Continuing education is vital for otolaryngologists to maintain and build on their knowledge base and skill sets. This article discusses the history of continuing medical education (CME) and describes the significant changes in CME that are currently underway. The development of CME has generally lagged behind other improvements in medical education. After a gradual evolution, however, CME is now incorporating many of the principles that are driving undergraduate and graduate medical education—namely, adult learning theory and technology-intensive applications. As attention is focused on maintaining physician competency and eliminating medical errors, CME is becoming more highly regulated, and CME providers are being held to higher standards. The future will see an increased emphasis on the effect of CME activities on altering physician behavior and improving patient outcomes.
Medical education in North America changed dramatically with the publication of The Flexner Report on Medical Education in the United States and Canada 1910. Funded by the Carnegie Foundation for the Advancement of Teaching and authored by Abraham Flexner, the study reported that there had been an “enormous over-production of un-educated and ill-trained medical practitioners” owing to a very large number of for-profit schools that offered mainly didactic instruction, without laboratory or practical experiences. This overproduction of so-called physicians had been defended by the argument of affording access to the profession “in the interest of the poor boy,” but was “in reality an argument in behalf of the poor medical school.” The conclusion of the report, as summarized by Henry S. Pritchett, then President of the Carnegie Foundation, was that a hospital with wards open for teaching and under the educational control of a medical school was as necessary as a laboratory of chemistry or pathology, and that this model should serve as “a starting-point … in a new national effort to strengthen the medical profession and rightly to relate medical education to the general system of schools of our nation” . In the report’s chapter on “The Postgraduate School,” Flexner raised the issue of continuing competence, advocating that a medical school should offer not only a rigorous course of undergraduate instruction, but also postgraduate education of “special courses adapted to the needs of those inclined to devote themselves … exclusively to some particular line of work (ie, specialization), and to become centers to which at intervals men practicing in isolated places may return for brief periods to catch up with the times” . The report successfully precipitated a revolution, principally in undergraduate medical education, in the United States and Canada, and laid the foundation for a series of improvements in the lifelong education of physicians that continue up to the present.
Another wave of educational improvements hit in the late 1950s and early 1960s, and mainly involved the largely unregulated area of postgraduate education, termed “continuing medical education” (CME). The American Medical Association (AMA) took a leadership position in CME by appointing, in 1957, an Ad Hoc Advisory Committee on Postgraduate Medical Education, which developed an agenda adopted by the AMA’s Council on Medical Education. The initial goals—to ascertain the ideal objectives of postgraduate medical education programs and to devise criteria or standards compatible with such—were published in 1957 in A Guide Regarding Objectives and Basic Principles of Postgraduate Medical Education Program . The council was requested to (1) publish a guide or guides setting forth and explaining the objectives and criteria of acceptable programs, and to distribute such to relevant institutions and organizations; (2) devise methods for evaluating courses and other programs, and then implement an appraisal program nationally; and (3) publish in The Journal of the American Medical Association only courses and programs meeting the criteria as determined above. This approach was embraced by the association of medical schools and major specialty groups; in fact, postgraduate courses were already being presented by medical schools and by specialty societies, including the Academy of Ophthalmology and Otolaryngology (1921; the precursor to the American Academy of Otolaryngology–Head and Neck Surgery), the American College of Surgeons (1928), and the American Academy of Orthopedic Surgeons (1933) . It is indeed interesting that the three early leaders in CME of specialists in the United States and Canada were all surgical specialties.
In 1961 the AMA advanced the CME initiative with the appointment of a Joint Study Committee to “spell out the dimensions of a program of continuing medical education .” This committee comprised the key players in both undergraduate and postgraduate medical education, as well as teaching hospitals and specialty organizations such as the AMA, the Association of American Medical Colleges, the American Hospital Association, the American College of Physicians, the American Academy of Pediatrics, the American Psychiatric Association, the American College of Obstetricians and Gynecologists, and the American Academy of General Practice. This group joined together to address three mutually agreed-upon topics: (1) CME was one of the most important problems facing medical education, (2) there was a serious gap between available knowledge and application in medical practice, and (3) a nationwide plan was the best solution .
