By Christopher Guadagnino, Ph.D.

University of Pittsburgh Associate Dean Barbara E. Barnes, M.D., M.S.

Published April 2001

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Physicians endeavoring to keep abreast of the latest advances in their clinical specialty, while earning Category 1 credit hours toward their continuing medical education (CME) quotas, typically attend lectures or audio-visual presentations on topics scheduled for a convenient time and place. Such traditional CME programming has recently been criticized by researchers who argue that formal, didactic modalities designed to enhance knowledge do a poor job leading physicians to significantly improve how they practice and thus improve patient outcomes.

While some defend the importance and appropriateness of traditional CME program formats, a variety of innovative CME programming, some involving the latest web-based technology, is increasingly being made available to physicians. The accessible, cost-effective, self-directed and interactive features of these non-traditional CME programs address some of the purported shortcomings of traditional didactic CME events.

Category 1 CME credit is currently available for take-home and online courses, online journal article study, live and online problem-solving cases, use of clinical guidelines in physicians’ medical practices, publishing in peer-reviewed journals, passing specialty board certification exams, earning a Masters of Public Health degree or MBA degree with a medical focus, teaching CME, using the Internet as a medical search tool, and participating in quality improvement activities.

Critics and Defenders of Traditional CME Format

Although more than 90 percent of CME activities in the U.S. is in the form of traditional courses or grand rounds, the traditional lecture format involves largely passive audience attendance, making it difficult for content to be personally adapted to attendees and difficult to assess program effectiveness, according to Barbara E. Barnes, M.D., M.S., associate dean for continuing medical education and assistant vice chancellor for continuing education in the health sciences at University of Pittsburgh.

A study comparing formal didactic CME formats (e.g., lectures or presentations with minimal audience interaction or discussion) with interactive formats (e.g., role-playing, discussion groups, hands-on training or problem-solving) found that didactic formats failed to achieve success in changing physician performance or health care outcomes, while interactive formats were generally more effective in changing those outcomes, according to a Sept. 1, 1999 article published in the Journal of the American Medical Association. The authors conclude that knowledge is necessary but not sufficient to bring about change in physician behavior and patient outcomes, and the article ended with an exhortation that medical licensing boards, as well as medical schools, specialty societies and other CME providers, reconsider the value of the CME credit system, including the American Medical Association’s Physician Recognition Award Category 1 credit.

New accreditation standards released in July 1999 by the Accreditation Council of Continuing Medical Education (ACCME) have begun to stimulate CME providers to design tools to measure CME effectiveness. Compliance with ACCME’s new standards requires educational activities to be evaluated for effectiveness in meeting identified educational needs as measured by satisfaction, knowledge or skills. CME providers typically meet the requirement by conducting physician satisfaction surveys or post-CME activity tests, says Barnes.

Only a small percentage of CME providers are able to meet ACCME’s new "exemplary compliance" accreditation category, which requires activities to be evaluated for effectiveness as measured by practice application and/or health status improvement, Barnes adds, noting that it inherently difficult to link traditional CME activities to those measurements. ACCME is currently considering whether to require outcomes data for those measurements, or whether to accept questionnaire data such as physicians’ stated intent to change their practice based on the CME intervention, adds Barnes, who is vice chairperson of the Accreditation Review Committee and surveyor for ACCME.

Not all large group lecturing is ineffective, and critics erroneously assume that a snapshot assessment of a CME intervention can be said to produce or fail to produce a change in a physician’s practice pattern, argues Robert Smedley, Ed.D., associate dean of continuing medical education at Temple University. Attendees of CME lectures experience collegiality, have live interactions with others, undergo critical self-reflection at a later time during patient care and pursue follow-up CME events—a multi-dimensional learning experience which must be taken into account when judging the impact of traditional CME. Learning styles also determine which modalities work best, and physicians are used to the didactic style that still comprises the bulk of coursework in medical school, Smedley notes.

Lecture-based CME can be effective, Smedley maintains. In a family practice CME course at Temple University School of Medicine, Smedley studied the questions that physicians were asked to jot down at the conclusion of 20-minute lectures and found that 75 to 80 percent of the questions began with a statement such as, "I have a patient who..." Such statements demonstrate that participants brought their cases to the CME lecture and were applying what the speaker was saying to their actual practices, says Smedley.

Lecture-based CME programs can be modified to make them more effective, Smedley notes, by shortening lectures to 20 minutes, following them with extended periods of interactive question and answer discussion, and adding clinical "pearls," or key lecture points to remember, e.g., what a certain vaccine will and will not do.

Non-Traditional CME Formats

Although still in the minority, a variety of Category 1 CME activities exist that do not require attending lecture-based events.

Journal-based CME allows physicians to select articles to read and answer questions to receive credit. The Journal of the American Medical Association’s web-based journal CME requires physicians to answer open-ended questions that stimulate the learner to reflect on the material read in order to receive credit.

