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Title:
A descriptive study of the view from the top : perspectives of experts in continuing medical education
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English
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Baker, Martha
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University of South Florida
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Subjects / Keywords:
Adult education
Continuing professional development
Commercial support
Performance improvement
Accreditation
Dissertations, Academic -- Adult, Career & Higher Ed -- Masters -- USF   ( lcsh )
Genre:
non-fiction   ( marcgt )

Notes

Abstract:
ABSTRACT: This study describes and explains the perspectives of selected experts in continuing medical education (CME) and provides a glimpse at their lived experience. The theoretical frameworks are inclusive of constructivism and social constructivism reflecting the learning that takes place in medicine and that which occurs in the interview process. The voice of the researcher is heard through her professional role as a continuing medical education provider. The major elements of CME are identified as the role of accreditation and physician involvement in the design and delivery of CME; the primary influences as funding, physician involvement and accreditation; the significant issue is the expertise of CME providers; the future of CME is to be molded by the funding of CME, its providers and technology in continuing education venues. Performance improvement continuing medical education will continue to be the gold standard of accredited organizations. Implications for practice are many as the role of the CME provider changes to meet the expectations of the Accreditation Council for Continuing Medical Education, the Institute of Medicine and organizations such as the American Association of Medical Colleges and American Association of Colleges of Nursing. Future research studies could include the following: interviewing experts in similar work environments may provide more focused findings that would assist that particular segment of the profession and their respective institutions; a comparison of local and national providers may shed light on how similar or disparate they are in the design, delivery, measurement, and funding of CME; a prospective longitudinal study looking at the implementation and outcomes of the IOM initiative for conflict of interest in medicine, the IOM initiative for the redesign of continuing education in the health professions or interdisciplinary lifelong learning in the health professions as proposed by the AAMC and AACN; investigate the proposed Continuing Professional Development Institute in five to seven years to determine if it achieved the desired design and function, and finally, repeating this study with experts from the same categories in about ten years should reveal significant changes in continuing medical education as compared to the findings presented in the current study.
Thesis:
Dissertation (EDD)--University of South Florida, 2010.
Bibliography:
Includes bibliographical references.
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by Martha Baker.
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Title from PDF of title page.
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usfldc doi - E14-SFE0004604
usfldc handle - e14.4604
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A Descriptive Study of the View from the Top: Perspectives of Experts in Continuing Medical Education by Martha C. Baker A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Education Department of Adult, Career and Higher Education College of Education University of South Florida Major Professor: William H. Young, III, Ed .D Bill Blank Ph.D Rosemary Closson, Ph.D James Eison, Ph.D Valerie J. Janesick, Ph .D Date of Approval: April 15, 2010 Keywords: adult education continuing professional development, commercial support, performance improvement, accreditation Copyright 2010, Martha C Baker

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Dedication This project is dedica ted to my parents, John W. and Jane R. Baker, whose guidance, love and perseverance inspired me to pursue this terminal degree and to my brother, Scott W. Baker, who would have celebrated his birthday on the day of my final oral examination.

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Acknowledgem ents There are so many who deserve to be acknowledged by name as a result of their support, encouragement and conviction but the list would be too long However there are some who must be named. My research participants, who remain anonymous, are the fi rst to be acknowledged and thanked for their time and perspectives as experts My siblings, John and Anne have been patient listeners as I offered all too infrequent updates I appreciate my children Michael, Patrick, and Sean who studied alongside me, t olerated my use of the dining room table as an office, delayed vacations, and supported my efforts without question. My employer and direct management team are credited with urging me to get started, supporting a flexible work schedule when needed, and providing financial support through tuition reimbursement I recognize my friends across the country and at home who were patient when I put my social life on hold and who have simultaneously been enthusiastic and supportive To my USF colleagues and support group members, Anne Cloutier Linda Phillips and Ginger Phillips who studied with me, read my work, listened to my meanderings, questioned my theories and ideas, and watched the final project emerge. I am especially thankful for their companionship whethe r near or far, in person or across cyberspace. To Stephen Alexander who has been a tower of strength, the calm after my stormy days and a constant companion during the last phase of my doctoral studies Finally, I acknowledge and appreciate my major profes sor William Young III, EdD and committee members, Bill Blank, PhD, Rosemary Closson, PhD Jim Eison, PhD and Valerie J. Janesick, PhD without whom this would have never been possible Your expertise, contributions encouragement and passion have been in valuable.

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i Table of Contents List of Figures ......................................................................................................................v List of Tables ..................................................................................................................... vi Abstract ............................................................................................................................. vi i CHAPTER ONE INTRODUCTION ...............................................................................1 Background ..............................................................................................................2 Purpose of the Study ................................................................................................4 Research Questions ..................................................................................................5 Problem Statement ...................................................................................................5 Theoretical Framework ...........................................................................................5 Me thod .....................................................................................................................7 Definitions and Abbreviations .................................................................................8 CHAPTER TWO LITERATURE REVIEW ................................................................14 Adult Education in the United States .....................................................................14 Continuing Professional Education .......................................................................17 The Update Model .....................................................................................22 T he Competence Model ............................................................................24 The Performance Model ...........................................................................27 Adult Lear ning Theories and Practices .................................................................29 History of Medical Education ................................................................................32 Continuing Medical Education ..............................................................................37 Reform and Repositioning......................................................................................47 Recent Reform Recommendations ..........................................................................51 Research .................................................................................................................55 Constructivism .......................................................................................................57 Qualitative Research ..............................................................................................62 Summary ................................................................................................................64 CHAPTER THREE METHOD ......................................................................................66

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ii Purpose of the Study ..............................................................................................66 Research Questions ................................................................................................66 Problem Statement .................................................................................................66 Theor etical Framework .........................................................................................67 Method and Rationale ............................................................................................67 Document Review ...................................................................................................74 Role of Researcher .................................................................................................76 Ethical Issues .........................................................................................................80 Pilot Study ..............................................................................................................85 Interview Format ...................................................................................................87 Interview Questions ...............................................................................................87 Timeline and Estimated Costs ................................................................................87 Purposeful Sample .................................................................................................88 Informed Consent ...................................................................................................89 Methodological Assumptions .................................................................................90 Delimitations and Limitations ................................................................................90 Data Collection and Preservation .........................................................................91 Summary ................................................................................................................92 CHAPTER FOUR PRESENTATION OF THE DATA ...............................................93 Introduction............................................................................................................93 Participant Overview .............................................................................................93 The Interviews ........................................................................................................96 Research Questions ..............................................................................................100 Question One What are the Major Elements of CME? ......................................100 Accreditation ..........................................................................................101 Physician Involvement ............................................................................109 Summary of Themes Question One What are the Major Eleme nts of CME? ....114 Accreditation ...........................................................................................114 Physician Involvement ............................................................................115 Question Two What Influences CME? ...............................................................116 Funding ...................................................................................................116 Physician Involvement ............................................................................128 Accreditation ...........................................................................................136

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iii Summary of Them es Question Two What Influences CME? ...........................141 Funding ...................................................................................................141 Physician Involvement ............................................................................142 Accreditation ...........................................................................................142 Question Thr ee What are the Most Significant Issues in CME? .......................143 Summary of Theme What are the Most Significant Issues in CME? .................150 Providers ..................................................................................................150 Question Four What is the Future of CME? .....................................................151 Funding ...................................................................................................151 Providers ..................................................................................................159 Technol ogy ..............................................................................................166 Summary of Themes Question Four What is the Future of CME?..................170 Funding ...................................................................................................170 Providers ..................................................................................................170 Technology ..............................................................................................171 What havent I aske d? Or, is there anything else you would like to add at this time? ..............................................................................................171 P erformance I mprovement CME ...........................................................172 Providers ..................................................................................................176 Accreditation ...........................................................................................178 Summary of Themes What havent I asked? Or, is there anything else you would like to add at this time? .................................................................180 P erformance I mprovement CME ...........................................................180 Providers ..................................................................................................181 Accreditation ...........................................................................................181 Summary ..............................................................................................................181 CHAPTER FIVE DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS ...................................................................................183 Purpose of the Study ...........................................................................................183 Document Review ................................................................................................184 Theoretical Framewor k .......................................................................................185 Summary of Findings ...........................................................................................186 Question One What are the Major Elements of CME? .....................................186 Question Tw o What Influences CME? ...............................................................188

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iv Question Three What are the most Significant Issues in CME?........................194 Question Four What is the Future of CME? .....................................................195 Wh at havent I asked? Or, is there anything else you would like to add at this time? ..............................................................................................202 Conclusions ..........................................................................................................206 Implications for Practice ....................................................................................209 Funding ...................................................................................................210 Design and Delivery ................................................................................211 Continuing Professional Development ..................................................213 Adult Education ......................................................................................214 Recommendations for Future Research ...............................................................216 Summary ..............................................................................................................220 A ppendi c es .......................................................................................................................221 Appendix A: Sample Letter of Invitatio n via e mail ...........................................222 Appendix B: Informed Consent Form .................................................................223 Appendix C: Peer Reviewer Form .......................................................................224 Appendix D: Sample Confirmation Letter via e mail ..........................................225 Appendix E: Sample Member Check Form ........................................................226 Appendix F : Interview Questions ........................................................................227 Appendix G : Sample Interview Transcripts with E mbedded codes ....................228 Appendix H : Sample Field Notes ........................................................................234 Appendix I : Original Catego ries and Codes ........................................................237 Appendix J : Final Categories and Codes .............................................................238 References Cited .............................................................................................................239 About the Author .................................................................................................. End Page

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v List of Figures Figure 1. Framework for Clinical Assessment ......................................................41 Figure 2. Question On e What are the major elements of CME? .......................187 Figure 3. Question Two Wh at influences CME ? ..............................................189 Figure 4. Question Four What is the future of CME? .......................................197 Figure 5. What havent I asked? Or, is there anything else you would like to add at this time? ......................................................................................202 Figure 6. Performance Improvement CME .........................................................203

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vi Lis t of Tables Table 1 Particip ant Demographic and Interview Details ......................................94 Table 2 Participant Work Settings, Work Roles and Leadership Roles ................95

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vii A Descriptive Study of the View from the Top: Perspectives of Experts in Continuing Medical Education Martha C Baker ABSTRACT This study describes and explains the perspectives of selected experts in continuing medical education (CME) and provides a glimpse at their lived experience. The theoretical frameworks are inclusive of constructivism and social construc tivism reflecting the learning that takes place in medicine and that which occurs in the interview process. The voice of the researcher is heard through her professional role as a continuing medical education provider. The major elements of CME are ident ified as the role of accreditation and physician involvement in the design and delivery of CME ; the primary influences as funding, physicia n involvement and accreditation; the significant issue is the expertise of CME providers ; the future of CME is to be molded by the funding of CME, its providers and technology in continuing education venues. P erformance improvement continuing medical education will continue to be the gold standard of accredited organizations Implications for practice are many as the role of the CME provider changes to meet the expectation s of the A ccreditation C ouncil for Continuing M edical E ducation, the Institute of Medicine and organizations such as the American Association of Medical Colleges and American Association of Colleges of Nursing. Future r esearch studies could include the following: i nterviewing experts in similar work environments may provide more focused findings that would assist that particular segment of the profession

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viii and their respective institutions ; a comparison of local and national providers may shed light on how similar or disparate they are in the design, delivery, measurement, and funding of CME ; a prospective longitudinal study looking at the implementation and outcomes of the IOM initiative f or conflict of interest in medicine, the IOM initiative for the redesign of continuing education in the health professions or interdisciplinary lifelong learning in the health professions as proposed by the AAMC and AACN ; investigate the proposed Continui ng Professional Development Institute in five to seven years to determine if it achieved the desired design and function, and finally, r epeating this study with experts from the same categories in about ten years should reveal significant changes in contin uing medical education as compared to the findings presented in the current study.

