizations with pharma support, says Judy Benaroche Johnson of Rx Worldwide Meetings in an article in Medical Meetings. "There is no single standard," she says.
While the European Federation of Pharmaceutical Industries and Associations (EFPIA) has a code, so do pharma associations in the UK, Greece, France and other countries. And then there is the code of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA). EFPIA's site does provide the regs for many European countries.
"It's best to apply the rule that the strictest ... guidelines apply," says Johnson. "Even if that means not serving wine at lunch, you will have a meeting above reproach."
As became clear at the GAME meeting (see right), those of us in CME often have problems defining what we mean, especially when we toss around words like "bias," "credits", and "ethics", to name a few.
Here in the US, the ACCME is concerned with bias only in terms defined by commercial support. Did the financing of a course lead to perversion of content to favor the supporting company? In Europe, bias is defined more broadly. Did the interests of the institution offering the course or of the speakers lead to favoring inappropriate use of the institution or speaker, e.g., referrals, tests, surgery? Did the health ministry push for lower cost drugs and tests?
In the US, CME credits are generally required without specification by state licensing bodies and to some extent by medical associations and certifying boards. In other countries, there are often very specific requirements for credit by type of program (lecture, small group, distance learning) and by area of specialty.
My associate, Dennis Wentz MD, recently mused about a current skirmish between the ACCME and the AMA over how CME faculty members can be awarded credit. "How many angels can dance on the head of a pin?" he asked, "and what has happened to the goal of better patient care through continuing education?"
The AMA has been involved in another strange battle over ethics in CME. Its powerful Council on Ethical and Judicial Affairs (CEJA) recently proposed to the AMA House of Delegates a report on "Financial Relationships with Industry in CME". It proposed 2 standards of behavior:
"Ethically preferable" CME, funded only by sources with no financial interest in a physician's clinical recommendations.
"Ethically permissible" CME, funded by industry only if planned independently and the funding is not restricted and fully disclosed.
THE AMA House of Delegates refused to accept the proposal on the grounds of confusing language. We agree. Determining right from wrong is not a matter of what is preferable and what is permissible.
There are many other instances of confusing language in CME around the world. Where is CME accredited and where certified? Is a company a sponsor or a supporter? Is a credit a unit of time? What's the difference between CME and CPD? As noted in the adjoining column, when is a satellite symposium accredited CME?
The Rome Group, an informal organization of CME leaders from around the world, have started a glossary that may be helpful, available on the GAME website. Even more valuable, as Dennis suggests, is to set aside the minor battles and concentrate on the principles we all agree on: how to change physician performance and patient outcomes as professionals.
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Our WM&A associates have a world of knowledge to share in CME planning and execution across borders. See our website for more information.
Dear CME colleague,
2 meetings of note are mentioned: GAME in June, CACHE in May. More on the GAME meeting in the next issue. If you would like copies of presentations mentioned from CACHE, not available to all on its website, email me at lew@wentzmiller.org.
Are CME professionals outside the US ready to follow all US standards? NO!
Attendees from 22 countries engaged in a spirited floor discussion on the role of medical education and communications companies (MECCs) and the rules for commercial support of CME at the 14th Annual Meeting of the Global Alliance for Medical Education (GAME) in Lyon, France, June 7-9, 2009. "We don't have to do everything the American way," said one European, and her comments were met with loud applause!
Bernard Maillet MD, secretary general of the European Union of Medical Specialists (UEMS), kicked off the debate on MECCs by stating that they had a limited place in CME, and might serve as logistics support for medical specialty societies and university providers. Representatives of MECCs -- both US and European based -- disagreed, citing their independence and capability to develop high quality CME. It was clear, however, that most countries outside the US have no provision for accrediting MECCs or their programs directly.
The ongoing pressure from US academicians to end commercial support of CME received little support from attendees -- with the exception of Dr. Felix Vartanian of Moscow, who favored only government support. The tight regulations of the Accreditation Council for CME (ACCME) also received little support. Most non-US attendees believe that it is possible to achieve fair balance and reduced bias with less rigorous prohibition on interaction between supporter and provider. However, Europeans proposed efforts to reduce not only commercial bias but also bias from government and medical organizations. One said: "On the one hand, pharma support may be seeking to influence prescribing of its drugs, but on the other, health ministries may be trying to unfairly control costs by discouraging certain prescribing."
2 approaches to changing physician behavior: "Just-in-time" EBM and use of narrative
Two challenging methods of improving physician performance were introduced at the annual meeting of the Canadian Association of Continuing Health Education (CACHE) last month in Toronto.
1. "We need up-to-date information twice for every 3 outpatients, and 5 times for every inpatient," said Sharon Straus MD, of the LiKaShing Knowledge Institute, University of Toronto, "but we rarely get what we need." The clinically important knowledge of physicians deteriorates rapidly after training, she noted, quoting a study of 300 untreated, uncontrolled hypertensive patients referred to local GPs, only two-thirds of whom had been started on treatment 6 months later.
One solution, she believes, is to practice "just-in-time" Evidence Based Medicine (EBM), that is, integrating individual clinical expertise with best available research evidence, with the patient's values, expectations and circumstances. She cited several internet sources for rapid, reliable access, among them the PIER program of the American College of Physicians, Clinical Evidence of the British Medical Journal, and Ovid. But she acknowledged that there is "no evidence that EBM works".
