Continuing Medical Education: Where Have We Been?

Modern medical education in the US began a century ago with the publication of the Flexner report which condemned the "system" of the time for excessive commercialization, unstandardized curricula, and lack of efficacy for actual patient care. This document led to radical reforms and regulation of medical education, the end result of which is today's system.

Around the same time, practitioners began to make note of efforts to provide ongoing education. The first documented continuing medical education (CME) program was the "Blackburn Plan." Weekly one-hour sessions taught basic science and treatment techniques to general practitioners with the opportunity for questions and answers. Sounds a bit like current grand rounds to me - except without PowerPoint.  The first medical school to open a dedicated CME unit was the University of Michigan, and they were one of the original "regional centers" for coordinating CME programs in the 1930's. Others included Albany and Tufts. Regional medical schools and their teaching hospitals provided ongoing programs for the smaller hospitals and practitioners in their locale. The first recorded "center" for CME arose in 1936 at the University of Minnesota.

After World War II, new technologies made advances in CME delivery possible, including color television (1948), telephone conferences (1951), and two-way radio (1956). As technology provides new toys, CME takes advantage of them. How many webinars and other online "learning opportunities" happen everyday? Difficult to answer, but my google search produced 7,850,000 results for "CME online courses."

The American Medical Association (AMA) has long advocated CME via its Physician Recognition Award (PRA); the AMA/PRA Category 1 Credit(TM) is the coin of the realm for CME in the US, a currency established by the AMA in 1968. Even before this level of involvement, the AMA tracked CME in the US. In 1946, 47 medical schools offered 491 courses. By 1966, CME no longer belonged to medical schools but to sponsors, of which there were 252 offering more than 1600 courses. Over the next 10 years these numbers doubled again (with 554 sponsors offering 5,000 approved courses), and more than 9,000 offerings from more than 1,000 sponsors by the mid-1980s. Tracking down current numbers can be challenging, given the explosion of offerings available through various venues now.

The funding of CME also changed over time as providers have moved from schools to sponsors. Today direct commercial support provides 38% of the $2,184,353,716 in CME income taken in by nationally certified providers. Advertising and exhibits at activities provides another 13% of the total, according to the 2009 report of the Accreditation Council for Continuing Medical Education. This commercial support of CME raises concerns about conflict of interest and the nature of CME as a marketing activity. Even though efforts have been made to resolve these issues, the monetary support from drug and product manufacturers remains a concern.

Even with all the money and gizmos that go into today's CME, most programs remain similar to the "Blackburn" courses at the turn of the last century. Most states require some level of CME attendance for maintaining a medical license; however, the rationale behind CME choices and the efficacy of many programs remains unknown. In other words, we have no evidence that current CME improves physician knowledge, let alone patient outcomes! I suspect many physicians choose CME as much for convenience of the offering or the location of the course as for their educational interest and needs.

CME research can only be aided by the recent call for change from the Institute of Medicine of the National Academies. Redesigning Continuing Education in the Health Professions (released December 4, 2009) calls for more research into effective ongoing professional development examining practice improvement and patient outcomes as end-points. Its authors and others in the CME community feel the time may be right to form a national continuing education institute to coordinate such efforts and to shift funding from commercial sources.

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Image adapted from PhotoXpress.

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