CLINICAL RESEARCH: MEDICAL EDUCATION: EDITORIAL COMMENT
Minding the gap: can continuing medical education bridge the quality chasm?*
Barbara Barnes, MD, MS, FACP*,*
* University of Pittsburgh Center for Continuing Education in the Health Sciences, Pittsburgh, Pennsylvania, USA
* Reprint requests and correspondence: Dr. Barbara Barnes, Associate Dean for Continuing Medical Education, University of Pittsburgh Center for Continuing Education in the Health Sciences, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213, USA.
barnesbe{at}upmc.edu
The Institute of Medicine (IOM)'s report, "Crossing the Quality Chasm" (1), is an indictment of our profession's ability to translate the body of medical evidence into the delivery of patient care. As research and technology rapidly advance, the gap between what should be done and what is actually practiced appears to be widening. Although many have criticized the conclusions drawn in the IOM report, there is increasing public concern about the current state of our health care system, particularly in regard to lack of access to appropriate treatment, ubiquity of unsafe practices, and wasteful uses of precious health care resources. As a result, physicians are under mounting pressure to demonstrate competence and satisfactory patient outcomes. One strategy for accomplishing this involves participation in ongoing and effective professional development activities. Questions have been raised about whether the current system of continuing medical education (CME) is capable of supporting physicians in this regard.
Calls for reform in the U.S. system of medical education have been long standing. As a result of the 1910 Flexner report, our profession entered into a social contract guaranteeing the production of doctors capable of meeting the country's needs (2). For the first half of the twentieth century, efforts for educational restructuring focused largely on medical schools. With the advent of specialization, residency programs were increasingly standardized and regulated. Not until the final quarter of the century did the social contract seriously focus on CME. Response to the mandate for an organized system of physician professional development was rapid, producing what is now a $1.6 billion industry (3). Continuing medical education credits, which have traditionally been based on the number of hours spent in learning activities, are accepted by a wide variety of organizations, including state licensure boards, hospital medical staffs, insurance companies, and professional organizations as a demonstration of ongoing professional development and maintenance of competence.
A subsequent report of the IOM (4) specifically addresses the effectiveness of medical education, as it is now delivered, on the quality of health care. Does the accumulation of CME credits have any bearing on competence or performance? The article by Patel et al. (5) in this issue of the Journal examines the effect of mandates for CME by state licensure boards on the care of patients with acute myocardial infarction. A large Medicare claims database was analyzed to determine conformance with guidelines. After adjustment for patient and hospital characteristics, there were no differences between states requiring CME and those that did not for use of aspirin, beta-blockers, calcium channel blockers, smoking cessation, or coronary intervention. In addition, there were no differences in patient outcomes. However, rates of coronary reperfusion (particularly involving patented agents) were higher where CME was required. The authors conclude that state-mandated continuing education has little impact on physician practice or patient outcomes, except perhaps as related to new therapies being promoted by the pharmaceutical industry.
Although this study examined a large amount of data and employed statistically rigorous methods, some limitations must be considered. The authors assume that physicians practicing in states with CME mandates have different patterns of CME participation. Unfortunately, there are no previous studies to support these conclusions, and the authors provide no description of the number or scope of activities undertaken by physicians who cared for the patients under review. It is not known how much education related to the care of patients with acute myocardial infarction. Because continuing education is required for hospital and insurance network credentialing, malpractice insurance, and professional association membership, it is plausible that physicians across the country have similar levels of CME attendance, regardless of the influence of licensing boards.
Is the significant difference in the use of thrombolytic agents a result of industry sponsorship of educational activities? As described by the authors, the contributions by drug and device manufacturers to CME activities are staggering and there is a growing body of evidence supporting the influence of drug manufacturers on prescribing behavior (6). However, it is also possible that the observed differences are a result of other factors. Recent studies have demonstrated that the processes involved in changing physician behavior are complex and may vary considerably for different clinical issues (7). Although the Patel et al. (5) review did control for some hospital and provider characteristics, it is conceivable that characteristics of the health care delivery environment in different states could account for the observed differences. In addition, the authors appropriately point out that the absolute difference in the use of thrombolytic therapy in states that do and do not mandate CME may not be clinically significant.
