WHITCOMB, MICHAEL E. MD
One of the most important challenges facing the medical profession is determining how to improve the quality of medical care. This month's journal contains a number of papers that address aspects of this important challenge that are particularly relevant to the leaders of academic medicine's institutions and the clinical faculty who provide care and teach clinical medicine in those institutions.
The lead paper, by Kimball and colleagues, summarizes key concepts about improving medical care quality; these emerged at a conference devoted to the topic that was sponsored by the American Board of Internal Medicine and the Agency for Healthcare Research. The three papers that follow were prepared to stimulate discussion and debate at that conference. Taken together, the papers establish both a theoretical and a conceptual framework for how the quality of medical care can be improved. Six other papers in this month's journal relate more specifically to how the academic medicine community can work toward that goal.
In this editorial, I expand on the main theme of the ABIM/AHRQ conference—namely, the responsibility that individual physicians have to engage in activities specifically designed to improve the quality of medical care.
Many of the activities proposed in the collection of conference papers are intended to improve the institutional processes involved in providing care. While this is clearly an important goal, the full benefit of the quality improvement movement will not be realized until practicing physicians begin to address quality-of-care issues in their individual practices. As the authors of a number of the papers point out, educating doctors about quality-of-care issues and how they might address those issues as they go about their daily work is one of the keys to improving medical care quality. But what needs to be done to make this a reality?
In my view, most of those leading the quality-of-care movement miss the primary target when they recommend how to improve the education of doctors about quality-of-care issues. Their comments tend to focus attention on the way that those issues are covered in the undergraduate and graduate medical education programs sponsored by medical schools and teaching hospitals. True, their comments present important challenges that those in the medical education community must respond to. But identifying strategies for improving the education of medical students and residents about quality-of-care issues should not be the primary goal. What is truly needed is a strategy for embedding education about quality-of-care issues in the daily lives of the large number of practicing physicians who are now, and who will be for the foreseeable future, responsible for most of the medical care provided in this country.
To achieve this goal, the medical profession must transform the way that continuing medical education (CME) is conducted. At present, the policies that govern how CME is carried out tend to encourage, and in some cases to require, physicians to engage in educational activities that promote merely the acquisition of facts—such as attending lectures or courses, or submitting answers to questions posed by online CME programs or by medical journals. The results of research studies show rather convincingly that acquiring facts in these ways does not affect physicians' practice behaviors. So what is to be done?
Some time ago (1990), the Association of American Medical Colleges issued a position statement that set forth how CME should be conducted to be effective in changing the ways physicians practice. Based on available evidence, the Association concluded that CME should be highly self-directed, with content, learning methods, and learning resources selected specifically for the purpose of maintaining or improving the knowledge, skills, and attitudes that physicians need on a regular basis in their practices. To accomplish these objectives, individual learning experiences should incorporate interactive learning formats, practice enabling and reinforcing strategies, and, to the degree possible, be accessible within physicians' practice or work settings. In other words, physicians should be encouraged to spend the time they can devote to CME in learning how they can improve the care they provide in their individual practices, and in putting in place mechanisms for translating that learning into practice behaviors.
This is not a novel concept. In early 1999, the National Health Service (NHS) in the United Kingdom began to reorganize the delivery of primary care services by creating primary care groups composed of general practitioners, community nurses, and other professionals. One of the stated purposes of the reorganization was to improve the quality of care provided in the community. The primary care groups are charged with using CME activities as one of the strategies for achieving this goal. Recognizing that the usual postgraduate CME courses do not affect physicians' practice behaviors, the NHS adopted a policy intended to promote learning activities that would. The NHS now allows the primary care groups to use funds that would have been available for physicians to attend postgraduate courses to support on-site CME activities that are linked to specific quality improvement goals in their own practices.
Reform of CME presents a daunting challenge to the profession. To begin, the rules governing the awarding of Physician Recognition Award (PRA) credits by the American Medical Association must be changed. The awarding of PRA credits has a major influence on the kind of CME activities that most physicians participate in because many states mandate that physicians acquire a certain number and category of PRA credits for relicensure. At present, the majority of physicians are required to attend lectures and courses, activities that are unlikely to change their practice behaviors, to obtain those credits. Fortunately, the staff of the medical education group at the AMA is studying this issue and plans to present a set of recommendations for change to the AMA's Council on Medical Education within the next 12 months. By revising the rules governing how PRA credits are awarded, the AMA has an opportunity to create incentives for doctors to link continuing education with quality improvement goals in their own practices.
Assuming that the AMA does make the needed changes, it is important to recognize that a great deal of work will still need be to be done by various professional organizations that affect how CME is conducted in this country. The specialty societies and specialty boards will have to adopt policies governing their members' recertification that support the new approach to CME. The Federation of State Medical Boards will have to work with its members to ensure that state licensure laws do not conflict with the goals of the new approach. Finally, the Accreditation Council for Continuing Medical Education will have to formulate a new and different role for CME accreditation that will serve the purpose of improving medical care quality.
The goal of CME reform is clear—to create a system that will support and enhance the efforts of individual physicians to improve the quality of care they provide in their practices. Given the magnitude of the challenge, it is important to get on with the work that lies ahead. Those leading the quality improvement movement can play an important role by focusing some of their energy on the need to reform the country's continuing medical education enterprise. The academic medicine community must provide the leadership to see that this goal is achieved. Practicing physicians and their patients deserve no less!