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1 CHAPTER ONE INTRODUCTION C ontinuing medical education (CME) has existed since medicine became a pr ofession due to the need for practicing physicians to remain current i n the field of medicine. Through study, research, practice, and time the field of medicine has accelerated at times faster than some physicians can keep pace. In an effort to ensure the competence and performance of practicing physicians CM E has developed along two paths : the development of producing and delivery of CME activities and CME credit leading to certification, membership in specialty organizations and licensure (Davis & Loofbourrow, 2007, p. 142) M ost states have established rules and laws regarding physician licensure which include participation in continuing medical education. I n addition, many states have mandatory CME topics required for licensure and relicensure. Providers accredi ted by the Accreditation Council for Continuing Medical Education (ACCME) must provide CME acceptable to state licensing boards and the American Medical Association (AMA). These providers are accountable for following the guidelines and policies set in pla ce by the ACCME to maintain accreditation status. P hysician participants rely on the providers for educational activities that meet their needs and assist in maintaining and improving competency and performance. That improvement can ultimately enhance the health of their patients and, eventually the health of the general population.

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2 As a provider of CME, I have witnessed a variety of changes in the field of CME in terms of accreditation guidelines, commercial support, outcome measurement, certification of providers, reform and repositioning initiatives, and just in time CME on the Internet among others The current study is designed to learn about the perspectives of experts to understand their lived experience and further m y knowledge about the field. Background S everal reports and recommendations between 2000 and 2007 suggested a study of CME from the perspective of experts in the field The Institute of Medicine produced two reports To err is human: Buildi ng a safer health system (2000) and Crossing the quality chas m : A new health system for the 21st century (2001) that captured the attention of the Conjoint Committee on CME of the Council of Medical Specialty Societies (CMSS) and led them to examine the current state of affairs in CME and set the stage for comprehensive change. This examination produced the Reform and Repositioning Recommendations in 2005 (Reforming and repositioning continuing medical education, 2005) The Accreditation C ouncil for Graduate Medical Education (ACGME) developed core competencies for medical residents ( Accreditation C ouncil for G raduate M edical E ducation, 2008a) comparable to the competencies established by the American Board of Medical Specialties (ABMS) Maintenance of Certification programs ( American B oard of M edical S pecialties, 2009.) I n 2007, a group of professional continuing education leaders met to address continuing education in the health professions The final product was a m o nograph entitled Conti nuing Education in the Health Professions: Improving Healthcare through Lifelong Learning published in 2008. Representatives of medical schools, medical

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3 journals, profess ional and organizational associations, medical systems, databases and government program s comprised the conference participants presenters and researcher s ( Continuing education in the health professions: Improving heal thcare through lifelong learning 2008) Published in 2007, the Agency for Healthcare Research and Quality ( AHRQ) report on CME investigated the effectiveness of CME and provided suggestions for future research including the impact of simulation in impro ving clinical outcomes and measurement of effectiveness at multiple points of post investigation. The report recommended that a national research agenda should clearly define what constitutes CME and offer standardized approaches to describing CME interven tions, media techniques and exposure volumes based on a conceptual model of effective CME ( Marinopoulos, Dorman, Ratanawngsa, Wilson, Ashar, Magaziner et al., 2007) The impetus for the current research was the consensus that CME needed change, and that research to advance the science of CME was essential for the field to move forward For the purposes of this research, the researcher analyzed reports and documents and i nfused them with the interview data. During my eight year tenure in CME change has been dramatic. The pharmaceutical industry evolved from being the host for social events with tidbits of education to moving educational grants out of the marketing divisi on into the medical affairs division. Pharmaceutical representatives in both office and hospital settings facilitated CME in the past ; however, they are no longer all owed to discuss funding via commercial support with providers ..

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4 In addition to changes in the pharmaceutical industry, government oversight brought to light issues regarding funding and commercial support of CME. Finally, the accreditation body, ACCME, promulgated new standards for commercial support to guarantee independence and transparency and new standards for accreditation forcing providers to demonstrate that learners were actually learning and changing practice behaviors rather than just filling seats at a conference or other educational activity. New CME formats approved by the American Medical Association include education via the Internet and self assessment and process improvement in individual practice Process improvement participation in the hospital setting is also a form of CME for those who complete all the required components ( American M edical A ssociat ion, 2010) In addition, ACGME developed new competencies for graduate medical students ( Accreditation C ouncil for Gr aduate M edical E ducation 2008a ) coinciding with those expected during the Maintenance of Certification process with the American Board of Medical Specialties ( American B oard of M edical S pecialties, 2009.) As of 2009, CME providers can gain community recognition by passing a certification exam offere d by the National Commiss ion for Certification of CME Professionals, Inc. Becoming a Certified Continuing Medical Education Professional assures the providers/ practitioners are qualified and competent to coordinate and manage CME programs ( National Commission for Certification of CME Professionals 2009) Purpose of the Study The purpose of this study is to describe and explain the perspectives of selected participants on continuing medical education.

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5 Research Questions The research questions th at guided this study were as follows : 1. What are the major elements of CME ? 2. What influences CME? 3. What are the most significant issues in CME? 4. What is the future of CME? Problem Statement T ension exists rega rding the future of CME in the United State s The oretical Framework Constructivism guided this study because it is the theory that best fits my personality and understanding of how learning occurs and develops Since one must consider the impact of others in the construct of knowledge s ocial constructiv ism was also a factor Social constructivism places a strong emphasis on dialogue and interaction with others, and negotiating meaning or refining understanding by contrasting personal perspectives with others Learning, then, occurs as the learners change their views based on, or in response to, the views of others A ccording to Svinicki (2004), meaning lies in the collective understanding that we achieve as we experience the world together. Constructivist theory is very similar to social cognitive theory in its assertion that learning is an interaction between the learner, the environment, and the behavior to be learned. (p. 243) Since CME is the last phase of lifelong learning for physicians, it is important for providers to understand how physicians learn and in what settings. Constructivism can

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6 explain how learning occurs and guide teachers/instructors to the most effective instructional techniques which in turn, can apply to CME. Physicians learn by comparing outcomes, by discussing patients with their colleagues, by trying new techniques and combinations of medications and by noting the results for the future They also learn by listening to national and local opinion leaders, researchers, and their patients. Sometimes learning occurs during hands on workshops or on the battlefield Self reflection and reflective practice are other learning experiences In short, physicians develop and refine their skills by the constant construction of new knowledge. In her article The Role of Educational Theory in Continuing Medical Education: Has It Helped Us Mann (2004) noted constructivism asserts that learning is the process of constructing meaning and making sense of our experience, based on our past experience Constructivism has served to facilitate analy sis of the process of reflection and aided understanding of those opportunities in which individuals mutually develop their understanding of situations and build knowledge together It informs the understanding of learning from experience and reflective pr actice and highlights the fact that individuals build their knowledge in very different ways. That is not to say that individuals have their own view of what knowledge is; every group has a core of mutually agreed on knowledge. However, the differences in the way in which knowledge is constructed and acquired are important in our recognition of how learning occurs from experience in practice. ( p. S28)

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7 Constructivism and social constructivism relate both to the learning process often observed in continuing medical education and to the act of interviewing wherein the researcher and the participant dialogue and interact and negotiate meaning or refine understanding by contrasting personal perspectives. Constructivism is reviewed in greater detail in Chapter 2 and briefly discussed in Chapter 3. Method This qualitative research study describes the lived experience of select experts in CME. Data collection include d eight semistructured interview s with eight participants re searcher observations documented in field notes a document review and a reflective journal The data collected allow ed crystallization as described by Janesick (2000), into a final set of conclusions. Summary Chapter One introduced the broad concepts of the study including the background, purpose, the problem statement, r esearch questions, theoretical framework, and the qualitative research method. The following definitions and abbreviations were suited to the purposes of this study A review of the literature in Chapter Two includes a brief history of adult education, continuing professional education, the history of medical education the current state of affairs, and the history of CME, highlighting recent and varied initiatives for reform and reposi tioning in CME and recommended research found in CME literature.

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8 Definitions and Abbreviations Academic m edical c enter Also known as a teaching hospital, an academic medical center is where Americans turn for specialized surgeries, lifesaving care, and complex treatments. They are where medical knowledge continuously evolves and new cures and treatments are found. They are where critical community services, such as trauma and burn centers, always stand ready. They are the training ground for more than 100,000 new physicians and other health professionals each year. Teaching hospitals also are a vital part of America's safety net, providing care to millions of the nation's uninsured ( Association of American M edical C olle ges 2009. ) Accreditation Council for Continuing Medical Education (ACCME) The ACCME's m ission is the identification, development, and promotion of standards for quality continuing medical education (CME) utilized by physicians in their maintenance of co mpetence and incorporation of new knowledge to improve quality medical care for patients and their communities (ACCME, 2008) Accreditation Council for Graduate Medical Education (ACGME) R esponsible for the accreditation of post MD medical training progra ms within the United States. Accreditation is through a peer review ed process and is based on established standards and guidelines (ACGME, 2008b) Accreditation Council for Pharmacy Education (ACPE) T he national agency for the accreditation of professional degree programs in pharmacy and providers of continuing pharmacy education (ACPE, 2008)

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9 Accreditation A voluntary process of evaluation and review based on published standards, following a prescribed process, conduct ed by a nongovernmental agency o f peers ( ACGME G lossary of T erms 2007) Accredited CME The ACCME uses the term accredited CME to encompass the educational programs and educational activities of providers accredited within its system. The ACCME ho lds (state and ACCME) accredited providers accountable for all activities presented under the mark of the ACCME/SMS accreditation statement. Any requirements we promulgate are applicable to all continuing medical education activities presented by ACCME/S MS accredited providers. In turn, the ACCME stands accountable to the public, the physicians, the government, the ACCME member organizations and the organizations of medicine, in general, for the manner in which this accredited CME is conducted and present ed. The ACCME cannot be held accountable for all CME for which learners receive credit or all CME that is certified for credit but only for CME presented under the umbrella of an ACCME (or state medical society) accreditation statement (Accreditatio n Council for Continuing Medical Education, 2008b) Agency for Healthcare Research and Quality's (AHRQ ) AHRQs mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Information from AHRQ's research hel ps people make more informed decisions and improve the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research (Agency for Healthcare Research and Quality Mission and Budget, 2009).