Since this January, the American College of Surgeons is making available to its fellows four articles each month chosen from the Journal of the American College of Surgeons which physicians can read and respond to multiple-choice questions written by the article’s authors to earn 0.5 credit per article, says Wendy Cowles Husser, the journal’s director and executive editor. Confirmation of having taken the exam is emailed back to participants as documentation for credit, and the College plans to have 24 articles available at any given time, says Husser. Credit is not contingent on correct answers, but the program offers a critique of an incorrect answer with details that guide the reader to the correct answer, Husser notes. Some 300 physicians have used the program so far, and the College expects usage to reach one percent of its 65,000 members, she adds.

Interactive courses supplement lecture-based CME at some of Pa.’s hospitals and health systems. Of the 125 CME courses offered at the University of Pennsylvania School of Medicine over the past year, approximately 25 incorporate an interactive format, including 25-40 credit hour mini-fellowships in Otorhinolaryngology and Radiology, according to Jodi Douglas, director of CME at Penn’s School of Medicine. Other interactive sessions at Penn include hands-on lab sessions in otolaryngology and orthopaedic trauma, and interaction with standardized patients in cardiology.

While Penn has traditionally focused on live CME formats, it intends to increase the number of non-traditional CME formats over the next year, says Douglas, such as videotapes from live courses, Internet courses and journal-based CME. A video course on sleep apnea and snoring currently offers 14 credit hours and includes a 27-question knowledge assessment component, she notes. Penn’s journal-based CME currently offers one credit hour per article and 12 issues per year of Clinical Geriatrics, six issues per year of Clinical Lessons in IBD and 12 issues per year of Post Grad OB-GYN.

Temple University is working with Challenger Corp. to develop seven to eight CD-ROM case-based courses, including radiology and dermatology, in which a real-time clock logs physician participation for up to 12 to 15 credit hours, says Smedley. The programs include text, graphics and audio, and require correctly answering a series of multiple-choice questions. The programs cost up to $50,000 to produce, and Temple is meeting with Independence Blue Cross to seek funding for them, Smedley adds.

The Department of Medicine at MCP-Hahnemann School of Medicine has constructed a CME website that offers virtual grand rounds programs on 29 primary care and internal medicine topics, each worth 1.5 credits, says Allan B. Schwartz, M.D., director of the project. Streaming video of selected grand rounds presentations that took place at MCP-Hahnemann allows participants to log on to their computers and download free software to look at slides and medical procedures, and listen to presenters. The programs are developed through sponsorship by CME grants from industry and pharmaceutical organizations, and Schwartz says the department expects to have over 100 programs online by the end of the year.

Each online grand rounds program includes a multiple-choice quiz for which a 70 percent passing grade is required to receive the CME credit, Schwartz explains. Each quiz question can be clicked for review, producing an immediate link to a 30- to 60-second portion of the presentation that contains the answer. Subtopics of each program are also indexed, allowing the user to access short segments for those knowledge elements.

MCP-Hahnemann Dept. of Medicine also has online monographs derived from its live grand rounds, each worth 1.5 credits and accompanied by a quiz with the click-for-review feature. Twelve monographs are currently online, says Schwartz, and the department plans to add more every few months.

For the past few years, MCP-Hahnemann has offered live, interactive video broadcasts of medical seminars, grand rounds and case presentations to a network of remote hospitals and medical centers. The broadcasts use voice-activated cameras at each participating hospital and involve moderated question and answer sessions with expert panels, notes Schwartz, and CME credit is either given by MCP-Hahnemann or by the remote sites.

Live, interactive clinical skills programs for CME credit have been developed by the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) which offers them at its annual meetings and makes them available to local ACP-ASIM chapters, as well as to health systems, medical schools, residency programs, and managed care companies for training purposes. Each program entails watching a live or videotaped session on a procedure, such as a skin biopsy, then practicing that procedure under expert supervision and receiving feedback, explains Patrick Alguire, M.D., director of Education and Career Development at ACP-ASIM.

Since the project was launched last year, programs on five topics have become available, including arthrocentisis, breast exams, pelvic exams, skin exams, and counseling for behavioral change. For the arthrocentisis program, participants insert a needle into a plastic model joint that provides mechanical feedback, while trained and certified "standardized patients" provide feedback for the physical and behavioral examinations, Alguire explains. Topics for future programs include sports medicine, musculoskeletal exams, neurological exams, ENT skills, ophthalmology skills, and interviewing challenging patients, he adds.

ACP-ASIM also offers Internet-based clinical problem-solving cases, developed by members of the College, which begin with a vignette of a patient’s history and clinical information, then ask the user to make a diagnosis or select a diagnostic strategy and plan a management approach, says Alguire. The program provides immediate feedback with rationales on the user’s choices and provides links to article abstracts, clinical photos, X-rays and other clinical aids for further information. Each case involves six to ten decision points, takes approximately 40 minutes and earns one CME Category 1 credit, according to Alguire. The program is in its 14th month and offers two cases each month.

Specialized companies such as application service providers offer nontraditional CME programming, either aggregating it from or developing it with medical institutions. Bisk Education, in conjunction with the University of South Florida, offers four online mini-certificate courses on topics related to the business of medicine: the business environment of health care, data-driven management, marketing and management of service quality, and managing people to develop teamwork, according to Sandy Levine, Bisk’s vice president of marketing. Each course earns 24 CME credits in Category 1.

