Oh Henry
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Does the CME process make better doctors? Let’s take a hard look at verifiable results.    

The choice is simple: process or product. Do we support the simple checking of boxes or are we concerned with producing something real? We have seen what happens to countries that feel that the process is more important than their products: they lose. In America, there’s hardly a better example of this mindless checking of boxes – without a whit of care for outcome – as continuing medical education.

Many years ago I sat on a committee in the Detroit metropolitan area that had representatives from some major corporations on its board, including the Ford Motor Company, General Motors and Chrysler. At one of the meetings, a PhD in electrical engineering from Ford was speaking on healthcare costs and what they were paying. As part of the discussion, he threw out in front of the doctors on the panel a pile of brochures offering the chance to earn Continuing Medical Education while sipping umbrella drinks in exotic locales. “So,” he challenged, “it is imperative that we study CME from a wondrous resort as opposed to attending something here in the state of Michigan?” The consternation and sarcasm in his voice came through crystal clear. I had no snappy comeback except to say that CME was an act or expression of true intellectual freedom. This is where physicians decided, by themselves, what they needed and pursued it with great vigor. The fact that it existed in a desirable location should not denigrate the quality of the education. The industrial giants around the table who basically paid the healthcare bills of Southeastern Michigan were not amused by this logic.

When we contemplate CME, we must first realize that we’re all involved in this theatre noir. The physician signs up for courses without any actual assessment of his/her academic needs. They can pick continuing education in any sphere they want as long as it qualifies for the credits they need. No other business would function this way. And then there is the fact that in medicine, no one seems to care. I have never seen any ED leader actually assess a physician in order to plan their next two years of CME based on their needs. What a novel concept that there might actually be a relationship between the process (the courses) and the product (becoming a better physician)! The electrical engineer who raised the CME concern went on to make the point that he assesses people in his department and decides what skills and talents they need to bring back to his organization. He then sends them out, with pay, to gain that expertise and bring it back in order to make a better functioning department. Seems logical to me, but I have never seen a medical director who actually sat down, looked at the mistakes of his physicians and programmed out continuing education to solve the problem. Actually looking at the product would be a radical concept in this country. It makes no sense to require CME unless it meets a societal need. Why is this tax deductible if it is not serving the public in some way?

This conspiracy to which we all collude has gotten even worse. Now the state is involved, making mandates on CME hours and creating yet another box to check. No one ever asks, “Did you learn anything? Are you any better? Is there any way we can find out how good a doctor you really are?” Everyone seems happy that we are forcing docs to go to medical education and nobody seems to care whether you learned anything or not. This is a very bizarre concept if we are to relate it to improvement in healthcare.

Having built my career in CME, I must confess to being a part of the process and having benefited from these activities. That said, viewing the system from the inside has shown me yet another way that this industry has gone awry. I recently spoke for a major medical school on the west coast, and I was asked to submit my slides in advance. A group of non-physicians had to approve whether my slides were politically correct. Heaven forbid I actually use the word Valium as apposed to diazepam. This sort of Gestapo oversight of everything that is going to be said at medical meetings is ridiculous and has nothing to do with the quality of the presentation.

Which brings us to perhaps the most amazing part of this whole business: the evaluations. All the various agencies from within the profession and within the state require that we evaluate CME. And yet, no one is required to do anything with that information. For the last 35 years, I have been involved in the process where people are asked to “rate the speaker” (i.e. quality of information, benefit to your practice). Everybody wants you to do this, and yet nobody knows what you should do with the results. Having just participated recently in a major CME event, I casually asked what they do with the results of these surveys. The answer was, “mostly nothing.” They file them in a drawer just so they can prove at some point in time that they did ask the question. I naively asked whether they’d ever kicked out a speaker because of a low rating. The woman in charge looked me in the face and said, “No, they don’t care.” In over 30 years, no accreditor had ever asked her to produce any of these hundreds of thousands of evaluation forms. If this isn’t process over product, I don’t know what is. Why we do this is beyond belief. If you are not going to use the information gained, why ask the question at all?

No one, by the way, ever carries this further and asks whether your CME has improved performance. We have no idea what the relationship is between the CME and its outcome. The people who want to maintain a level of excellence will do so. They will get it from journals, discussions at their own department or at some offsite CME. Others will go to educational events and sign their name on an attendance sheet without ever turning their brain on. For anyone who is into evidence-based medicine, show me the evidence that CME attendance correlates with improved performance. Show me that forcing doctors to fill out evaluation forms has ever changed the process.

Please, someone help me out here. I’m certainly not against continuing medical education. What I’m against is process for process sake. Show me where it’s doing some good. Show me where we’ve advanced over the last 40 years. Show me how we’ve produced better doctors. I am not advocating the dissolution of CME, but taking a fresh look at the process so that it actually reflects the product which we would all hope to produce, that is better care for our patients.

 

Comments   

# medical directorstephen miller md 2010-06-11 12:44
Kudos to Dr Henry for saying something we probably all knew but never verbalized but he didn't mention how much money CME costs, not just for the doctor but also for the person covering from them while they're gone. Wonder if he has ever seen a study that it is cost effective in any way, shape, or form. CME requirements are laughable at best. Docs that want to stay abreast will without compulsion.
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# It's a business, just like medicine itselfShant Garabedian 2010-07-14 08:42
There are only few CME's that actually give physicians practical information that they then put to use in their daily lives and practices; which in turn translate to improvement in patient care - if the information is true and evidence based. There are many if's, one of the biggest of which is biased information, especially by big Pharma, that tells you what they want you to hear, versus what is time tested and proven. CME's are also big business it seems for the companies producing them. Pack a hundred docs in a conference room, charge them $500 a piece, pay the speakers a few thousand a piece, get credits approved, some overhead, and bingo - money in pocket. It must be profitable since I get a CME offer every day in the mail. Universities and Medical schools are in on it; prostituting their reputations and names. You see one from UCLA and you think, this must be good. It may or may not be decent info, but it still was put on by UCLA!!! The certificate even looks good.
I do believe there is a tremendous value in educating physicians and keeping them abreast on newer and better ways of practicing medicine. It's just that the "fluff" has to be taken out.
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