2. John Parboosingh MB, professor emeritus, University of Calgary, proposed that performance improvement can be achieved through a Performance Assessment Community Engagement Model (PACE), incorporating narrative, or story-telling, as a way of building trust and identifying practice improvement needs among members of a healthcare team. In practice circles, the team replays recorded narratives and seeks evidence-based approaches for change. Using a process of practice audit, change can be implemented and later measured. Without the inter-disciplinary story-telling, Parboosingh says, change would be much more difficult to accomplish.
Politics: Canada struggles to unite 4 accreditation systems while emphasizing practice improvement
There are 4 CME accreditation systems in Canada -- and "we need to unify these", said Bernard Marlow MD, director CPD, College of Family Physicians of Canada (CFPC), at the recent CACHE meeting. He called for the creation of a Canadian Council for CME Accreditation. His counterpart, Craig Campbell MD, director, professional affairs, Royal College of Physicians & Surgeons of Canada (RCPSC), offered no comment.
Marlow's proposal calls for 2 levels of providers: one can offer its own accredited CME; the other can accredit other CME, including activities. This would allow the current systems to accredit according to provider or activity. At the CACHE business meeting, most members endorsed the principle that CME/CPD in Canada needs a set of harmonized standards.
Both speakers put emphasis on the need for physicians to participate in programs offering the chance for practice improvement. CFPC's Mainpro has elements now that reward evidence-based journal clubs, rapid 'Plan, Study, Do, Act' cycles, and a basic CPR course. RCPSC's Mainport will be focusing on competence assessment, including the promotion of simulation centers; and linking learning to performance assessment.
One area of clear disagreement: The new RCPSC standards now classify satellite symposia as "unaccredited". CFPC still accredits such programs. Just an example of how difficult unification can be!
Revalidation in the UK: The program kicks off with licensure this autumn
The UK's General Medical Council (GMC), after years of back and forth, has just issued a sequence for its program to ensure that doctors are qualified to practice:
Revalidation includes relicensure and recertification.
Starting this fall, all doctors must be registered and licensed to practice.
Doctors will next be required to participate in revalidation every 5 years, in which they demonstrate to the GMC that they are up to date and fit to practice. This is still in a pilot phase.
Recertification in a specialty will be done simultaneously with revalidation.
Annual appraisal will be conducted for each physician by a Responsible Officer, generally a senior doctor in a healthcare organization. The role is still to be defined.
The Global Alliance for Medical Education (GAME) meets in Lyon France June 7-9, and will again examine the harmonization of CME formats, content, and concepts around the world.
We had occasion earlier this month to meet with a group of CME leaders in Europe to discuss off the record what they see in the future for CME/CPD in the European Union and beyond. The meeting was organized by WentzMiller & Associates based on a grant from MSD.
Their general observations make sense, and correlate well with the scant body of evidence on what makes for effective CME:
1. A stress on independent CME, free of bias, whether from commercial or institutional sources -- and offering fair balance to physicians participating.
2. Evidence-based lifelong learning not only in clinical areas but also in other areas of professional life -- employing adult learning principles.
3. Needs assessment as the foundation of programs, based on identifying gaps in individual, group and community care of patients, particularly those with chronic diseases.
4. Use of a variety of media, emphasizing interactivity and small group discussions in a continuum of learning.
5. Outcomes measurement, not only of physician satisfaction and knowledge change, but also of improvement in competence, performance and patient outcomes.
6. A solid relationship with industry, based on mutual trust and industry's recognition that CME/CPD needs to be controlled by the CME providers in terms of topic selection, faculty selection, content development and outcomes measurement.
The benefit to such a framework, our European colleagues agreed, should be improved patient care. There was a desire, but not an expectation, that national governments would proving more funding support. And, encouragingly, a commitment to sharing best practices across borders, not only in Europe but also around the globe.
We hope that the GAME meeting will support these objectives, and bring about more shared dialogue among the representatives of many countries. Go to the GAME website if you haven't already registered.
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Meet us in Lyon
Lew Miller and Dennis Wentz will be in Lyon for the GAME meeting from Sunday-Tuesday, June 7-9. We would be glad to share ideas and expertise with you on an individual basis.
How effective is the CME you provide or support? We examine how difficult it is to have new clinical guidelines adopted in practice. We look at the spread of the Internet among Latin American physicians but wonder whether users are benefiting their patients or enjoying Facebook. And we applaud academic medical centers for their CME leadership but have concerns about the effectiveness of traditional course offerings, and lack of outreach to community practicing physicians. Your views?
Do physicians change practice when evidence-based guidelines are published?
No, says Dr. Jean Robson of Dumfries, Scotland, in an article in the British Journal of General Practice. "Unsolicited distribution of guidelines or posting these on the internet does not lead to changes in practice. Guideline distribution needs to be combined with effective educational interventions and implementation plans to change practice," she writes.
The gold standard for learning about guidelines would be collegial exchange among colleagues to reach agreement not only on acceptance of the guidelines, but also on steps to change, she says. But not all physicians can participate in such live discussion groups.
The author and her associates designed an interactive approach using Problem-Based Learning (PBM) modules that could be used by individual GPs. Participants responded to a short series of extended matching questions, followed by stimulus material They were then asked to write down their learning needs, and compare these with a list of suggested needs. Then they could download guidelines, and implement a management plan.
