Response to the 2011 Question of the Year
Dorman, Todd MD; Miller, Bonnie M. MD
Dr. Dorman is associate dean and director, Office of Continuing Medical Education, and professor and vice chair for critical care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, with joint appointments in medicine, surgery, and the school of nursing.
Dr. Miller is senior associate dean for health sciences education, Vanderbilt University School of Medicine, Nashville, Tennessee.
Correspondence should be addressed to Dr. Dorman, 720 Rutland Ave., Turner 17, Baltimore, MD 21205-2195; telephone: (410) 955-5928; e-mail: firstname.lastname@example.org.
The past century has seen spectacular gains in the breadth and depth of biomedical knowledge, but the potential of these gains has been limited by inadequate, inequitable, and inefficient translation of knowledge and skills to the health care workplace. We propose that a radically transformed continuing medical education (CME) system is essential to realize biomedicine's ever-expanding potential to improve the health of patients and populations.
CME today is not the CME of the past. Its historical reputation for ineffectiveness has been dispelled, and new standards of commercial support create a principled firewall that prevents undue industry influence. With a focus on specific needs and gaps, CME is transitioning from an instructor-centric to a learner-centric model that will increasingly integrate with professional development. When appropriate, CME seeks to demonstrate associations with patient outcomes and thus is increasingly integrated with performance and quality improvement. A transition from time-based to value-based CME-credit systems is also under way.
In coming years, all these transitions must accelerate. Performance-improvement CME (PI-CME) must grow, both in importance and in proportion, within a physician's CME portfolio. PI-CME links continuing education (CE) to the documented needs and gaps of institutions and practices. By focusing on precise areas of need, the effectiveness of CME will be measured not only by enhanced physician knowledge but also by the association of that knowledge with improved performance and meaningful patient outcomes.1 In addition, health care reform will force a transition to team-based models of care. This in turn should force an alignment of the CE systems of the various health professions, allowing the development of interprofessional CE with outcomes measured by both individual and team performance. Given the importance of communication in highly functioning teams, we predict a growth in simulation-based CE, in which providers learn, practice, and demonstrate advanced teamwork skills.
For CME to achieve maximum benefit, learning at the point of care must augment the traditional model of learning activities remote in time and place. CME must become fully integrated into the workplace, rapidly responsive to what providers do on a daily basis and how they do it. Process-of-care CME will require new technology capabilities, such as automated self-assessment systems in which patient status will direct providers to appropriate educational resources, ensuring that the right patient receives the right care at the right time. It may even be possible to integrate searches performed during the course of work into CME. Ultimately, the combination of PI-CME and process-of-care CME will create iterative improvement cycles that align education outcomes with patient outcomes, and perhaps even payment incentives, which will be critical as providers become more accountable for the value of care across longitudinal delivery systems.
With the complexity of the health care system creating greater time demands, physicians will find it increasingly difficult to complete maintenance of certification (MOC), maintenance of licensure (MOL), and health system credentialing if these remain distinct processes. Moreover, the aims of these processes should be the same—namely, the provision of timely, safe, effective, efficient, equitable, patient-centered care.2 With its dual focus on physician performance and health care outcomes, the new CME can serve as a link that connects and coalesces the processes for MOL, MOC, and credentialing.
The above shifts will move CME from a purely educational paradigm to one that functions more broadly as a professional development paradigm. Using frameworks defined by the core competencies of the Accreditation Council for Graduate Medical Education as well as the specific competencies outlined by specialty boards, CME can enhance continuity between the phases of medical education. Physicians should experience CME as a truly continuous process, but this demands that the skills of lifelong learning and performance improvement become embedded throughout undergraduate and graduate medical education, beginning with matriculation.
Academic CME will reside at several important and unique intersections. It will sit at the intersection of lifelong learning, knowledge integration, health information technology, and performance improvement. As a facilitation tool, it will sit where the various regulatory requirements intersect, including specialty certification, licensure, and institutional accreditation. Finally, academic CME will reside at the intersection of emerging theoretic and foundational knowledge about how physicians and health teams learn and the translation of that knowledge into practice for both specialist and primary care teams. This last intersection is where the confluence of benefits will accrue and where CME will demonstrate its role as an essential component of professionalism as well as its commitment to the creation of a health care system that produces continually improving outcomes for patients and populations in a highly efficient and equitable manner.
The authors wish to thank the Joint Working Group—which consists of the CME section of the Group on Educational Affairs within the Association of American Medical Colleges—and the leadership of the Society for Academic Continuing Medical Education.
1Moore DE Jr, Green JS, Gallis HA. Achieving desired results and improved outcomes: Integrating planning and assessment throughout learning activities. J Contin Educ Health Prof. 2009;29:1–15.
2Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.