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10 American Association for Adult and Continuing Education (AAACE ) AAACE is dedicated to the belief that lifelong learning contributes to human fulfillment and positive social change. We envision a more humane world made possible by the diverse practice of our members in helpi ng adults acquire the knowledge, skills and values needed to lead productive and satisfying lives ( American A ssociation for A dult and C ontinuing Ed ucation 2009) American Medical Association (AMA ) The American Medical Association helps doctors help patients by uniting physicians nationwide to work on the most important professional and public health issues AMA policy on issues in medicine and public health is decided through its democratic policy making process in the AMA House of Delegates The AMA's activities with for profit entities are directed by AMA guidelines for corporate relationships and its Internet products follow AMA guidelines for health and information Web sites ( American Medical Association, 2010) American Medical Association Physician Recognition Award ( AMA PRA Category 1 Credit(s)TM) The AMA Physician's Recognition Award (PRA)and the related credit system recognize physicians who demonstrate their commitment to staying current with advances in medicine by participating in certified continuing medical education (CME) activities (American Medical Association, 2006) Association of American Medical Colleges (AAMC ) The AAM C and the medical schools, teaching hospitals, academic and professional societies, faculty, residents, and students we represent are committed to improving the nation's health through medical education, research, and high quality patient care. We are dedi cated to the communities we serve, committed to advancing the public good, and steadfast in our

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11 desire to earn and keep the public's trust for the role we are privileged to play in our society ( Association of American M edical C olleges 2009 ) . Continuing Medical Education (CME ) CME consists of educational activities which serve to maintain, develop, or increase the knowledge, skills, professional performance and relationships that a physician used to provide services for patients, the public, or the profession. The content of CME is that body of knowledge and skills generally recognized and accepted by the profession as within the basic medical sciences, the discipline of clinical practice and the provision of health car e to the public ( Accreditation Council for Continuing Medical Education, 2008b). Medical Education and Communication Companies (MECCs) NAAMECC was founded in 2002 by four medical education professionals and their companies and has since grown exponenti ally. There are hundreds of medical education and communications companies (MECCs) in the United States and approximately 110 are accredited by the Accreditation Council for Continuing Medical Education (ACCME). As a result, MECCs play a crucial role in ed ucating thousands of medical professionals and patients each year, ultimately affecting millions. In the past, there has been no organized voice for MECCs. In the ever changing and complicated medical education and communications environment, NAAMECC funct ions as a representative and advocate of our industry. ( North American A ssociation of M edical Ed ucation and C ommunication C ompanies 2010) Continuing Physician Professional Development (CPPD ) Also known as, Continui ng Professional Development (CPD) CPPD or CPD is the term that describes the wider arena of skills and specialized education, including but not limited to cognitive

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12 knowledge that physicians employ in the delivery of patient care. Leadership, team manage ment, communication skills and systems based competency all provide examples of professional skills that improve the quality of care. CPPD asserts not just that physicians will continue learning new medical knowledge but also that they will learn how to ke ep learning (i.e., use of new electronic clinical resources to assist with patient care, continuous assessment of practice through performance improvement interventions, etc.). CPPD also refers to the division within the Medical Education Group at the AMA, which deals with CME/CPPD related issues ( American M edical A ssociation 2010) Pharmaceutical Research and Manufacturers of America ( PhRMA ) PhRMA represents the countrys leading pharmaceutical research and biotechnology companies, which are devoted to inventing medicines that allow patients to live longer, healthier, and more productive lives. PhRMA companies are leading the way in the search for new cures. PhRMA members alone invested an estimated $44.5 billion in 2007 in discovering and developing new medicines. Industry wide research and investment reached a record $58.8 billion in 2007. PhRMA's mission is to conduct effective advocacy for public policies that encourage discovery of important new medicines for patients by pharmaceutical/biotechnology research companies ( Pharmaceutical Research and Manufacturers of America, 2008). United States Food and Drug Administration (FDA ) The FDA is responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, our nations food supply, cosmetics, and products that emit radiation. The FDA is also responsible for advancing the public health by helping to speed innovations that make me dicines and foods more

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13 effective, safer, and more affordable; and helping the public get the accurate, science based information they need to use medicines and foods to improve their health (United States Food and Drug Admi nistration, 2010)

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14 CHAPTER TWO LITERATURE REVIEW The purpose of this study wa s to describe and explain the perspectives of selected participants on continuing medical education. The researcher compared t heir perspectives to the existing literature, se lect documents and personal experience as a CME professional. The literature review outline s a brief history of adult education, continuing professional education, the history of medical education and continuing medical education, a review of reform initiatives, suggested future research in CME and the authors theoretical framework concluding with an overview of qualitative research Adult Education in the United States The history of adult education is a rich resource that can help us understand our p ast and how we fit into the mosaic of the field Each of us has a responsibility to develop some understanding of our past so that we can avoid being controlled by it Often, the preparation or professional development of adult educators ignores or downplays the history of the field This is unfortunate because history can be an invaluable tool in the development of reflective practitioners and scholars. (Merriam & Brockett, 1997, pp.7475) Merriam and Brockett (1997) discuss ed five books that provided a comprehensive history of adult education, each covering similar topics but with individual interpretation s.

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15 Merriam and Brockett noted that Stubblefield and Keane (1994) wrote from the perspective of adult educators rather than historians in their 1994 book Adult Education in the American Experience. Stubblefield and Keane explain ed that a dult education in the United States and in Western Europe coincided with the expansion of democracy and the industrial revolution with the term adult education first used in England early in the nineteenth century Although there were a variety of other terms adult education became the preferred term around 1910. Stubblefield and Keane identified five major themes in the development of adult education. First, Americans value d education in adulthood and created multiple educational systems Second, minority groups such as women, immigrants, Native Americans, African Americans, farmers and industrial workers had limited opportunities for adult education, thus the y created alternative educational systems Third, new forms of education reflect ed a dynamic society and its change from an agricultural to an industrial to an information society For those in professions, education became a lifelong pursuit Fourth, creating new forms of adult education shaped individuals and society and was an agency for change. Fifth, adults use d existing information systems to bring them closer to the larger world of culture and knowledge (Stubblefield & Keane) In the 1920s the Carnegie Corporation charted the field via commissioned studies that highlighted the social significance of adult education These studies led to the organization in 1926 of the American Association for Adult Education (AAAE) which supported research studies, projects, conferences and publications The second book recommended by Merriam and Brockett Adult Education written by Lyman Bryson in 1936, was the f irst textbook on adult education. His definition of adult education was all

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16 activities with an educational purpose that are carried on the people engaged in the ordinary business of l ife ( cited in Stubblefield & Keane, 1994; Merriam & Brockett, 1997) Bryson regarded adult education as a voluntary activity characterized by the self direction of adult learners who were attempting to improve their personalities: personal improvement was the fundamental motive of individuals for learning, and liberal education wa s the term that best described this kind of education. From the perspective of the agencies providing adult education, their purposes ranged f ro m the remedial to the occupational to the relational to the liberal (education for the new leisure) to the polit ical The definition emphasized adult education as the provision of institutions, and the participation of individuals as motivated by the desire for self improvement. (Stubblefield & Keane, 1994, p. 3) The three other books written by early contributors who framed the history of adult education between 1944 and 1962, included historians James Truslow Adams ( Frontiers of American Culture 1944) C. Hartley Graham ( In Quest of Knowledge 1955) and professional adult educator Malcolm S. Knowles ( The Adult Education Movement in the United States 1962, revised 1977) These authors were followed by revisionists in the 1960s that attacked the traditional view of the history of education. Next, radical r evisionists expressed the ir concern about the glossing over of conflict and struggle in adult education while others wrote more inclusive histories of adult education that included gender, race and class perspectives and issues (Stubblefield & Keane, 1994)

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17 Later, Knowles (1980) presented his view that adult education ha d at least three meanings : the process of adults learning, the technical aspect of organized activities and a combination of the two into a movement or field of social practice. In this sense adult education brings together into a discrete social system all the individuals, institutions, and associations concerned with the education of adults and perceives them as working toward the common goals of improving the methods and materials of adult learning, extending the opportunities for adults to learn, and advancing the general level of our culture. (Knowles, 1980, p. 25) Merriam and B rockett (1997) offered the following definition of adult education: activities intentionally designed for the purpose of bringing about learning among those whose age, social roles, or self perception define them as adults (p. 8) They also point ed out t hat the modern era of adult education focuses on education and retraining programs to keep the United States competitive in a global market. Population trends, shifts from industrial to a service and information based economy and technological advances i nfluence d adult education now The related term, continuing education, combined with adult education in the 1990s resulted in the preferred term adult and continuing education (Merriam & Brockett, 1997) Conti nuing Professional Education Adult education provided the foundation for c ontinuing professional education (CPE). The works of Malcolm Knowles, Cy Houle, Phil Nowlen and others guide the field from theor y to program deve lopment.

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18 The ultimate aim of every advanced, subtle, and mature form of continuing education is to convey a complex attitude made up of readiness to use the best ideas and techniques of the moment but also to expect that they will be modified or replaced The major lesson of continui ng education is to expect the unexpected will continue to occur. (Houle, 1980, p. 75) Cervero (2001 ) reflected in his International Journal of Lifelong Education article entitled Continuing Professional Educa tion in T ransition, 19812000 that it had been assumed the pre professional training with a few refreshers now and then were sufficient to s ustain an effective professional practice. However, the first sign th at Continuing Professional Education (CPE) was the way to prepare professionals for the rapidly advancing research based knowledge, technology and social change was Dryers 1962 Journal of Medical Education publication entitled Lifetime Learning for Physicians: Principles, Practices and Proposals Th e use of continuing education as a basis for re licensure and recertification became widespread in the 1970s followed by the appearance of CPE as a distinct area of practice and study with many books and proposals on how to improve the conceptualization, organization and delivery of CPE the 1980s. The update model of CPE, which will be described later was predominate in the 1990s and, as will be addressed later, persists today Cervero noted the state of transition in continuing education as provider s experimented with various purposes forms and institutional locations While conduct ing this analysis of CPE from 19812000, Cervero identified five trends :

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19 1. t he amount of continuing education offered at the workplace dwarfs that offered by any other ty pe of provider, and probably all other providers combined, 2. a n increasing number of program mes are being offered in distance education formats by universities, professional associations and for profit providers, 3. t here are increasing collaborative arrangements among providers especially between universities and workplace 4. t he corporatization of continuing education has increased dramatically 5. and c ontinuing education is being used more frequently for to regulate professional practice. ( pp. 1924) Cervero the n discussed three fundamental issues, posed as questions, to be addressed in the building of systems of continuing education. 1. continuing education for what? The struggle between updating professionals knowledge versus improving professional practice 2. wh o benefits from continuing education ? The struggle between the learning agenda and the political and economic agendas of continuing education 3. who will provide continuing education? The struggle for turf verses collaborative relationships. (pp. 2528) Cer vero states that workplace, professional association, university and government leaders needed to consider these issues as they further developed systems of CPE and c oncluded with the following.