About 70% of the time, the 45 participants who completed a module reported that the process resulted in a practice change. No data were available on those who visited the site but didn't start or finish a module.
While this is an encouraging report on a method to improve guideline compliance, another study from the Medical University of South Carolina, published in Family Medicine, is less so. Family medicine residents participated in a 24-month series of chart audits and educational sessions based on clinical guidelines covering 7 topics. The authors concluded that this "had a modest and inconsistent effect on practice behaviors."
Moral for CME professionals: Physicians must take ownership of guidelines to change, just as patients must, to adopt healthy lifestyles.
"Digital fever" sweeps through Latin America: 80% of doctors access the Web daily
Use of the Internet is growing by leaps and bounds in Latin America, and physicians are at the forefront, reports Medimix International, a specialist in global healthcare market research.
A surprisingly high 80% of Latin American physicians said they accessed the Internet at least once a day, more than double the number 2 years previously. Brazil reported an 85% rate of daily usage; the lowest was Colombia at 74%. Only half were willing, however, to participate in online surveys; Argentina doctors had the highest resistance.
While broadband penetration at the end of 2008 was well below the rates in Europe and the US, 23% of Latin American physicians reported to surveyors that they are on the Internet "all the time". Phone interviews showed that most physicians connect at their homes rather than from their offices. They search for information about diseases, current therapies and drugs -- and for sites to recommend to patients, Medimix said.
The data offer opportunities to developers of online CME, so long as content can be offered in Spanish and/or Portuguese.
CME in medical schools in North America: Highly productive in traditional courses, but less innovation
Two score years ago, very few academic medical centers in the U.S. had much involvement in CME; it was left to professional societies. The pendulum has swung. A 2009 survey by the American Assn. of Medical Colleges (AAMC), the Society of Academic CME (SACME) and the Assn. of Faculties of Medicine of Canada (AFMC) shows 96% of respondents (114 schools) are accredited providers of CME.
The schools produce on average 147 traditional courses per year, attracting an attendance of 9190 physicians and 4656 non-physicians. But only 15% either use practice enablers (patient education materials, flow charts, etc.) or do any followup on the effects of the courses on a regular basis. Even fewer use performance data regularly to evaluate impact.
Substantial use of alternative media was reported by 77 schools, employing the internet, video and audio with an average reach yearly of 6900 physicians and 3800 non-physicians. Most of the programs were enduring materials rather than live interactive courses.
The CME units primarily focused on a target audience within the medical school (39%), while only 24% targeted external primary care physicians and 19% external specialists. Funding support from industry totaled 56% of revenue for U.S. schools, despite more and more opposition from the academic community to such support, vs. 14% for Canadian schools. The latter derive 17% from their institutions, three times that of U.S. schools. Registration fees account for 29% overall.
A farewell tribute to a groundbreaker in European CME: Cees Leibbrandt
Dr. Cees Leibbrandt of the Netherlands has announced his retirement as an associate of WentzMiller & Associates, and we accept this with regret and admiration for his accomplishments.
When Secretary General of the Union of European Medical Specialists (UEMS) early in the 21st century, Dr. Leibbrandt formed the breakthrough organization, the European Accreditation Council for CME (EACCME), the first step in harmonizing CME requirements across the European Union.
Before his retirement from UEMS, he signed what was the first reciprocal agreement on recognition of CME credits with Dr. Dennis Wentz, then head of CPPD at the American Medical Association. EACCME has built on this foundation to strengthen relationships with national authorities and scientific societies.
We will miss Dr. Leibbrandt's participation in the CME field.
Last month, Lew Miller focused on the pending national "Sunshine Act" that in fact parallels actions in several states, and he concluded that it was "just another manifestation of political (and academic) attacks on the pharma industry and doctors".
Academia has responded by public announcements of major changes in policy. A parade of institutions has joined the early leaders, Michigan and Stanford, to enact strict limits on funding and contacts with industry, and the rules are getting tighter. This month the Harvard institutions (Partners Health Care) and Johns Hopkins have announced strict limits on gifts to anyone in the institution and on faculty, including participation in national "speakers bureaus".
Do you recall that the AMA 19 years ago asked doctors to behave ethically in these matters, by enacting the Ethical Opinion on Gifts to Physicians and, often forgotten, the Ethical Opinion on CME? About 8 years ago the National Task Force coordinated a campaign to create awareness of these principles among physicians and others; perhaps it made a small difference but it didn't last. The mentality of "give-me" (Wall Street?) seems to taken over our profession.
One of my frustrations is that CME is always mentioned in the same breath as inappropriate gifts to doctors. Why is this? There is no connection. We have fallen into some kind of an abyss.
A new word has been coined to describe those who helped put us there: "pharmascolds" (Stossel & Shaywitz, WSJ, April 8 2009), i.e., the critics of industry practices. They are the ones who garner media attention -- and we have responded feebly or not at all. CME is a noble venture; it is not a "gift" to doctors. The National Task Force, the Alliance for CME and others are making efforts to get the facts out and to be advocates --but the time is limited to climb out of the abyss.
I share Lew's despair as he wrote: "Too bad, when our political emphasis should be on reforming the healthcare system for the benefit of patient care." That's why CME and CPD need to take a leadership role.