Despite these limitations, the article by Patel et al. (5) adds to a body of literature underscoring the limited effects of traditional CME (8). The current system for delivering CME has achieved the results that it was designed to accomplish: ensuring that physicians attend ongoing professional development activities. Requirements of state licensure boards (including allopathic and osteopathic licensure boards in U.S. states and territories), 56 of 68 which now stipulate CME participation, have assisted in meeting this goal. It is time to raise expectations for CME by designing an educational system that has demonstrated an impact on physician behavior and patient care. Drawing on literature describing how doctors learn and change, major stakeholders in the maintenance of physician competence have already begun to take up this challenge. Representatives of specialty boards, state licensing bodies, professional societies, the accreditation system, and CME providers are coming together to more adequately determine the learning needs of physicians, develop effective learning venues, design methods for periodically assessing knowledge and skills, and implement stronger oversight mechanisms to ensure that educational activities are free of commercial bias. The core competencies being adopted across the entire continuum of medical education are a major driving force to move CME into domains such as professionalism, systems-based practice, and communications skills that are critical to the improvement of health care quality and safety (9). Drawing on prototypes for continuing professional development being implemented in Canada, Great Britain, academic educational research centers, and specialty societies such as the American College of Cardiology (10), it will be possible to conceive of new ways to deliver CME that are concurrent with practice and based on data, such as that employed in the study by Patel et al. (5), demonstrating specific learning needs (11). The currency of this new system of professional development will be based not on credits granted for passive participation in educational programs but on metrics that reflect enhanced competency and performance. State medical boards are already considering how such a transition can be effected.
Although most would probably agree that CME, as practiced in this evolving system, is necessary for improving the quality of health care, is it sufficient? The rate of adoption of new practice patterns is dependent on a wide variety of factors, including the nature of the change, characteristics of the individuals responsible for innovation, as well as organizational and social environments (12). In addition to addressing the competency of physicians and other health care professionals, efforts must also be directed at ensuring competent systems of care through the implementation of quality improvement processes, installation of electronic health records, and removal of regulatory and economic barriers that constrain the implementation of safe and effective practices. Improvements in patient outcomes will come about only when continuing professional development is integrated into these types of health system improvements.
Studies such as that by Patel et al. (5) make us mindful of the gap between the current practice of CME and the systems of professional development that are required to ensure competence, performance, and health care quality. Key stakeholders are accepting the challenges raised by these authors and the IOM through the development of unprecedented collaborations that should lead to systemic change in the way CME is delivered and assessed. As these efforts move ahead, the public perceives that the quality chasm is growing wider and deeper. It is critical that our profession's social contract be affirmed by the rededication of practitioners to continuously improving their competence, the commitment of CME providers to deliver educational activities that effectively convey the best available evidence without influence by commercial interests, the development by regulators of oversight mechanisms focused on improving health care quality, and funding of research agendas to gain further knowledge about how physicians learn and change.
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Footnotes
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* Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. 
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References
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1. Institute of Medicine. Crossing the quality chasm; a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
2. Ludmerer KM. Time to HealAmerican Medical Education From the Turn of the Century to the Era of Managed Care. New York, NY: Oxford University Press; 1999. 22
3. Accreditation Council for Continuing Medical Education. Available at: http://www.accme.org. Accessed February 27, 2004
4. Greiner AC, Knebel E. Health Professions Education: A Bridge to Quality. Washington, DC: National Academy Press; 2003.
5. Patel MR, Meine TJ, Radeva J, et al. State-mandated continuing medical education and the use of proven therapies in patients with an acute myocardial infarction. J Am Coll Cardiol 2004;44:192–8
6. Moynihan R. Who pays for the pizza? Redefining the relationships between doctors and drug companies: entanglement. BMJ. 2003;326:1189–1192[Free Full Text]
7. Naylor CD. The complex world of prescribing behavior. JAMA. 2004;291:104–106[Free Full Text]
8. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA. 1995;274:700–705[Abstract/Free Full Text]
9. Accreditation Council for Graduate Medical Education Outcome Project. Available at: http://www.acgme.org/outcome/comp/compFull.asp. Accessed February 27, 2004
10. Wentz DK, Jackson MJ, Raichle L, Davis D. Forces for change in the landscape of CME, CPD, and health systems-linked education. Davis D, Barnes BE, Fox R. The Continuing Professional Development of Physicians. Chicago, IL: AMA Press; 2003. p. 25–47
11. Barnes BE. Creating the practice-learning environment: using information technology to support a new model of continuing medical education. Acad Med. 1998;73:278–281[Medline]
12. Berwick DM. Disseminating innovation in health care. JAMA. 2003;289:1969–1975[Abstract/Free Full Text]
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