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20 This process will be marked by fundamental struggles over the educational agenda and the competing interests of the educational agenda and the politicaleconomic agendas of the multiple stakeholders for continuing education A s a political process, then, it is crucial that all of the stakeholders participate in a s ubstantive way on negotiating these agendas for continuing education. F or the immediate and long term negotiation of these struggles will define whether continuing education can make a demonstrable impact on the quality of professional practice. (pp. 2829) One area of continuing medical education that is politically driven is mandatory education for the purpose of re l icensure. Florida, for example, requires two CME hours of prevention of medical errors for each licensure renewal and two CME hours of domestic violence every other renewal. A total of 40 CME hours are required for each renewal. My first research project revolved around the why of mandatory CME. Typically it is determined by the state legislature and may have nothing to do with public health concerns or challenges facing local physicians Young (1998) noted that mandatory education was often debated and criticized, but he sought to find the positive aspects and its impact on continuin g professional education. With a group of his students, he had also looked at the why various professions embraced mandatory continuing professional education (MCPE). Via a modified nominal group process they studie d higher education institutions professional associations employers, government agencies, society and individual practitioners to determine why they supported M CPE Across those six domains, the common reasons were litigation avoidance improved revenue and maintenance of uniform standards of practice. Of course, some reasons

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21 identified wer e unique to each group. In reviewing MCPE, Young like Cervero (2001), stated that it began in the early 1970s as a result of political and social forces, which continued through the time of his research, rather than educational rationales. It is much easier to legislate classroom activities than it is to restrict or rescind licenses to practice. It appears next to impossible for professions to creat e standar ds of practice that go beyond minimal levels of competence. MCPE will go on being used as a me thod to promote positive public image by informing the public that a ll members of a profession are engaged in educational activity that helps maintain, expand, and extend competence and performance. (p. 135) MCPE has however been used effectively to address incompetent impaired or otherwise unable to perform professionals who do not meet expectation s in standards or level of practice. T his is remedial education which is especially effective wh e n paired with lifestyle changes. It has also been an insul ator for professional s against public scrutiny and criticism. In summary, the dinosaur, the multimillion dollar mandatory continuing professional education enterprise, is al i ve and well and increasing in importance, sophistication and power (p. 138) T he alternative presented by Young was to take the CPE p ersonnel from the budget page to the content presentation page ( p. 138139) Diverting room rental, meals, faculty expenses, etc. to the development of appropriate learning activities would lead to immediate changes in curriculum and would take place with the focus on the learner rather than the sponsor. He said Put it together, your professional customers will love it (p. 139) Young discovered and documented an improved al ternative to how MCPE

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22 a nd CPE in general should be provided. The field of CME is still struggling to reach this goal as will be seen in the results of the current study. The theories of c ontinuing professional education for health professionals incorporate three existing program development models update, compete nce and performance, addressed below. The Update Model Knowles (1980) described the difference between pedagogy, the art and science of teaching children, and andragogy, the art and science of helping adults learn. The transmittal of knowledge and ski lls in a pedagogical model does not always meet the needs of adult learners who are not dependent but self directed, who use previous experience as a resource for further learning, and whose readiness to learn associates with their social role. Adults appl y new knowledge immediately making their orientation to learning performance centered as opposed to subject centered and their preference for participatory experiential techniques (Knowles, 1980) CME utilizes both approaches depending on the model for program development. One of the models typically used in continuing healthcare professional education is the update model which deliver s knowledge updates gleaned from scientific research to professionals in a s hort course didactic setting The update model keeps professional practice and skill base in line with the latest research, new technology, or new legislation. Its popularity is likely due to the continuing education providers lack of familiarity with adu lt education concepts and innovative practices but its objective unifies the field of continuing professional education (Nowlen, 1988) Nowlen noted that professional associations and universities we re more intereste d in the impact of new information, legislation, conceptual frameworks, skills, procedures

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23 and technology. However, the Accreditation Council for Continuing Medical Education was less concerned with updating physicians than with requiring improved compete ncies and outcomes in terms of changes in practice behavior and, ultimately in improved patient outcomes. Mott (2000) state d that this model fails to account for the subjective, social and negotiated aspects of knowledge in professional practices that a re complex, indeterminate, and value laden (p. 25) If professionals adhered only to this model, they could not keep up with the knowledge base required for professional practice. Cervero (2000) identifie d the bottom line of continuing education as the improvement of professional group practice, but note d the update model was unsuccessful in improving performance in these groups (Cervero, 2000) Based on their review Davis, O'Brien, Freemantle., Wolf, Mazmanian, & Taylor Vaisey (1999) questioned how th e model could persist considering the consensus that didactic programs did not change practice performance when paired with knowledge about adult, self directed learnin g They noted that activities based on the update model wer e easy to create and deliver, commercial support wa s relatively easy to acquire, and providers relied on the undergraduate medical education model ( Davis et al. ) In guiding physicians in the selection of appropriate CME activities, Davidoff (1997) shared a dim view of the update model. Although it met the hour requirements for licensing or credentialing, it c ould be expensive for the physician participant and offer ed little in terms of competency, improved practice performance or health outcomes. He referenced Nowlen, as have other scholars, describing the informational update as professionals sitting in audiovisual twilight, making never to be read notes at rows of

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24 narrow tables covered with green baize and appointed with fat binders and sweating pictures of ice water ( cited in Davidoff, 1997, p. S15) Cervero (2001) used the same quote adding it would be amusing if the subject matter w ere not so important. He characterized continuing education in the late 1990s as devoted mainly to updating practitioners about the newest developments, which are transmitted in a didactic fashion and offered by a pluralisti c group of providers (workplaces, for profits, associations and universities) that do not work toge ther in any coordinated fashion ( p.18). In researching medical Grand Rounds (a recurring traditional teaching format for physician, medical residents and me dical student audiences), Herbert and Wright (2003) also questioned why they persist. They noted the format created inertia where education was not the only objective; lectures we re easy to deliver and efficient in disseminating information to large groups versus small group sessions that we re less practical but promote d adult learning The Competence Model Assessing, creating, maintaining, reviewing, enhancing, or assuring competence is frequently not only the goal that providers and consumers have in mind, but also a goal that immediately reveals the limitations of the update paradigm (Nowlen, 1988, p. 31) Competence, as described by Nowlen, is sufficient aptitude, skill, strength, judgment, or knowledge without noticeable weakness or demerit ( p. 31 ) Professional organizations define standards of competence and design educational programming to enhance them (Nowlen) Mott (2000) illustrate d this by describing the curricula based on competencies require d in specific work settings and enhanced through relevant exercises, role playing, c ase studies and problem solving (p. 25) Knowles (1980) outlined four ways to develop models of required competence throug h research, the judgments of experts, task analysis, and group participation. He

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25 added, Since the conditions and requirements for performing most roles are constantly changing it is important that competency models be co ntinuously reviewed and updated (p 229) According to Heffron (2007), competency acquisition of physicians can be described from the trainee level to a practicing physician level as occurring over time or as an identifiable threshold where one either has it or doesnt have it continue d competence becomes an evolving life long process towards expertise (p. 215) Heffron describes the six general competencies for residents and fellows developed by the Accreditation Council for Graduate Medical Education (ACGME) and the same ones for practicing physicians by the American Board of Medical Specialties (ABMS) Heffron also reviewed the focus of certifying boards on self audit s and competency based education In order to build on these, the Accreditation Council for Continuing Medical Education (ACCME) Task Force on Competency and the Continuum advised that common definitions and terms be established so that these competencies c ould be utilized through the continuum (Heffron 2007) Harrison and Mitchell (2006) recommend ed using a job competence/functional analysis model so that competence is defined in terms of performance outcomes and not the qualities someone should possess (p. 169) In medical education the aim of competencebased education is to make links between education and practice with education tailored to the requirements of practice or learner Current CME providers must design programs that link to these competencies and create outcome measures to show that educational activitie s impact competence, performance, or patient outcomes. The Kaiser Permanente system implemented Havens

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26 model (based on the work of Donald Kirkpatrick in 1994 and 1996, which was the outcome measure model recommended for CME providers. In the model, the levels of outcome, from least to most desirable (Level 1 Level 5), are 1) participant satisfaction ; 2) change in knowledge, attitudes or skills or intent to change ; 3) self reported behavior change; and 4) objectively measured change in practice and objecti vely measured change in treatment outcomes or health status. Measuring the first two levels could take place immediately after an educational intervention ; however, the last two m ight require significant time to elapse before identifying a change, thus making them more difficult to measure (Haven, Bellman, Jayachandran, & Waters, 2005) Currier (2007) add ed that the last two we re also expensive to measure using traditional paper charts However, the increased use of electronic medical records would make the identification and quantification of improvements quick and easy The most serious flaw in the competence approach is its implicit assumption that performance is entirely an individual affair that leads the model logi cally, if erroneously, to an exclusive focus on the individual Even in the methods that are sensitive to the organizational context of business and professional activity, it is the individual and his or her individual competence that is at the center of i nquiry. (Nowlen 1988, p. 60) An important factor absent in this model involved situations where a practitioner m ight be competent, but for a variety of reasons such as marital conflict, illness, caring for aging parents, among others might demonstrate impaired performance for short or long periods of time In addition, impaired or enhanced performance could be the result

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27 of organizational influences such as peers, supervisors, and systems. Intervention at an individual level m ight be required to return performance to the previous level Organizations, then, designed continuing education programs to boost individual and organizational performance When performance critical learning objectives drive the design and selection of continuing education experie nces, the field will have progressed from updates, through the competence model, to a performance model (Nowlen, 1988, p. 62) The Performance Model Assessment of performance in the areas of knowledge, understanding and insight, skills, attitudes interests and values require different assessment procedures. The purpose we are concerned with here is to help individual adults look objectively at their present level of performance in a relatively small sample of behaviors that are important to them at a given time in their development to determine where they want to invest energy in improving their performance in the light of their models of desired behaviorsThe final step in the self diagnostic process is for individuals to assess the gaps that ex ist between their models of desired behaviors and their present level of performance. (Knowles, 1980 p. 230) P erformance can be viewed as a double helix composed to two interactive, matched or mismatched strands cultural and individual. Individuals in va rious cultural structures influence other individual performance as well as the performance of the group or organization. The continuing education performance model could be a type of triage system where both the individual and the organization employ gui ded self assessment to