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Our readers react
On Miller's March editorial:
"There should be no question that some physicians and some pharmaceutical companies brought all this oversight and publicity upon themselves. The rotten apples in the barrel are very prominent physicians who skirt very close to the boundary and have affected medicine as practiced by the rest of us." -- K. M. Tan, MD
On Saxton's article in JCEHP: "The article only serves to reinforce the public's misunderstanding of CME provider/industry collaboration. Unfortunately, the confluence of interest between accredited CME providers and research-based pharmaceutical manufacturers that focused on patients' wellbeing instead of avoiding any appearance of conflict of interest appears to have been forgotten." -- Frederic S. Wilson, BS, CCMEP
Dear CME colleague,
This issue brings an overview of CME around the world: a reminder that there is a universal value to helping doctors keep up for the benefit of their patients. Despite turf wars and disputes over funding sources, those of us in the field can find common ground for working together to bring about improved health care, wherever we are.
A colleague from India provides
updates on CME in 5 Asian countries
Dr. Saurabh Jain, Director, CME Solutions, Indegene Lifesystems, Bangalore India reports on the growing importance of CME in several Asian countries, based on interviews conducted on recent trips to Manila and Kuala Lumpur, where he met with officials from Thailand, Indonesia, Malaysia and Singapore:
Philippines: CME is now been made mandatory by the Philippine Medical Association for their members. Every PMA member must re-register every 3 years. But the catch is that it's not mandatory for doctors to be members of PMA to practice in Philippines. PMA is pushing the government to make it so.
Thailand: CME is presently carried out on a voluntary basis under the Thai Medical Council. CME in Thailand has been in effect since 2000. Courses are mainly provided in collaboration among professional organizations, medical schools, and large hospitals nationwide. The target of 100 CME credit every 5 years is set and achieved in 58% by Thai physicians.
Singapore: On 1st January 2003 the Singapore Medical Council (SMC) made CME compulsory for all doctors. Since 1st January 2005 all doctors renewing their 2-year practice certificates with SMC are required to have 50 points within the 2-year period, and are given a 1-year grace period, if necessary to comply. Ten points must be in Category 1A activities -- pre-approved established CME programs held in hospitals, specialty centers or institutions.
Malaysia: All registered medical practitioners in the country are encouraged to register with the CPD secretariat of the Malayasian Medical Association (MMA) to participate in the grading system. This system is voluntary. But all the doctors who practice in Ministry of Health hospitals have to go through the CPD program, and maintain their points online. The Ministry of Health new CPD program is linked to promotion and salary increment.
Indonesia: The Indonesia Medical Association (IDI) manages the CME system, which starting this year is mandatory for all doctors. All the specialist bodies fall under IDI, which is investing heavily to build an online system maintaining a database of points for every doctor.
Closer cooperation now a reality between UEMS and specialty accreditation boards
The European Union of Medical Specialists (UEMS), parent of the European Accreditation Council for CME (EACCME), has reached an agreement for a 12-month pilot of cooperation with the European Board for Accreditation in Pneumology (EBAP), presaging similar arrangements with other specialty accreditation boards.
The agreement delegates to EBAP the right to evaluate the quality and independence of all applications for CME events or products in pneumology, granting combined EBAP/EACCME accreditation. EBAP must transmit the applications to EACCME for submission to relevant national authorities for their recognition of credit. EBAP can apply its own fee structure, but must then remit to EACCME its standard fee per event.
"It looks as if increasing numbers of specialties will now open negotiations with UEMS to allow them to work more independently and to charge more realistic fees," says Dr. Robin Stevenson, president of EBAP. "However, I am concerned that the more we go down this road, the more entrenched event accreditation will become in Europe -- even if provider accreditation proves to be a better system over time."
ACCME retains policy permitting commercial support and proposes setting up a CME funding entity
The Accreditation Council for Continuing Medical Education (ACCME), after months of examination, has decided not to take any action to end commercial support of accredited CME. The ACCME believes that its internal controls provided in Standards for Commercial Support and associated policies "support the development of independent CME that is a) free of commercial bias and b) does not result in an inclination by professionals to direct care that is unwarranted or unnecessary."
At the same time, the ACCME announced that it will consider creating an "independent granting entity that will accept unconditional and unrestricted donations, from all U.S. sources, that will be distributed to ACCME recognized and accredited organizations to be used for the development and presentation" of CME. The idea of a central granting agency has been floated before -- but the pharmaceutical industry has never embraced it; it would mean funding programs that do not fall into standard therapeutic categories.
Project Globe pilots moving ahead
in Russia and Venezuela
The Project Globe Consortium for Continuing Professional Development, organized in 2006 to improve health care in developing countries, is in the midst of pilot projects in Russia and Venezuela to prove the concept that blended CME/CPD learning solutions can change both physician behavior and patient outcomes in these countries.
Reports Dr. Pablo Pulido, president of Project Globe: "A cardiovascular risk factor (CVRF) practice improvement course was launched in Russia in seminar format in 2008-9, and in blended (internet/live) format in Venezuela in December 2008. Physician reaction has been positive. We will shortly start to monitor change in patient outcomes in both countries."