The Joint Study Committee subsequently proposed creation of a nationwide “University without Walls” for CME, tailored to the realities of community, professional, and personal demands. All physicians were to have an equal opportunity to continue their medical education at a time, place, and pace convenient to the demands of their ongoing clinical and personal obligations. The curriculum was to be organized around a continuously, or at least frequently available, sequential, and comprehensive program of instruction, with the participant able to choose any or all of the curriculum. The physician–learner was expected to actively participate in the program, and be afforded an evaluation of her or his performance, including a variety of voluntary examinations, and the opportunity to likewise evaluate the program. The curriculum was initially to be designed and produced by a national “faculty,” and then regularly modified according to feedback from participants. Although nationally organized and developed, the program was to gradually become available on a regional and local selective basis, for the convenience of participants.
Administrative requirements for the aforementioned plan were substantial, entailing development of not only “core curricula,” but also a nationwide distribution system. The venues for presentation were to be specialty organizations, medical centers or other groups with the ability to deliver direct bedside teaching, and local or regional discussion groups. Teaching materials for the local programs would be furnished by the national agency, and each regional or local distribution center could decide to receive and distribute all or any part, with each physician being able to elect to participate in any part of the program, or to take the entire program. A series of self-appraisal examinations was integral to the process . This initiative, published as a guide in 1962, was never fully realized, but started the CME community down the road to accreditation and the establishment of guidelines for consistency in CME courses and programs.
Shortly after the recommendations outlined above, the AMA council disbanded the Ad Hoc Committee and replaced it with a permanent structure, the Advisory Committee on Continuing Medical Education, whose first action was to recommend establishment of an accreditation program. Surveys were conducted to help establish procedures and mechanisms for accreditation, and included on-site visits to gather information and observe the organizations that were conducting postgraduate courses. On the basis of the results IBID of those surveys, in 1964 the Advisory Committee recommended to the council, and the Council forwarded to the AMA House of Delegates, consideration of approval of “formal appraisal procedures” for accreditation.
Guidelines for conducting CME, and the accreditation of valid programs, were half of the equation, and in 1968 the AMA added the other half—namely, a “Physician’s Recognition Award” (PRA)—to denote practitioners who demonstrated a satisfactory level of participation in the CME process. The related AMA CME credit system codified two types of education attainment, Category 1 and Category 2. The former initially entailed the traditional methods of learning such as formal interaction between faculty and physician audience in a certified activity or review of enduring materials, such as monographs, followed by a self-assessment exam. Category 1 was gradually expanded during the subsequent 30 years to allow audio, video, online/electronic delivery of learning materials; participation in focus groups (such as a “journal club”); writing or reviewing articles for peer-reviewed journals; and for faculty time preparing lectures and writing test items. Credit for active participation in a performance review and improvement process—pursuits that have recently been mandated by some of the Boards of the American Board of Medical Specialties (ABMS)—has been the most recent addition to Category 1. Category 2 credits are more loosely defined, being self-reported rather than tallied by accredited CME providers, and not subject to documentation requirements by the participating physician. Examples include preceptorships, research activities, consultation with peers or experts, teaching medical residents or students, and reading journals. The AMA views both categories of CME as integral to a continuing educational framework, and offers 1-, 2-, and 3-year PRA certificates based on a mix of such. For instance, the 3-year PRA entails a minimum of 60 hours of Category 1 and 90 hours of Category 2 CME. Resident training is assumed to entail all aspects of Category 1 and 2 activities, and so 3 years in an accredited (by the American Council on Graduate Medical Education [ACGME]) training program automatically meets the criteria for a 3-year PRA certificate. Recently, physician attainment of a Maintenance of Certification certificate from an ABMS Board has been added as sufficient validation of current medical knowledge to warrant a 3-year PRA, without the need for other documentation.
