A recent article published in the New England Journal of Medicine (NEJM) provided a comprehensive overview of the evolution of continuing medical education (CME), and highlighted the modern challenges confronting CME. The piece was published by Graham McMahon, MD, MMSc, President and CEO of the Accreditation Council for Continuing Medical Education (ACCME), who emphasized the importance of "self-awareness" in CME, or the notion that health professionals who know their own strengths and weaknesses are more likely to have a productive experience when they choose the activities that they believe can best help them grow in their field. Dr McMahon concludes that positive change in CME "begins with each of us having the humility and presence of mind to ask ourselves, 'What do I need to learn today?'"
The full article is below.
What Do I Need to Learn Today? — The Evolution of CME
The point at which a clinician takes ownership of his or her own learning agenda is a pivotal moment in professional growth. But as postgraduate medical education evolves to become more learner-centric, new approaches and expectations have created pressures on the continuing medical education (CME) system and left some physicians frustrated.
Now that information is ubiquitous, simple information exchange has relatively low value; in its place, shared wisdom and the opportunity to engage in problem solving in practice-relevant ways have become key. Physicians seeking professional development can recognize when they’re actively learning and tend to embrace activities that allow them to do so. Education that’s inadequate, inefficient, or ineffective, particularly when participation is driven by mandates, irritates physicians who are forced to revert to “box-checking” behavior that’s antithetical to durable, useful learning.
Many clinicians appreciate learning alongside their peers but may struggle with the feeling that time spent in group educational settings is not efficient or productive enough to be worthwhile. Furthermore, the quantity of learning opportunities can be overwhelming, as our in-boxes continually brim with promotional and marketing e-mails. Some traditional gatherings, such as grand rounds, have reported declines in perceived utility and attendance.
So how can we as learners evolve, and how should the system evolve to meet our diverse needs? A key element is self-awareness: professionals who know their own strengths and weaknesses are most likely to have a productive experience when they identify the types of activities that help them grow and then actively participate in them. There are many ways to increase self-awareness, such as taking a self-assessment quiz, asking a colleague to observe one’s practice and provide feedback, asking patients or staff for suggestions, and reviewing patient charts. To become self-aware, we have to step out of the protective cocoon of self-confidence and become humble and open enough to assess both how we can best maintain what’s working and how we can grow further.
Educators, for their part, can create more clinician-friendly and effective learning environments. Research shows that CME is most effective in changing physician performance and patient health outcomes if it is interactive, uses varied pedagogical methods, and involves multiple exposures to the same or related material.1 We’ve understood for years the principles of adult learning — that adults prefer education that’s self-directed, based on needs they have identified, goal-oriented, relevant, and practical — yet many of us still feel more comfortable with traditional, passive approaches that are essentially teacher-focused, not learner-centric. Much CME continues to rely on traditional approaches such as annual meetings and grand rounds (see pie chart Types of CME Activities in the Accreditation Council for Continuing Medical Education System, 2014.), though these, too, are evolving.2
Small steps in educational design can make a big difference. Grand rounds, conferences, and other live sessions are made more interactive, relevant, and meaningful by limiting the time for formal lecture, incorporating case examples, and allowing substantive time for discussion and for learners to work in pairs or groups to share, reflect on, and solve problems. Readily accessible and relatively inexpensive technology can facilitate interaction. By answering polling questions on their smartphones, for example, participants can learn how their attitudes, knowledge, or problem-solving skills compare with those of their peers. Given the opportunity to interact with colleagues, physicians can measure themselves against professional norms and provide one another feedback, while building collaborative relationships. Faculty development is needed to support these modest educational innovations and sustain the necessary change.
Increasingly, physicians are expected to practice in teams, and interprofessional continuing education gives them opportunities to learn from, with, and about colleagues in other health professions and to build the competencies needed for successful collaboration. Patients are also part of the team, and including patients as CME speakers can engage physicians’ hearts as well as their minds and reinforce the reasons why our work matters. Patients’ stories often provide insights that clinicians can immediately apply in their practices.
Educators are deploying new information and communication technologies in accredited CME programs, using simulation centers, games, blended learning (combining digital and face-to-face formats), social media, and other applications. Simulation technologies can provide safe, controlled environments, with realistic visualization, where clinicians can practice and get feedback on their leadership, teamwork, communication, and technical and problem-solving skills without posing a risk to patients. Technology lends itself to learner-controlled training that accommodates diverse learning styles and is particularly well suited to younger clinicians who are comfortable in the digital world. As new technologies emerge, physicians and educators need the freedom and encouragement to develop new learning methods.
At health care institutions, CME programs and educators are increasingly working to support strategic objectives and help address important system issues. Hospital and health system leaders report that investment in CME has helped them improve physician performance, patient outcomes, and care coordination; drive and manage change, including behavioral and cultural change; improve teamwork and collegiality as well as leadership skills; and reduce burnout and turnover.3 These benefits extend beyond hospitals and health systems; accredited educators work in settings including specialty societies, state medical societies, government and military organizations, medical schools, and publishing companies. Of the approximately 2000 accredited CME programs, about two thirds participate in quality-improvement initiatives within their health systems and institutions.
The regulators, too, need to evolve. By relinquishing the fixed structural requirements for health education and instead focusing on educational outcomes (rather than process and time spent), regulators and accreditors can create the right conditions for maximizing educators’ flexibility and promoting innovation. By creating a diverse system that can address even superspecialized needs, we facilitate choice among formats, activity types, and locations. I envision a future in which educational expectations and professional competency obligations are aligned and integrated and in which all physicians have an educational “home” that helps them navigate their continuing growth — so that education is intertwined with practice throughout their careers.
At the Accreditation Council for Continuing Medical Education (ACCME), we are working to harmonize postgraduate educational systems to provide more flexibility for clinicians and educators. I know that as a practicing endocrinologist, I want to participate in activities in which I can feel myself learn — and like many of my colleagues, I want those activities to count toward my Maintenance of Certification (MOC) requirements. In response to physician requests, the ACCME and the American Board of Internal Medicine collaborated to simplify the integration of MOC and CME, giving physicians more options for receiving MOC credit through participation in accredited CME, which they already use to meet licensure and other professional obligations. Now, accredited CME providers can register their activities for both MOC and CME using the same system, physicians can find activities using that database and receive MOC and CME credit at the same event, and diplomates’ completion records are reported seamlessly to their certifying board.
If more regulatory authorities recognize the value of education in driving clinical practice and quality improvement and allow educational activities to count for multiple requirements, they can reduce the burden on physicians and promote lifelong learning. For example, participation in CME could be designated as a method for meeting the clinical practice improvement expectations of Medicare’s new Merit-Based Incentive Payment System.
The accredited CME community in the United States delivers nearly 150,000 activities each year in myriad specialties and competencies2; these activities are required to be evidence-based and free of commercial bias and influence. The current CME system can do more to promote performance and quality improvement, collegiality, and public health. But it will struggle to do so without the engagement of health care leaders, educators, and learners — and won’t succeed until health care systems, organizations, and institutions recognize education’s strategic value in driving change.
At ACCME, we’ll be doing what we can to facilitate the needed transformation in postgraduate education, to encourage meaningful education leadership at the heart of our health systems and profession, and to further expand the opportunities for educational innovation that improves physician practice and ultimately benefits patient care and the health of our country. All that change begins with each of us having the humility and presence of mind to ask ourselves, “What do I need to learn today?”