Project Globe's initial funding came from Pfizer. The nonprofit organization is now conducting a campaign to raise additional funds from organizations including foundations.
Don't forget CACHE and GAME meetings!
May 22-24 Toronto -- Canadian Association of Continuing Health Education (CACHE)
June 7-9 Lyon, France -- Global Alliance for Medical Education (GAME)
Here is the US, politicians are in favor of sunshine. That means disclosing all payments or transfers of value to physicians worth $100 or more.
That's the heart of a bill titled the Sunshine Act, introduced in the US Senate, and it parallels laws already in place in several states.
It's difficult to know why these bills are so important. Yes, transparency is a virtue in business dealings, but the terms of the bills, and their penalties, are severe enough to cast a dark cloud over physician-industry relationships... to say nothing of the cost of compiling and publishing data.
The Senate bill says that beginning in April 2011, companies would be required to report consulting fees, honoraria, gifts, travel, entertainment, food, education, research, CME speaker fees and grants, and anything else the Secretary of Health and Human Services might specify.
Some of the states have even stricter requirements. California, for example, tells companies to establish and make public spending limits to doctors. Minnesota limits payments to $50 per doctor per year.
Theoretically, these laws will reduce healthcare expenditures, and reduce bias among physicians. But a study in West Virginia didn't show any monetary benefits to the state or its population.
Unfortunately, the Sunshine Acts are just another manifestation of political (and academic) attacks on the pharma industry and doctors. The scene is unlikely to change. Dark clouds will remain overhead for the foreseeable future. Too bad, when our political emphasis should be on reforming the healthcare system for the benefit of patient care.
*************************** Need help developing a CME expansion strategy? WentzMiller & Associates is experienced in helping organizations learn what works and what doesn't in other countries. Our network of global consultants can be of assistance. Contact lew@wentzmiller.org.
Dear CME colleague,
Pfizer is a positive force in CME, as illustrated by the first 2 stories below. The company supports leaders who want to improve the value of CME in patient care. That's why we wonder, as in the Commentary, why the political pressure on the industry continues without let-up.
Will pharma heed an insider's call to transform CME support to a new model?
Pharmaceutical industry support of continuing medical education has been based primarily on courses that impart up-to-date knowledge in fields of therapeutic value to the supporters. Now an influential and longtime pharma executive has issued a call to his counterparts to adopt a new model addressing professional practice gaps.
In an article in the Journal of Continuing Education in the Health Professions, Mike Saxton, senior director, medical education group, Pfizer, writes:
"To receive commercial support, the learning intervention [of the future] must (1) represent a viable benefit to patients; (2) be based on needs identified by a health care system quality gap and/or a health care provider performance gap, and (3) be compatible with the business of the industry."
Saxton argues that this model, if followed, can largely mitigate "the likelihood of bias and the risk for CME-provider independence. In the meantime," he writes, "industry does not fulfill its responsibility to patients by waiting for an extended debate to be resolved."
Other pharma companies are beginning to adopt this model in the US, to a greater or lesser extent. More are requesting documentation of practice gaps and of plans for outcome measures that extend beyond attendee satisfaction and knowledge gain. In Europe, some trial efforts are underway -- but few.
Perhaps the biggest shock in the Saxton article comes from his premise that the CME provider must contribute its own resources to its CME programming: "Support from any one commercial entity should not exceed 50% for a major activity. ... any organization requiring too high a percentage of commercial support to maintain its overall program should be required to disclose the percentage (perhaps more than 50%) and perhaps be sanctioned in other ways."
Powerful statements from a major player! Let us know whether his proposals make sense -- and are feasible. Lew@wentzmiller.org.
Performance improvement a focus of the proposed new French law on CME/CPD
An ambitious health care law, incorporating performance improvement (PI) as a CME/CPD requirement, is currently being discussed in the French parliament, to be published in July 2009, reports Hervé Maisonneuve MD, CME manager of Pfizer France. If passed, it would take the place of the system abandoned suddenly a year ago.
But some government experts want to exclude credits for CME activities such as live events, e-learning, journals or peer review. Some want to prohibit commercial support as well, and set a tax on pharma. This, says Dr. Maisonneuve, "means that the French system is in trouble for the next 2-5 years; battles will continue among unions, CME experts, civil servants, the French Medical Association and others."
Meantime, under the former system, there are around 400 accredited providers of CME and 100 of performance improvement programs. Physicians still attend these programs and are usually satisfied, adds Dr. Maisonneuve, "even though the credits are useless!"
Role of journals in CME -- a controversial topic -- will keynote GAME meeting
Richard Smith, former editor of the British Medical Journal, will address the role of medical journals in CME as the keynoter at the 14th annual meeting of the Global Alliance for Medical Education (GAME), June 7-9 2009, at Université Claude Bernard, Lyon, France.
Controversy over the place of journals in CME was revived this month in an article on "Effectiveness of Continuing Medical Education", providing a set of guidelines from the American College of Chest Physicians. Among other recommendations, the authors state: "Print media should not be used alone to improve physician practice improvement." The implication is that print can be considered as part of a multimedia approach.
The GAME meeting will be truly global, featuring speakers from Asia, Middle East, China, Russia and Africa, in addition to those from Europe and North America.