Accreditation of CME for physicians was initially performed, beginning in 1968, by the AMA’s Council on Medical Education, but by 1976, the volume of courses had increased over 10 fold. Accreditation was becoming a sufficiently complex undertaking to warrant formation of a dedicated subsidiary organization, the Liaison Committee for Continuing Medical Education, which morphed into the current Accreditation Council for Continuing Medical Education (ACCME) in 1981, and under whom the more recent guidelines for Categories 1 and 2 as outlined above were promulgated. During this evolution, the AMA broadened input into the CME process and accreditation thereof, and ACCME constituents were expanded to include the ABMS, the American Hospital Association, the Association of American Medical Colleges, the Association for Hospital Medical Education, the Council of Medical Specialty Societies, and the Federation of State Medical Boards .
A paradigm shift in continuing medical education coincident with the transition between the twentieth and the twenty-first centuries
The ACCME guidelines had completed the initial phase of growth by 1984, and periodically received modest updates when technology warranted, as when the Internet became a viable vehicle for learning. However, in 1998 a substantially different system was introduced, centered on three essentials and a set of required elements for each: (1) purpose and mission, (2) educational planning and evaluation, and (3) administration. The ACCME also put in place guidelines for commercial support of CME, which have become progressively more explicit over the years. Initiatives outside the ACCME and the constituents of its board impacted the way organized medicine, state licensing boards, and other governmental entities viewed postgraduate physician competencies, and are today reflected to some degree in the CME landscape. In 1999 the Institute of Medicine (IOM) published To Err is Human: Building a Safer Health System , which emphasized reduction in errors in patient care by specific physician education, and integration of continuous practice evaluation and improvement by both the individual physician and by health care organizations (eg, hospitals). In 2001 the IOM issued Crossing the Quality Chasm , which re-emphasized process improvement and accountability, and in 2003 Health Professional Education: A Bridge to Quality , with specific suggestions regarding the organization and evaluation of CME, and reflecting some of the ACGME’s recommendations from 2001. These IOM recommendations encompassed five competencies (instead of six proposed by the ACGME in 2001, Box 1 ), as follows: providing patient-centered care, working in interdisciplinary teams, employing evidence-based practice, applying quality, and using informatics.
Medical knowledge
- •
Acquisition
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Analysis
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Application
Patient care
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Gathering information
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Synthesis
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Partnering with patients/families
Practice-based learning and improvement
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Lifelong learning
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Evidence-based medicine
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Quality improvement
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Teaching skills
Systems-based practice
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Health care delivery system
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Cost-effective practice
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Patient safety and advocacy/systems causes of error
Professionalism
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Professional behavior
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Ethical principles
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Cultural competence
Interpersonal and communication skills
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Communicating with patients and families
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Communicating with team members
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Scholarly communication
In a parallel timeframe, with emphasis on continuing physician competence, the Council of Medical Specialty Societies (CMSS) released in 2002 Repositioning for the Future of Continuing Medical Education . In 2005, in conjunction with a large group of organizations (eg, ACCME, ACGME, ABMS, Federation of State Medical Boards, American Hospital Association, AMA), the CMSS published Reforming and Repositioning Continuing Medical Education ( Box 2 ), a process that remains ongoing and from which further position papers are expected; drafts of such are open for public comment on the CMSS Web site ( www.cmss.org ) .
- 1.
Medical education continuum—CCCME serves as forum for communication and coordination, builds relationships, and ensures visibility and accountability among all stakeholders.
- 2.
Self-assessment and lifelong learning—Physician learners, CME professionals, and physician educators should engage in self-assessment of competencies and lifelong learning to maintain competency.
- 3.
Core curricula and competencies—specialty-specific core curricula should be developed to improve physician competencies. The core competencies described by ABMS/ACCME and ACGME/American Osteopathic Association.
- 4.
Valid content: Evidence-Based Medicine—Assure that all recommendations for patient care presented in CME are based on current best evidence, physician expertise, and patient values.
- 5.
Performance and continuous improvement—Facilitate continuously improved approaches to evaluate CME’s effectiveness.
- 6.
Metrics to measure and recognize physician learning and behavioral change—Current CME credit system should evolve and the CME system should facilitate evaluating CME’s effectiveness in forms and technologically advanced tools that are user-friendly.
- 7.
Resources and support—“Blue-Ribbon” panel, medical, entrepreneurial, foundation, and governmental, and other organizational leaders should be established to offer advice, guidance, and support to focus CME as the practice and scope of medicine evolve .
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