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28 produce learning and development agendas The product for providers could be referral to their programs and performance related assessment data re measured to ascertain performance improvement. When moving to a performance model, programs w ould be more varied, use different resources, and extend constituencies to include organizations as well as individuals (Nowlen, 1988) Education programs within the performance model assess the needs of the professionals and the system in which they work. They are more difficult to develop and harder for practitioners to locate, but are potentially the most e ffective of educational approaches. If performance mode education sounds familiar, it is because it shares many of the elements of continuous quality improvement, the increasingly powerful approach to managing messes that has evolved outside, and in parallel with, continuing education over the past several decades (Davidoff, 2007, p. S16) Mott (2000) state d the model asks, and therefore challenges continuing professional education to answer, What is the profession all about ? (p. 25) The literatur e reviewed indicated that appropriate educational interventions, or combinations thereof, could be effective in changing physician practice and performance and, in some cases, health outcomes. Melnick (2004) discussed physician performance and the challeng es for CME and continuing professional development He recommend ed that programs be based on needs within a competency framework, focus on behavior change and knowledge acquisition, and integrate assessment to determine baselines and monitoring for behavior change, thereby aggregating data. He expect ed that licensure and

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29 certification would drive programming and anticipated desirable changes in behavior would be evident if providers implement these steps. Rouse (2004) concur red that the medical literature demonstrates that continuing education c ould be effective but are not usually curricular in nature, do not optimally address all required competencies, and are not always successful in affecting change in practice behaviors (p. 2071) However, using mult iple methods and participatory learning activities could produce sustainable learning and practice change when efforts we re self directed, based on identified needs, are relevant to practice, interactive and ongoing, have defined outcomes, and can be reinf orced through practice Adult Learning Theories and Practices A dult education forms the basis for continuing professional education, and as such providers rely on learning theories and practices to develop appropriate programs Felch and Scanlon (1997) noted new developments in CME that included an influx of nonphysicians such as experts in adult education, computer science, quality assurance, communications and continuous quality improvement as well as a shift from focus ing on the educator and the teaching process to the learner and the learning process. CME changed to being self directed and related to problem solving The update model is designed to help professionals keep abreast of whatever is new. As noted, the didactic nature of the update model is pedagogical and reflects undergraduate medical education. L earner s must reflect on their practice and be self directed to ascertain updates critical to their practice and select them accordingly. Competence based programming also involves reflec tive practice and self direction to determine what areas of practice require bolstering Because credentialing

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30 and certifying boards pre determine some of the areas, many professionals might simply select those areas for study. Remaining competent requir es cognitive development Eva (2003) present ed four theories to explain that the aging process and age induced cognitive changes could affect clinical competencies He report ed the work by the Physician Review and Enhancement Programme (PREP) point ed to in creasing age as one of the strongest predictors of poor clinical performance. Certain kinds of skills which require identification, were more likely to decline than were others Another factor in aging was whether individuals we re intuitively aware of cog nitive decline and whether they consequently, reduced their practice or narrow ed its scope These implications need to consideration when planning continuing education and ways in which to maintain competence. The performance model and a new model described later utilize d adult education theories in program development and employ ed a variety of strategies to make an impact on individual practice change and organizational performance The theories incorporate d andragogy, reflective practice, self di rected learning, cognitive development, knowledge translation, interprofessional education, and transformative learning Educational interventions c ould be practicebased, problem based, evidence based or guideline driven and delivered in a variety of val uable formats (Eva) Mann (2004) discussed the role of educational theory in CME and questioned how it has helped. In addressing the ways in which practice and theory inform each other, she review ed seven approaches : behaviorist, cognitivist, humanist, social learning, constructivist sociocultural, and situational

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31 1. Examples of practice in the behaviorist approach include systematic design of instruction, behavioral objectives, competency based education, skills train ing and feedback 2. The cognitive orientation in practice is problem solving wherein the basis of physician competence is the ability to frame and solve problems in a variety of circumstances 3. According to Mann, [S] elf directed learning, reflective practice and critical reflection, experiential learning, transformative learning and adult learning theory all have their roots i n the humanistic orientation (p. S26) 4. Social learning theories incorporate behavioral and cognitive theories and focus on learni ng interaction with others and the environment. The use of role models and observation, educational influentials or opinion leaders typifies this theory in practice. The goal of this approach in medicine is practice change. 5. Constructivism in practice inc ludes learning from experience through the process of reflection 6. S ociocultural learning an emerging theory reveals that knowledge exists not only within the individual but also in the community 7. Situated learning in medicine is an apprenticeship where in students move from the periphery of the community toward the center a theory, which furthered the notion of communities of practice Mann concluded by suggesting the need for more theory based research Medical education and CME incorporate each of the models depending on the need of the target audience. Graduate medical education initially employs didactic approaches and

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32 gradually moves students into the perfor mancebased model. In order to understand the genes is of each model, it is necessary to review the history of medical education. History of Medical Education The American Medical Association (AMA) created the Council on Medical Education in 1904 to promote the restructuring of educational programs, recomm end standardized entry requirements for medical school promote a curriculum with two years of laboratory science training and two years of clinical rotations in a teaching hospital. The AMA C ouncil asked the Carnegie Foundation for the Advancement of Teac hing to help initiate the reform. (Beck, 2004) In 1905, the Carnegie Foundation was entrusted with an endowment created to benefit teachers, colleges, and universities in the United States Canada and Newfoundland. F oundation president, Henry Pritchett selected Abraham Flexner, a schoolmaster and educational theorist to study and report on medical schools in 1908. His report, Medical Education in the United States and Canada A Report to the Carnegie Foundation for t he Advancement of Teaching, was published in 1910. Flexner studied undergraduate and graduate medical education by visiting 150 medical schools in the United States and Canada, gathering information on facilities, resources, and methods of instruction The American Medical Association, the Association of American Medical Colleges and independent observers confirmed the information in the report, which included all sections of medical schools As Pritchett stated in the volumes introduction, It is clear that so long as a man is to practice medicine, the public is equally concerned in his right preparation for that profession, whatever he call himself, allopath, homeopath, eclectic, osteopath, or whatnot It is

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33 equally clear that he should be grounded in the fundamental sciences upon which medicine rests, whether he practices under one name or another. (Flexner, 1910, p. viii) Flexner described the history of medical education in the United States as wel l as its status at the time of his study He discussed the development of commercial medical schools and recommended moving them to university settings He also suggested more stringent admission criteria Finally, he provided detailed descriptions of each medical school he visited. One of the major concerns was the commercialization of medical education resulting in poorly trained physicians Other findings were as follows: 1. An overabundance of uneducated and ill trained practitioners produced over the past 25 years 2. T oo many commercial schools attract ed those employed in an industr y that produced poorly trained physicians 3. Because the didactic method was the primary mode of learning, it was profitable to run a medical school until the need for modern tec hnical laboratories and hands on training were recognized 4. Hospitals under educational control were necessary for medical school s and advanced teaching in a hospital was beneficial Flexner suggested having a smaller num ber of medical schools that were bet ter equipped and administere d, producing fewer practitioners who were well educated and trained. Universities with medical schools should take responsibility for the professional school and provide support (Flexner, 1910)

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34 Beck (2004) note d that Flexners unique contribution was to promote educational reform as a public health measure (p. 2140) along with promotion of the university based medical school model including laboratory and hospital based research That plan reached fruition in the 1930s, coinciding with the demise of the proprietary schools The University of Medicine and Dentistry of New Jersey commemorated the seventy fifth anniversary of Flexners report with a meeting of invited speakers in November 1985. In the forward to the published proceedings of that meeting Stanley Bergen, Jr. described the reason for the conference The essay, entitled Flexner: 75 Years Later : A Current Commentary on Medical Education noted it was an opportune time to recall the critical spirit of its findings and the reforms associated with them, to evaluate the issues and problems confronting present day medical education, and, through these linkages, project the future of medical edu cation and professional medical practice We sought insight into the changing role and responsibility of the physician. Equally important to us was a judgment about the impact upon medical education of the social and behavioral science disciplines and the ties to the humanities to technology in medicine. (Vevier, 1987, pp. vii viii) Despite efforts to improve medical education in the United States since Flexners seminal work, there was still a need fo r reform For example, Arky (2006) delivered the 115th Shattuck Lecture for the 2005 Annual Meeting of the Massachusetts Medical Society entitled The Family Business To Educate . He offered a brief summary of the

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35 Flexner r eport noting that the recommen dations implemented in the 30 years following the report brought the standard of the medical schools in the United States and Canada up to and then beyond, those in Europe Arky spent four decades observing the consequences of Flexners work, which led to improvements in undergraduate medical education, the goal of which wa s to ensure that students can be transformed into the most effective deliverers o f patient care that is possible (p. 1925) However, he was concerned about the level of teaching in medicine and compared the triple threat football player who could run, pass and punt, to the triple th reat medical professional who could be a physician, researcher, and teacher He observed there were few triple threat physicians remaining because teachin g as a medical specialty was not valued and most teachers had to supplement their income with clinical work or research. In terms of continuing medical education, the time allotted for a practicing physician to read and reflect was limited plus the concep t of just in time learning via the I nternet or through electronic medical records was still under development Unfortunately, the findings he reported indicated inappropriate treatments given 50% of the time during general practitioner visits That, combined with the extent of commercial support in CME, was enough for him to suggest a restructuring of CME In truth, the analogy between the state of undergraduate medical education in 1905 and the state of continuing medical education 100 years later is stri king Clearly we are in dire need of another Flexner or Carnegie (Arky, 2006, p. 1926) Whitcomb (2007), Editor of Academic Medicine, also recommended medical education reform and suggested a new Flexner r eport in his January 2007 editorial. He reflected on a series on contemporary issues in medical education published by the New

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36 England Journal of Medicine and applauded their commitment to discuss current issues and needed reform. His concern was that professional organizations controlling a spects of medical education failed to change policies and procedures that would improve physician education He suggested establishing a commission to study and report on the state of medical education, as did Flexne r, with a special focus on how well it served patient interests In 2008, the AMA realized that, in some respects, the process of training physicians ha d not kept up with the times To help address this need, the AMA is working to strengthen the medical education and training system across the continuum, from premedical preparation and medical school admission through continuing phy sician professional development (p.1) Guided by the Initiative to Transform Medical Education, the association identified gaps in physician education and the intersection with modern health care systems At the time of the current study, the last step, implementation of recommendations, wa s underway initially focusing on the learning environment to ensure it support ed the dev elopment of appropriate attitudes, behaviors, values, knowledge and skills Other focus areas included the admission process, physician lifelong learning, and physician re entry with 2010 targeted for completion as a celebration of the 100th an niversary o f the Flexner report (Makeover under way in medical education 2008) Subsequent to undergraduate medical education, students proceed to graduate medical education where they complete internships and residencies in a specific area of medicine. Some receive fellowships for further specialization All practicing physicians begin a lifelong learning process coined continuing medical education or continuing