Australia Medical Association battles government proposal for "absolute control" of medical standards
The Council of Australian Governments -- a body representing all the states -- proposed last year to create a national registration and accreditation scheme for all health professions, and the Australian Medical Association (AMA) is up in arms. The scheme is to go into effect in July 2010.
The AMA believes that the proposal "will give politicians ultimate authority over accreditation standards for medical practice ... with no recourse for appeal." Among their concerns:
** "No recognition, and no guarantee, of the ongoing role of the [specialty] colleges in ... continuing competence and professional development.
** "The scheme seeks to introduce new onerous CPD requirements."
As an alternative AMA proposes retaining state registration boards working in a system of mutual recognition and data sharing.
NO. But unless CME providers wake up to the new reality -- much reduced pharma funding -- many CME providers may go away.
As I said on a closing panel at this year's Alliance for CME conference:
"CME offices in academia may be in trouble as their institutions rule out category-specific pharma support, and have no immediate replacement.
"More medical education companies will shift from accredited CME to promotional CME, or go out of business.
"Government is not likely to fill the gaps.
"Medical societies will have reduced income.
"Doctors will choose from fewer free CME programs -- and that may be a benefit!"
What are some alternatives?
* Organized medical practices and hospitals can fund CME that is for practice improvement -- where they can see a benefit. Carol Havens of Kaiser Permanente, a huge practice group, reported at the same Alliance session that in 2004, all pharma funding was eliminated, replaced by an internal fund to support regional conferences, local CME and individual education. It's working but requires more oversight, she noted.
* Also on the panel was Maureen Doyle-Scharff of Pfizer, who said her company is ahead of most CME providers in emphasizing performance improvement despite reduced funding. But providers, she said, still view commercial support "as a right, not a privilege." Pfizer wants to make a difference, but "we're damned if we do, damned if we don't".
* Foundation funding is possible but not yet frequent. Groups such as Macy Foundation and Commonwealth Fund are more likely to support research and white papers than delivery of CME.
* Doctors do pay for some of their CME, particularly if it provides a benefit, such as recertification in a specialty or increased income (particularly true of surgeons who learn neew procedures).
In developing countries, there is a paucity of funding, and a paucity of high quality programs. Will the same happen in the US and Europe if pharma funding dries up? Or can a model like Kaiser Permanente be modified to work on a global basis?
No easy answers, but all of us in the CME field must ponder the funding question, and begin to plan -- soon -- for a new approach to support.
Dear CME colleague,
There's a gloomy forecast for pharmaceutical company funding of CME and congresses in the future. Is your organization planning ahead to meet the challenges? Let us know (lew@wentzmiller.org).
Paying delegate travel outside US: Is the pharma elephant leaving the CME room?
For years, the pharmaceutical industry has paid travel and hotel expenses for non-US physicians to attend CME conferences, whether abroad or in the US. That has ensured high participation in major congresses in the Europe, the US and elsewhere. You might call this practice "the elephant in the room", since such expenses in Europe often take up 50% or more of a medical society CME event.
The practice may be coming to an end, if not this year, some time soon. The consequences to medical societies are likely to be severe -- when the elephant leaves the room.
This was forecast at meetings of both the International Pharmaceutical Congress Advisory Association (IPCAA) and the International Congress and Convention Association (ICCA) late last year. As quoted in Medical Meetings magazine, here were key comments:
Anna Frick, marketing services director, AstraZeneca: We are feeling increasing political pressure in Europe regarding sponsorship of delegates. We expect the system will change dramatically in the future. In addition, we are seeing restructuring of companies, and have less money to spend on meetings. We are going to focus on major meetings in the US, Asia Pacific and Europe. Every congress must work on its unique selling proposition to gain the business.
Keith Spencer, executive director, IPCAA: The meetings that survive are those that can demonstrate value, whether in terms of science, education or business success. Medical associations need to be more creative, determine other means of sponsorship, e.g., the economic benefit to cities in hosting meetings.
Mariano Castex, managing director, ICS Congresos Internacionales, Argentina: What will happen in the less developed countries? Will Brazilians, Argentines and Chileans have no opportunity to network with professors from Europe and the US? Probably congresses that have 10,000 delegates today will have 5,000 in the future.
Alliance meeting also highlights concern over pharma funding of CME -- particularly in US
"High anxiety concerning the future of pharmaceutical funding of continuing medical education permeated the Alliance for Continuing Medical Education annual conference, held January 28-31 in San Francisco," according to a report on the Medical Meetings website.
"Continuing medical education will continue to be attacked in 2009, and we need to start controlling our own destiny," said one speaker from a pharmaceutical company. "If we don't control inappropriate bias, CME will be tainted. We need to look deep into ourselves and take [commercial] influence out of content."
"Companies are becoming much more discriminating about approving grants," says the report. "One speaker said that five years ago her company approved 70% of the grant applications it received; that figure has dropped to 26%. It's particularly important that providers include a mechanism for measuring and publishing the outcomes of education activities so that grantors can demonstrate the value of the programs internally to their higher ups, as well as to the public, speakers said."
Also at the Alliance meeting, members of the International Strategies Committee were awarded certificates -- for recommending that the committee be abolished. Its mission had been to recommend strategies for building Alliance membership from outside the US. The committee determined that this objective was incompatible with the Alliance's primary mission to educate US members in US requirements. Instead, the Alliance will work with organizations such as the Global Alliance for Medical Education (GAME) to promote principles of CME.