Bisk’s instructional designers help the university’s business school faculty develop Power Point slides and streaming video to make content accessible online either through high-speed T1 Internet connections or with a CD-ROM that permits an AOL dialup, says Levine, making the program accessible from nearly any user’s computer. The programs also allow participants to communicate with each other or with faculty via online chat rooms and bulletin boards monitored by the university’s business faculty. Each course must be completed within two months and requires passing a multiple-choice exam that can be taken as many times as needed, Levine notes.

Bisk is working with University of South Florida physicians to expand the program into medical topics and plans to have available by July courses in the ethics of end-of-life care, and in managed care contracting, says Levine. Bisk is also interested in partnering with other medical schools to develop further programs.

Pittsburgh-based CECity builds online symposia for accredited CME content providers such as Pittsburgh Mercy Health System, according to Simone Karp, co-founder and vice president of CECity. Other content providers and accrediting organizations for the company include the University of Pittsburgh Cancer Institute, the Philadelphia-based Institute for Continuing Healthcare Education, and several other medical schools, health care associations and pharmaceutical manufacturers.

CECity does not develop or accredit its own content, but the company’s proprietary software application renders other providers’ CME programming into interactive, online audio and slide presentations of live events, streaming video, teleconferences and journal CME, each with post-tests that are automatically graded to receive CME credit, says Karp. Program topics include oncology, osteoporosis, HIV, depression and psychosis, she adds.

Philadelphia-based Current Communications Co., a division of Medical Broadcasting Company, was recently accredited by ACCME to sponsor its own CME programming and has a team of physician writers, artists, information architects and multimedia specialists to develop innovative CME activities, according to John DeMaio, M.D., Current’s vice president and senior strategy consultant.

The company is co-developing a video- and monograph-based CME project on the pathophysiology of asthma with a national asthma expert, scheduled for release in May, says DeMaio. Online CME programs that Current has developed in conjunction with other institutions, such as one on congestive heart failure, illustrate anatomical aspects of the condition using 3-D imaging and animation, as well as audio of heart and lung sounds. The programs present participants with diagnostic choices driving decision trees of case management strategies, DeMaio explains. Other case-based learning projects Current is considering include topics such as women’s health, psychiatric illness, and gastrointestinal health, he adds.

The Pennsylvania Medical Society (PMS) has an agreement with HealthStream, a company that aggregates CME programming content, which discounts online CME program costs when PMS members access HealthStream via the PMS website, according to Mary Barton, CME assistant at PMS. HealthStream aggregates 1,400 hours of online CME course content provided by various medical institutions, and the courses require users to view every page of every lesson and pass a multiple-choice exam, with the ability to review the lesson and retake the exam.

Integrating Education With Practice

In response to physicians who say that they seek more useful CME activities than those requiring "seat time," the AMA has been studying ways to allocate Category 1 CME credit to self-directed physician activities that have no formal CME provider, are documentable and in which learning occurs, according to Dennis K Wentz, M.D., director of the AMA’s Division of Continuing Physician Professional Development.

Since Jan. 2000, the AMA has accepted physician applications for Category 1 credit for activities it recognizes as educational and documentable, including publishing an article in a peer-reviewed journal as first or second author for up to 10 credits, passing a specialty board certification or recertification exam for up to 25 credits, earning a Masters of Public Health degree or an MBA with a focus in health for 25 credits, and teaching CME activities for two credits per each hour of teaching time up to ten total credits per year, says Wentz.

The AMA’s Council on Medical Education approved the first of several planned pilot programs to write rules by early 2003 on how to allocate CME credit for using the Internet as a search tool for health information at the point of need, and for participating in a peer review quality improvement/outcomes assessment activity.

For the first activity, the AMA is giving credit to physicians who access SKOLAR.com, an Internet-based program developed by Stanford University that allows physicians to type in descriptions of symptoms during an actual patient visit and search 40 parallel databases of articles that have been selected as the best in their field by Stanford physicians, Wentz explains. Criteria for credit allocation may include documentation of the information search and answering questions related to the information, he adds.

For quality improvement/outcomes assessment activities, says Wentz, credit allocation rules will need to be written for group-structured activities in hospital or HMO contexts which are not teacher-directed.

Taking CME credit perhaps furthest into the realm of clinical practice than other CME programs, the University of Pittsburgh has integrated its use of practice guidelines into the educational venue. Based on chart audits of Pitt’s employed physician practices, data on the management of diabetes, congestive heart failure, colorectal cancer screening, and osteoporosis is presented to each practice in a case-based, small group format, after which clinical interventions are tracked to see if appropriate changes have been made based on the specific needs of individual practices, according to Barnes. The needs assessment activity earns CME Category 1 credit on the basis of participation hours—for a maximum of ten credits per year—and is benchmarked to other physicians and regional hospitals in the UPMC Health System, as well as to other national norms, Barnes adds.

The practice-based CME activity provider also benefits from the program, as the medical director of Pitt’s medical practices learns about barriers to best practices, such as difficulties in scheduling a procedure or in securing health insurance payment, Barnes adds.