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37 physician professional development which is, of course, t he longes t phase of a physician s education. Since it include s requirements for licensure, maintenance of certification and credentialing, continuing education is a popular topic of discussion among physician learners faculty and academics as well as in medical s ocieties and associations. Continuing Medical Education Public medical lectures gained popularity in the mid 1700s with the smallpox epidemic and absence of medical schools. These lectures supplement ed the apprenticeship of medical practi tioners as a form of continuing professional education, promoted general cultural development or simply provided entertainment Since the colonial governments lacked resources to meet the educational need s of the public, another educational venue was voluntary associations that offered libraries, societies and institutions For example, the founding of the Boston Public Library in 1673 was a due to a donation of books from an individual collection, and the Boston Medical Society provided continuing professional education t o early practitioners. The society published articles and held meetings to promote professional interests and the science of medicine in 1735. The Massachusetts Medical Society began in 1781, followed by a library in 1782, and the publication of Medical Co mmunications These organizations and their outreach efforts benefited a small number of individuals outside of the profession. However, they la id a foundat ion for more popular agencies and informal education that eventually served everyone (Stubblefield & Keane, 1994) Continuing education or self education of physicians most likely existed since the beginning of the profession; however, it was not until the early 1900s that it became

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38 formalized (Davis & Loofbourrow, 2007; Rosof & Felch, 1992) Interest in CME categorized by Uhl was in four stages : 1) Sir William Oslers identification in 1900 that lifelong study would be necessary for clinici ans to maintain their competence ; 2) the 1930s postgraduate study courses with content developed to meet the needs of individual practitioners ; 3) the post Worl d War II explosion in medical science and specialization that made continuing education imperati ve ; and 4) the influence of educators in the 1960s that applied the principles of adult learning to the f ield of postgraduate education ( Uhl, 1992) George Miller, MD, then the Director of Research in Medical Educatio n at the University of Illinois College of Medicine, presented to the section of CME at the 77th Meeting of the A ssociation of A merican M edical Colleges in 1966. His presentation entitled CE for What? was published in the Journal of Medical Education t he following year. The answer to that question was to improve the quality of patient care He then asks, what care needs improvement ? (p. 320) He note d that physicians were flooded with information and CME educators seized any programmed instructio n based on categorical content which failed to change substantially physician behavior. Miller called for a different education evidencebased model based on how adults learn (student centered) rather than teach er centered He coined it the Process Mode l which involved the learners in problem identification and seeking ways to solve them thereby identifying their own learning needs and selecting their preferred l e arning experience. The ultimate objective is lead ing practitioners to a study of what they do, to an identification of their own educational deficits, to the establishment of realistic priorities for their own educational programs (p.323) T o accomplish this end, Miller suggested

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39 delineating the health need of the populations served and the n studying hospital data in order to improve patient health. the method provided a start in systematic definition of the individual and social problems physician encounter in the patient population with which they dea l (p. 323) Physicians then need t o be involved in resource identification and solution implementation to solve the problem or conduct research problems that stil l need to be solve d. He also encouraged physicians to be involved in an analysis of the exten t to which they use themselves a nd the available resources to meet the needs that have been identified ( p. 324) His concern was that content oriented educators would not be able to produce process oriented continuing education programs without intervention via faculty development. Th is approach is now identified as process improvement CME When I inquired of William H. Young, III, EdD why the field did not pick up on this model early on he stated that Miller and his associates were way ahead of their time (Personal communication, May 12, 2010) In 1986, Miller presented at the First International Conference on Continuing Medical Education and the presentation in full was published in the J ournal of the American Medical Association (J AMA) the following year. He reiterated his earl ier observation that CME did not meet the needs of the learners but rather was content oriented in an update format. H e was also concerned, as we are now, about the role of commercial support in CME and that biomedical research was pushing the CME agen da In America, at least, it is big business and that commercial flavor is being sensed in an ever widening geographic area. In most of the world, CME is content oriented; everywhere, it is teacher dominated. On the other hand, it is not continuing but episodic; it is rarely education as much as instruction With few

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40 notable exceptions it is not process oriented, and i t does not often address the question of whether specific behavioral learning objectives have been achieved But if CME, as well as basic medical schooling, is to contribute more to effectively improving health care, then a very different program mode is surely called for. (p. 1352, 1354 ) Twenty years had passed since Miller introduced his concept of the process oriented model and he was be ginning to notice problem based or com pe tency oriented curriculum development H e encouraged approach ing CME with a fresh view and a focus on efforts rather than f orm ( 1987) Three years later, Miller was invited to address the use of standardized pati ents as a method to assess practicing physicians Acknowledging that no single assessment method could provide an adequate amount of data for a complete review of a physicians delivery of professional servi c es he began by presenting the now well known Miller P yramid as represented in Figure 1.

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41 Does ( Action ) Shows How (Performance) Knows How (Competence) Knows (Knowledge) Adapted from Miller (1990 ) Figure 1.Framework for Clinical Assessment The learner can be at one of four phases in the process of clinical assessment ranging from novice to expert The first is that the learner knows progressing to knows how, shows how and finally does representing knowledge, competence, performance and action respectively. The common measurement of knowledge is objective test ing wh ich is important but would yield an incomplete appra isal. Competence is the skill of acquiring knowledge, analyz ing and interpret ing data and translat ing findings into a diagnostic or management plan demonstrating functional adequacy. M iller described measuring performance as a challenge Typically perfo rmance was measured by limited direct observation an d limited sample s of clinical proble ms so the final measure was the accuracy of the diagnosis and patient management rather than the process used to reach the conclusion. The action component, what a phy sician actually does in practice, is the most difficult to mea sure accurately and reliably Miller stated the most effective

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42 substitute for reality was simulation of a clinical encounter with a standardized patient Further he discussed the difficulty in determining the component s of professional behavior to be assess ed an d the best method for scoring such an encounter He encouraged broader adoption of standardized patients as the most effective method to measure action (Miller, 1990) Pijanowski (1998) called for transition in CME because despite a significant amount of research in the field in the previous decade which suggested way s to improve CME current practices still looked like traditional CME. She called for a modification in CME to better f acilitate change in physician practices an d ultimately impact patient care outcomes. By training physician s how to learn they could better utilize CME resources to meet personal lifelong learning needs and gain more meaning from formal learning activities Pijanowski presented selected emerging issues for health care, practicing physicians and accreditation that were challenging business as usual CME The establishment of a nationwide managed care environment will have many implications for CME; educa tional activities will become learner centered and will respond to individual learning needs. Quality management principles will link CME with measureable outcomes of patient care (p. 152) The challenges here are changing demographics of practi ti oners and patients, population expansion, the variety of health conditions continues to expand, social consideration, and the implementation of continuous quality improvement plans in hospitals CME providers have a difficult time providing just in time training and physicians str u gg l e with remaining current as the result of the expediential development of pharmaceutical products, medical technology,

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43 information technology as well as protocols and procedures Physician s also had to worry about managed care and recertification to prove competency. As a result of integrated h e al t h systems she expected tha t CME providers would be able to link interventions with patient health status and ultimately health care outcomes to determine the impact of CME. Pijanowski briefly discussed the 1995 emergence of the new ACCME policies and procedures moving CME from a process orientation to a focus on outcomes. The goal was to further develop CME programs that would promote change in physician practice whi ch in turn would positively influence the health status of patients. In order to address all of these issues, Pijanowski outlined a new paradigm for the 21st century noting that CME needed to c ommence a dramatic transformation. Central to this model was a learner centered orientation inclusive of identification of learning needs, learning style preferences and the evaluation of the experiences. This can be individualized to assist physicians pursue life long learning goals and maintain, or better yet, enhance competency. Ideally, CME interventions would be presented with attention to frequency, intensity and timing utilization of multiple resources as well as the data and feedback gathered f rom an individual practice group or system to effect a change in physician perf ormance. Additionally Schns reflective practice model based on ones ability to learn from experience can also change behavior and performance. In terms of CME providers, it was recommended that these educators become facilitators of learning to dire ct the transfer of new knowledge into practice. The didactic model was not expected to disappear but would be used appropriately long with instructional methodologies such as journal clubs, role playing, academic detailing, etc. Clearly, then, providers would need to a c quire a more sophisticated skill set inclusive of

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44 technology, self directed learning and quality improvement. Collaboration or the strategic formation of alliances to garner resources was envisioned a long with true interdisciplinary educat ion to support a team oriented approach to health care delivery. I t i s clear th a t the primary focus of the new CME paradigm will b e to improve patient health care through the facilitation of cha n g e in physic ian practice... The enterprise will no longer ex ist as an isolated ineffectual, albeit revenue generating, activity. Continuing medical education will become a dynamic force within an integrated health care system; transformational acti on oriented, lifelong learning will characterize the CME paradigm of the future. (p. 165) Pijanowski summarized beautifully what the experts were writing about and accurately pre dict e d where the experts in the current study say we are today. Now we turn to the history of the CME credit system. Davis and Loofbourrow (2007) delineated the development of CME in two areas the development, production and delivery of CME activities and the CME credit movement. P rofessional organizations in medicine be came actively involved in the credit movement for continuing medical e ducation. Davis (2004) state d that i n 1947, the bylaws of the American Academy of General Practice (AAGP) required 150 hours of continuing medical education per every three years of membership with formal training provided by medical schools and AAGP and informal training by other providers In 1955, category I and category II credits replaced th ose hours Later the AAGP Commission of Education allowed external organizations to provide continuing education for general practitioners as long as those organi zations completed an application process and met the criteria. This paved the way for the American Academy of Family Physicians

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45 (AAFP) CME accreditation system which required 150 hours of CME, 75 of which prescribed by AAFP, for every three years of membership (Davis & Willis, 2004) In turn, the American Medical Association (AMA) established the Physicians Recognition Award (PRA) in 1968 as a formal way to identify and quantify postgraduate continuing medical edu cation ; by establishing an award that could be achieved by all physicians, regardless of specialty, the AMA brought sharp focus to its efforts to increase the role and visibility of CME as the traditional third phase of the medical education continuum (Wentz, 2008a, p. 2) Prior to the PRA, the AMA House of Delegates (AMA HOD) established the standing Advisory Committee on Continuing Medical Education in 1961 that, by 1962, suggested that a nationwide a ccreditation system for continuing medical education providers was feasible By 1967, a formal system was in place. As the number of providers and the popularity of CME increased, the hours of participation became AMA PRA credits. In 1977, five CME related organizations formed the Liaison Committee on Continuing Medical Education and became the Accreditation Council for Continuing Medical Education (ACCME) in 1981. Providers accredited by the ACCME could offer AMA PRA credits (Wentz, 2008a) During the 1990s the AMA PRA required strict adherence to the ir guidelines for Gifts to Physicians from Industry and Continuing Medical Education for approved AMA PRA activities Teaching at conferences and s elf directed lear ning became options for earning AMA PRA credit, as was credit for learning new skills and procedures More recently, journal based CME, publishing in peer reviewed journals, manuscript review, test item writing, performance improvement activities, pointof care learning using the Internet, independent learning plans, education committee membership, and obtaining