Coming up: CACHE in Canada
and GAME in France
Canadian Assn. of Continuing Health Education
(CACHE) 2009 Conference May 22-24 2009 University of Toronto Conference Centre
At the first annual meeting of the European CME Forum in London last November, Eugene Pozniak reported that "two central issues for CME development in Europe resonated loudly: the quality of programs and the impact they have on clinical practice."
He further noted that "despite a fragmented and disparate environment" characterized by national differences, "efforts to develop a recognized system for CME accreditation across Europe and to establish a harmonization of credits and practices are progressing.
"Definitions of CME remain subjective ... whether it should just address levels of knowledge and competence or ... have a positive effect on clinical performance. Determining which activities actually constitute CME is challenging ... and accreditation of satellite symposia remains contentious."
As we enter the New Year, we wish you joy and prosperity. But the latter may be in short supply as we survey the predictions for CME in 2009.
Clouds on the horizon:
Pharmaceutical funding will be reduced -- from 10-30% depending on the country and the target audience. Primary care will probably suffer the most. Pipelines of new products are moving slowly, government approvals even more so. The general cutbacks at corporate levels are affecting the flow of support to CME.
Requirements for practice improvement as a result of CME are increasing in the US -- both from regulators and from funders. These are costly exercises, not yet evaluated on a cost--benefit basis in a time when budgets are tight.
Attendance and revenues at major congresses in the US and Europe are expected to be down 5% or more. This is the result of both the regulatory and economic environments. In Europe, political pressure is reducing the number of sponsored physicians at meetings.
The economic downturn is likely to affect attendance at meetings a distance from home. Physicians, like the rest of us, are worried about spending when patient loads decrease and revenues decline.
Bright spots on the horizon:
Use of web-based CME will continue to rise, particularly in Europe, where the European Accreditation Council for CME has finally decided to provide credits for distance learning. Everywhere, reductions in physician spending will lead to more time online for CME.
A CME system for France offers a glimmer of hope, after years of mandated CME with no government program in effect. The current health minister plans to have a new concept in place sometime this year. (Maybe, our French colleagues say.)
Better research on CME value may be launched before year end. Challenges and reports in 2008 pointed to the dearth of well-designed research on CME effectiveness and on the presence or absence of bias in industry-funded CME. We expect efforts to be funded during 2009 in both areas.
Dear CME colleague,
What is your forecast for 2009? Our commentary shares one view. Yours may differ, and we will be glad to share it with other readers. Meantime, below you will find reports on improving competence and making it easier for physicians to interpret guidelines. Once again, industry-MD ties are questioned, this time in India.
Congresses on CME focus on improving physician competence
CME/CPD must foster meaningful improvements to practice, not simply knowledge improvement. This was the theme of 2 major conferences in 2008 held in North America:
CME Congress 2008, held in May in Vancouver, Canada, attracted 515 registrants, including 38 from Asia, Australasia, Europe, the Middle East and Africa. Its emphasis was on scholarship, innovation and research.
The 19th annual conference of the National Task Force on CME Provider/Industry Collaboration, held in Baltimore, Maryland, brought some 700 US (and a few non-US) CME providers and industry representatives to discuss the trends in CME and in industry support.
At CME Congress 2008, Dr. Marietje de Villiers reported on a new system now in place in South Africa, moving from 50 credit hours to 30 continuing educational units per year. Physicians are now strongly encouraged to get as many units as possible in formally structured learning programs with measurable outcomes. "The system is now based on professional and trust, using an audit system rather than obligatory submission of compliance," Dr. de Villiers said.
At the same congress, Dr. Barry Taylor reported on how the CPD system of the Royal Australasian College of Physicians is working to educate New Zealand's medical workforce "to serve and care for the health needs of a multiethnic population appropriately." Judith Mackson et al of Australia's National Prescribing Service provided results of academic detailing to GPs that led to demonstrated changes in the use of prescription products. And Dr. Ian Starke described the approach of UK Academy of Medical
Royal Colleges to link CPD activity to a personal development plan resulting in behavior change.
Copies of many plenary session papers are available by using the link above.
At the Task Force conference, Dr. Norman Kahn, CEO of the Council of Medical Specialty Societies, challenged participants in his keynote to move doctors from "Trust me, I'm keeping up" to a "Culture of improvement" through regularly measuring and improving the care they deliver.
Union health minister A. Ramadoss of India was recently quoted in The Economic Times as saying that under a proposed act, "we are making it compulsory for doctors to get re-registered every 5 years after they have attended 60 hours of continuing medical education."
In response to charges that pharma companies were plying doctors with expensive freebies in exchange for prescribing their drugs, Ramadoss urged the Medical Council of India and state medical councils to ensure that their voluntary code of conduct is strictly followed by doctors. The code limits gifts to those of modest proportion. He said he was aware that irrational uses of drugs are rampant in India.
The Economic Times was critical of the health minister for not taking a stronger stand!
-- Submitted by Dr Saurabh Jain, Director - CME Solutions, Indegene Lifesystems, Bangalore.
Ontario CME leaders simplify application of research to practice
There may be as many as 50 guidelines existing on a common clinical topic -- making it impossible for most practicing physicians to know which are correct. Now the Guidelines Advisory Committee in Ontario, Canada, has assessed all available guidelines on 70 clinical topics, using a validated and transparent process involving community-based physicians as assessors. A single best guideline is selected per topic and a summary of its evidence-based recommendations produced. The GAC website has more than 100,000 hits per month.
Another Ontario group, at Queens University, has developed a Critically Appraised Practice Reflection Exercise (CAPRE) program, which takes best available evidence on 40 common practice problems and presents summaries for both physician and patient. If the physician carries out the reflection exercise, he/she gains CME credits.
Ina Weisshardt, former European CME director for MSD, joins WentzMiller & Associates
We are pleased to welcome our new WM&A associate, Dr. Ina Weisshardt of Munich, Germany, who most recently was head of the CME team at Merck Sharpe & Dohme, for Europe and other countries. Dr. Weisshardt spent 22 years with MSD, as a research manager, product manager and marketing manager in Germany, as European marketing director for the migraine franchise, and later as European direction of CME based in the US.
Dr. Weisshardt studied medicine at the Universities of Wurzburg and Frankfurt, received a PhD in clinical pharmacology, and later training in internal medicine and nephrology.
She adds a much-needed pharma company perspective to the outstanding group of European-based WentzMiller Associates.
SEARCHING THIS SITE: PRESS CONTROL F AND ENTER YOUR SEARCH TERM. YOU CAN SEARCH ANY SECTION LISTED TO THE LEFT, ONE SECTION AT A TIME.
Dr. Steven Nissen, top cardiologist at the Cleveland Clinic and long a lover of attacks on the establishment, took aim at the Accreditation Council for CME (ACCME) at a recent 
Nissen's comments dovetailed with those of the hearing chair Sen. Herb Kohl, who said that corporations wouldn't spend large sums on CME "unless they think they can get something out of it." He wanted to know whether industry-funded programs "stay true to their mission of providing unbiased education" or instead use the programs "to market the latest products." 
Does Britain need testing (and CME) for doctors from other EU states?
Sullivan (left) of In Vivo Communications reported that CME is compulsory in Australia, Singapore, Taiwan and Korea. Dr. Wang Kun (right) of 
25 credit points a year as a criterion for promotion, though there is no national requirement. Moving westward,Dr. Saurabh Jain of 
needs identification, learning objectives, local case studies for each market (India, Indonesia, Philippines and Malaysia) and a support system online, plus telephone and web chats with mentors. The HYS system has been licensed for national category CME in China since 2001, said Dr. Wang; in 2008, 900,000 students participated in 250 programs online! But in 
Italy, distance learning is accredited only in one state, Lombardia, Dr. Marco Cavallo (right) reported. Jann Balmer of the University of Virginia emphasized the need for web learning to be nonthreatening, delivered in small packets for those doctors who want to use smartphones, and connected to local environments through the use of local mentors.
Medical Specialists (UEMS), kicked off the debate on MECCs by stating that they had a limited place in CME, and might serve as logistics support for medical specialty societies and university providers. Representatives of MECCs -- both US and European based -- disagreed, citing their independence and capability to develop high quality CME. It was clear, however, that most countries outside the US have no provision for accrediting MECCs or their programs directly.
The ongoing pressure from US academicians to end commercial support of CME received little support from attendees -- with the exception of Dr. Felix Vartanian of Moscow, who favored only government support. The tight regulations of the Accreditation Council for CME (ACCME) also received little support. Most non-US attendees believe that it is possible to achieve fair balance and reduced bias with less rigorous prohibition on interaction between supporter and provider. However, Europeans proposed efforts to reduce not only commercial bias but also bias from government and medical organizations. One said: "On the one hand, pharma support may be seeking to influence prescribing of its drugs, but on the other, health ministries may be trying to unfairly control costs by discouraging certain prescribing." 
A farewell tribute to a groundbreaker in European CME: Cees Leibbrandt
negotiations with UEMS to allow them to work more independently and to charge more realistic fees," says Dr. Robin Stevenson, president of EBAP. "However, I am concerned that the more we go down this road, the more entrenched event accreditation will become in Europe -- even if provider accreditation proves to be a better system over time."
cardiovascular risk factor (CVRF) practice improvement course was launched in Russia in seminar format in 2008-9, and in blended (internet/live) format in Venezuela in December 2008. Physician reaction has been positive. We will shortly start to monitor change in patient outcomes in both countries."
Professions, Mike Saxton, senior director, medical education group, Pfizer, writes:
reports Hervé Maisonneuve MD, CME manager of Pfizer France. If passed, it would take the place of the system abandoned suddenly a year ago.
of the Global Alliance for Medical Education (GAME), June 7-9 2009, at Université Claude Bernard, Lyon, France.
registration and accreditation scheme for all health professions, and the Australian Medical Association (AMA) is up in arms. The scheme is to go into effect in July 2010.
Advisory Association (
future. In addition, we are seeing restructuring of companies, and have less money to spend on meetings. We are going to focus on major meetings in the US, Asia Pacific and Europe. Every congress must work on its unique selling proposition to gain the business.
Union health minister A. Ramadoss of India was recently quoted in 
Weisshardt spent 22 years with MSD, as a research manager, product manager and marketing manager in Germany, as European marketing director for the migraine franchise, and later as European direction of CME based in the US.