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46 medically relevant advanced degrees were AMA PRA eligible The Physicians Recognition Award and credit system Information for accredited provide rs and physician 2006 revision lists all eligible formats for AMA PRA Category 1 Credit(s)TM. A ll states and licensing boards acknowledge the AMA PRA, and most physician learners consider the award a seal of approval for the CME of fered In opposition to states that req uire mandatory CME, t he AMA officially opposes educati on that has no relationship to learning or clinical performance just to get credit. O btaining CME at an international conference is acceptable and physicians can enjoy reciprocity with the AMA and the European Accreditation Council for CME of the Union of European Medical Specialists. The AMA continue s to redefine the credit system in order to stay relevant and Wentz (2008b) contended that the AMA PRA w ould continue to meet many requirements for practicing physicians As noted above, formal accreditation for CME was in 1947. Since that time, much as been written about CME in terms of mandatory education, efficiency, effectiveness, needs assessment, evaluation, outcomes, program development, lear ning models, and commercial support P rofessional organizations such as the Accreditation Council for Continuing Medic al Education ( ACCME ) and the Alliance for Continuing Medical Education ( ACME ) develop and enforce accreditation standards and provide support for professional CME providers However, no individual organization conducts research specifically on C ontinuing M edical E ducation, but the CMSS Conjoint Committee on CME initiative beginning in 2002, brought together stakeholders to discuss CME reform and repositioning.

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47 Reform and Repositioning CME is an important aspect of the continuous learning process for phys icians; however, many, including professional associations, have questioned its effectiveness in the modern healthcare environment. The need to restructure and strengthen the CME system became a priority beginning with the establishment of the Conjoint Co mmittee on Continuing Medical Education in 2002. This group, organized by the Council of Medical Specialty Societies, was comprised of 15 s takeholder organizations listed below, and 32 members. They outlined system deficiencies and sought solutions to ref orm CME (Spivey, 2005) The rationale for reform was due to the questionable effectiveness of the CME system in the contemporary healthcare environment compounded by the evidence that the quality of patient care was variable, and th e safety of patients was not uniformly optimal. Q uality and performance improvement, regulation/accreditation, public scrutiny, funding, and global trends also influenced the need for change (Reforming and repositioning continuing medical education 2005) The stakeholder organizations are as follows: Accreditation Council for Continuing Medical Education (ACCME) Accreditation Council for Graduate Medical Education (ACGME) Alliance for Continuing Medical Education (ACME ) American Academy of Family Physicians (AAFP) American Board of Medical Specialties (ABMS) American Hospital Association (AHA) American Medical Association (AMA) American Osteopathic Association (AOA) Association for Hospital Medical Education (AHME) Council of Medical Specialty Societies (CMSS) Federation of State Medical Boards (FSMB) Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Liaison Committee on Medical Education (LCME) National Board of Medical Examiners (NBME) Society for A cademic Continuing Medical Education (SACME)

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48 The Conjoint Committee initially presented their report, Reforming and Repositioning Continuing Medical Education, at the Alliance for CME Annual Conference in January 2005. The rationale for reform noted: One key to rectifying this lapse in consistency of quality care is a restructuring and strengthening of the existing CME system. Todays physician must stay current by learning smarter, not working harder. Continuing to educate physicians beyond medical school and medical specialty training requires a coordinated lifelong learning process of timely and effective CME, with measurable outcomes. Because it is imperative that every physician practice at the highest possible level, the CME system must be ever vigilant and responsive to a physicians educational needs (p. 1) In addition, the system will need to be sufficient to support physicians ongoing needs for periodic re licensing, re credentialing, re privileging, and Maint enan ce of Certification (Reforming and repositioning continuing medical education. 2005, p.2) In the second part of the report entitled Recommendations and Next Steps (2005) the Committee presented a list of seven recommendations along with steps intended to steer implementation. Each component was assigned to a lead organization within the stakeholders group that established timelines (Reforming and re positioning continuing medical education, 2005) .The se recommendations were one of the documents reviewed during the data collection process for the current research Spivey (2005) outl ine d the 22 next steps for the seven recommendations and listed the evi dence, including qualitative studies the experience of those involved with

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49 the committee and the lead organizations in charge of implementation. He discusse d the ways in which the committee planned t o implement th e reform in a three to five year timeline The physician end user was the focus of the various CME entities in order to achieve a functional and improved format including s implified rational and identical reporting of CME credit Th e intent of the reform was to reduce bias, enhance behavioral change, and facilitate lifelong learning (p. 142) The lead organizations assigned were already innovators and had a special interest in the implementation. For example, the American Medical Association was assigned to take the lead i n m etrics because they were already involved in novel educational activities such as I nternet based point of care and just in time activities. The American Academy of Family Physicians led Valid Conte nt and Evidence based Me dicine because they ha d been working in these areas and already had mech anisms in place to address them (Reforming and repositioning continuing medical education, 2005) The Alliance for CME manage d those areas relating to CME professionals ha d already identified competencies and performance indicators and w as in process of desi gning self assessment modules ( Dr. B.J. Bellande, personal communication, July 25, 2005) The committees PowerPoint presentation, Reforming and repositioning CME; Report of the Conjoint Committee on CME; Context, Recommendations and Implications, includes Current and Future CME Implications delineated 16 categories that need ed to be addressed by CME providers. For example, classroom/meetings s hould evolve into point of care and just in time learning and credit hours into measurement metrics and outcomes; from expert driven instruction to self assessment and lifelong learning; from faculty driven content with potential bias to valid and evidenc e based content; and from

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50 physician self dir ected learning to directed self learningCME core curricula. Others include d an increase in external assessment, balanced funding, uniformity in reporting requirements, and maintenance of cer tification/licensure/competence (Reforming and repositioning continuing medical education, 2005) Leach (2005) note d that th e report from the Conjoint Committee came when there was hopeless fragmentation of organized medicine at a time when it was important to have a united front However, with the emergence of common language for competencies, common metrics of competence, technologic advances in learning portfolios, conceptual advances about the use of data on physician competence and an inexorable focus on improved patient care (p. 162) a more coherent system would be possible. He also anticipated that onc e the reform t ook place, a radical transformation of medical educati onal accreditation w ould follow (Leach, 2005) Nah rwold (2005) point ed out the fundamental impetus for this reform wa s the development of the six general competencies by the ACGME that residents must learn and demonst rate. The American Board of Medical Specialties (ABMS) ha d identical competencies used for the Maintenance of Certification (MOC) programs The four requirements for MOC include d evidence of professional standing (licensure), cognitive expertise (a secure examination), practice based learning and improvement (CME) and per formance in practice (outcomes) ( Nahrwold, p. 169) The six compe tencies shared by both groups included patient care, medical knowledge, practicebased lea r ning and improvement, interpers onal and communication skills, professionalism and system based practice. Practicing physicians should also demonstrate these competencies for the MOC program but the categories were difficult to address in the traditional CME program

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51 However, the Conjoint Committees proposition for reform should allow CME to be relevant to the day to day practice o f physicians Another aspect of the reform, as noted by Nahrwold, was the importance of the publics health and the hope that the new CME would be practice sp ecific and centered on the needs of the individual physicians patients He also discussed the burden of CME reform on physicians because of their responsibility for educational self assessment, locating specific CME to address the identified needs and re cording the CME for future verification. He suggested electronic documentation, especially via the electronic medical records where just in time CME c ould be easily documented (Nahrwold, 2005) Recent Reform Recomm endations Davis and Loofbourrow (2007) reported on the scope and delivery of CME for the Macy Foundation Conference on CE in the Health Professions and looked specifically at regulatory policy, research, and data collection They examined data f ro m the accreditation bodies for CME, contacted key informants and search ed and reviewed the literature to identify the major categories of CME providers, the types of activities provided, and trends They also considered the forces affecting the CME enterprise, suc h as accreditation, professionalism and training for CME providers, commercialization, and outcomes and the social, contextual and practical issues shaping CME However, they were not able to reflect on the content or method of educational delivery, the l ocation or the effect on the patient or healthcare system s because the data they reviewed did not contain this information. Thus, it is evident to us that what we portray here the numbers and types of courses and other offerings, the history and proces ses of accrediting

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52 bodies, and the processes for producing education operates at a level removed from the actual delivery of care or even the delivery of education Further these elements operate in ways that appear to be at odds with what is currently k nown about physician learning and change. Examination of this complex structure reveals a heavy dependence on at least two major premises on which these systems are built, and on which their linkages to competence, performance, and healthcare outcomes are maintained The first is the dependence on the physicians ability to self assess learning needs and to direct his or her attention to meeting them; the second is the heavy dependence despite attempts to augment this category of learning or add new independent leaning methods to it on formal CME or similar educational activities, such as clinical meetings, rounds, and conferences ( Davis & Loofbourrow, pp. 160161) The authors offer ed possible s olutions in four areas : the physician as learner, the methods and means of the educational system, the accreditation of those systems and the competence of the learner clinician and the healthcare system. Self assessment by physician s and commercial bias we re both issues in CME. P hysicians should determine their learning needs including competency in evidence based healthcare, and conduct their own performance appraisal. These areas could be included as required areas of instruction by CME providers or ev en as state mandated courses (Davis & Loofbourrow, 2007) Cohen (2006), President of AAMC concurred that CME failed to meet the need of practicing physicians for effective support of lifelong learning. Physician practice

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53 should drive CME in order for the quality of healthcare to improve In his opinion, the traditional lecture format should be only for basic scien tific breakthroughs, while the majority of CME should be self directed, interactive, and relevant to e nable physician learners to acquire the knowledge and skill s needed to go beyond minimum expectations Davis and Loofbourrow (2007) suggested that CME providers should have a more comprehensive understanding of the CME literature and its incorporation int o the production and delivery of educational interventions (p. 162) They posited that the accreditation s y stem should be more evidencebased to match the essentials and standards to the principles of effective CME delivery and to provide practicebased feedback focused on performance or outcomes Finally, the measurement of physician competence in CME is in effect, the number of hours spent in lectures the equivalent of awarding a medical degree based on attendance. They recommended using portfolios r eviewed annually with a senior physician, to triangulate self learning, self identified needs, and competency and performance. This would allow scientific measurement and incorporate the principles of adult learning Additional suggestions included the app lication of quality improvement and 360degree assessments of clinical performance. Marinopoulos et al. (2007) investigated the effectiveness of CME, and presented the results in a report to the Agency for Healthcare Research and Quality We conducted a systematic review of the medical literature to evaluate the effectiveness of CME in improving knowledge, attitudes, skills, physician behavior and clinical outcomes. Overall, despite the generally low quality of the evidence, most of the studies reviewed s uggest that CME is effective, at least to some degree, in not only achieving, but also in

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54 maintaining the objectives studied. Despite the wide variety of CME techniques, media, exposures used, and despite the heterogeneity of the studies reviewed, we found common themes among studies which applied across objectives CME appears to be generally effective not only in the acquisition or achievement of knowledge, attitudes, skills, behaviors, and clinical practice outcomes, but also in their retention, and the re are certain techniques, methods or exposures which seemed to be better than others. Unfortunately, most studies did not describe 60 multiple evaluation points after the intervention, which did not allow us to determine at what point the CME effect, when persistent, became extinguishable and might have needed reinforcemen t (p p. 57, 59) The authors suggest ed several areas for future research including the impact of simulation in improving clinical outcomes and measurement of effectiveness at multiple points of post investigation. They suggested a national research agenda with a clear definition of what constitutes CME including standardized approaches to the descriptions of CME interventions, media techniques and exposure volumes based on a conceptual mo del on the effectiveness of CME They further suggest ed a national consensus conference to lay the foundation for a comprehensive research agenda for CME In addition, greater resources should be devoted to funding education researchers to design higher quality CME studies as well as tools to evaluate CME outcomes (Marinopoulos et al., 2007, p. 60) A White Paper Continuing Medical Education, Professional Development, and Requirements for Medical L icensure: A White Paper of the Conjoint Committee on

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55 Continuing Medical Education, ( 2008) also advocated the urgent need for research. Specifically, Research in CME and physician assessment should be raised as a national priority, eventually allowing for greater uniformity of CME for licensure requirements as well as creating best practices for physician continuing professional developmen t and maintenance of competence. (Miller et al., 2008, p. 97) Beginn ing in 2002, the Conjoint Committee on CME with support from the 15 stakeholders led the movement for reform and repositioning The committee published and presented the original recommendations in 2005 with updates posted on the Council of Medi cal Speci alty Societies website With the continued work of the Conjoint Committee and its stakeholders, the conference sponsored by the Josiah Macy, Jr. Foundation, the Effectiveness of Continuing Medical Education report from the Agency for Healthcare Research and Quality (AHRQ) and recommendations for further research found in the literature, it was logical to conduct research at a national level. The Macy Conference participants proposed establishing a national interprofessional CE institute devoted to medic ine, nursing and pharmacy. Although proposing an institute model is beyond the scope of the current study, the first phase was initiated by the IOM Committee on redesigning continuing education in 2009. Research Most of the C ME literature recommend ed future research Authors offered a variety of suggestions to demonstrate the breadth of needed research.

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56 Nahrwold (2005) state d, Because the goal of CME reform is to improve the outcomes of care, the CME industry and providers must design and conduct studies to determine if this goal is being met. Only through research w ill the ideal CME be identified (p171) He suggested research regarding the burden on CME providers and physicians and interdisciplinary CPD/CE Harden (2005) de scribed the CRISIS (convenience, relevance, individualizations, self assessment, independent learning and systematic) model developed by Harden and Laidlaw in 1992 and the ways in which the criteria related to Brookfield s six principles of effective practice in facilitating adult learning Distance or elearning could meet the CRISIS criteria for effective CME Harden suggested continued research and development to identify the delivery and evaluation of CME as well as a longitudinal analysis across the d iverse content areas and CME activities He also recommended that developing standards for online distance CME could be a synthesis of practical knowledge, wide agreement on best procedures, and scientific evidence (Harden, 2005, p. 49) Other recommended research from the literature include d: teamwork technologies ; CME in practical settings with functional groups; utilization of advanced simulation technology (Smith & Schmitz, 2005) ; analysis of strengths and weaknesses; efficiency and effectiveness; expansion of focus to continuing professional development (Pohlmann, 2007) ; physician motivation and behavioral change (Abrahamson et al., 1999) ; professional development in practice (Calman, 1998) ; I nternet technology ; asynchronous versus synchronous learning; CME design, development and delivery fo rmat s (Curran & Fleet, 2005) ; impact of c omplex interventions with multiple

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57 professions in quality improvement (Grol, 2001) ; trusted agent and REBEL (Leach, 2005) ; CME/CPD impact on patient outcomes (Melnick, 2004b) ; medium to long term benefit of evidence based educational program design (Sanci & Coffey, 2005) ; In ternet based CME (Fordis et al., 2005) ; relationship between commercial support and bias in accredited CME (Cervero & He, 2008) ; valid and reliable evaluation tools (Wood, Marks, & Jabbour, 2005) ; data collection; self study of practice (Manning, 2003) ; performance improvement; systems thinking; (Margolis e t al., 2004) ; physician preference of CME instructional method (Bower, Girard, Wessel, Becker, & Choi, 2008) ; faculty development in CME research; assessment of faculty interest and overall level of medical educatio n research in an academic institution (Christiaanse et al., 2008) ; role of portfolios and informationists in CME (Zeiger, 2004) ; and integrating CME and quality improve ment models to sustain organizational change and achievable patient and health system outcomes (Price, 2005) Constructivism Knowing and cognitive processes are rooted in our biological structure, The mechanisms by w hich life evolved from chemical beginnings to cognizing human beings are central to understanding the psychological basis of learning. We are the product of an evolutional process and it is the mechanisms inherent in this process that offer the most probable explanation of how we think and learn. (Fosnot 2005, p. 11) Constructivism is perhaps the most current learning theory, according to Fosnot and Perry (2005) Although the basis of const ructivism was initially derived from the later work of Jean Piaget and Lev Vygotsky contemporary biologists and cognitive

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58 scientists extended the theory when they studied complexity and emergence. The theory differs from behaviorism because cognitive deve lopment and deep understandings are the focal points rather than the goal of instruction. The stages are not the result of maturation where conceptual knowledge is dependent on one s developmental stage, but are constructions of active learner reorganizati on. It is complex and nonlinear Piaget began to look at the mechanism of learning rather than the global stages as descriptive of learning and t he process enabling constructions of new perspectives instead of identifying the type of logic used by learne rs. The impact of social interaction on learning and cognitive structuring was an important aspect in Piagets work. Vygotsky focused on the effect of social interaction, language, and culture on learning He agreed that learning was devel opmental and cons tructive but differentiated between spontaneous and scientific concepts. Spontaneous learning occurs in a childs everyday experience whereas scientific concepts emerge in the more structured activity of a classroom. He studied the ways in which a child c ould move from spontaneous concepts to the scientific via the proximal development (Fosnot & Perry, 2005). In the social sciences, constructivism is the belief that the mind is active in the construction of knowledge (Schwandt, 2001, p. 30) Knowing is active, not passive or a simple imprint, and the mind does something with impressions to form abstractions or concepts. In other words, humans do not discover knowledge, they construct it. We invent concepts, models, and sc hemes to make sense of experience, and we continually test and modify theses constructions in the light of new experience We do not construct our interpretations in isolation but against a backdrop of shared understandings, practices, languages, and so

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59 f orth This ordinary sense of constructivism holds that all knowledge claims and their evaluation take place within a conceptual framework through which the world is described and explained. ( Schwandt, pp. 3031) Said another way by vonGlaserfeld (2005) establishing the fundamental principle that learning is a constructive activity that the students themselves have to carry out From this point of view, then, the task of the educator is not to dispense knowledge but to but to provide students with opportunities and incentives to build it up. (p. 7) Phillips (1995) described constructivism as a secular religion in The good, the bad, and the ugly: The many faces of constructivism with each sect somew hat distrustful of the other. He noted that the literature on constructivism available at the time was enormous including the 1993 AERA (American Educational Research Association) Annual Meeting Program sessions. He reviewed the range of constructivist au thors including Ernst von Glasersfeld, Immanuel Kant, Linda Alcoff, Elizabeth Potter, Thomas Kuhn, Jean Piaget, and John Dew e y. He followed with his framework for comparing the different forms of constructivism noting that they represent ed not one issue but a variety of complex issues which included: individual psychology versus public discipline humans the creator versus nature the instructor and construction of knowledge as an active process described in terms of individual cognition or social and pol itical processes. The dimensions were epistem olog ically related but differ with respect to the intensity with which they harbor various educational and sociopolitical concerns. For it is apparent that although

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60 some constructivists have epistemological en emies whom they are anxious to defeat, most have pressing social and political concerns that motivate their work. (Phillips, 1995, p. 10) Phillips concluded that the ugly indicated the quasi religious or ideological aspects of constructivism, the good emphasized the active participation of the learners and the recognition of the social nature of learning, and t he bad identified as the different forms tending toward relativism or treating the justificatio n of knowledge as being entirely a matter of sociopolitical processes. My own view is that any defensible epistemology must recognize and not just pay lip service to the fact that nature exerts considerable constraint over our knowledge constructing a ctivities, and allows us to detect (and eject) our errors about it This still leaves plenty of room for us to improve the nature and operation of our knowledge constructing communities, to make them more inclusionary and to empower long silenced voices. ( Phillips 1995, p.12) Svinicki (2004) provided a review of constructivist theories noting their relationship to cognitive theory because they focus ed on mental representation s of information by the learner. Some constructivists held that a learner s constr ucts of reality were unique while others posited there was an external reality [and] that the learners representation of that reality can coincide with it and with others constructions, and, as a result, it is possible for a teacher to mold a learners construction Constructivist methods put the learner

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61 at the center of the process and in the drivers seat Learning will follow the path dictated by the learners activities. (p. 243) By using instructional methods such as student discovery and active interaction with the environment and other students, the learner could form a construction of reality from the experiences (Svinicki, 2004) P rinciples from Fosnot and Perry (2005) include d: learning is development which requires invention and self organization of the part of the learner including the generation of hypotheses, testing the validity and then discussing them disequilibrium facilitates learning and errors need not be minimized or avoided; contradictions need to be illuminated, explored and discussed reflection (journaling or discussing connections over experiences or strategies) is a driving force of learning and dialogue wi thin a community offers the opportunity to defend, prove, and justify learner constructed big ideas which may lead to undoing or reorganizing earlier conceptions They defined constructivism as: Constructivism is a poststructuralist psychological theory (Doll, 1993), one that construes learning as an interpretative, recursive, nonlinear building process by active learners interacting with their surround the physical and social world It is a psychological theory of learning that describes how structures language, activity, and meaningmaking come about, rather than one that simply characterizes the structures and stages of

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62 thought, or one that isolates behaviors learned through reinforcement It is a theory based on complexity models of evolution and de velopment. The challenge for educators is to determine what this new paradigm brings to the practice of teaching. (p. 34) Qualitative Research Denzin and Lincoln (2003) defined qualitative research as cutting through disciplines, fields and subject matt er In addition, interconnected terms, concepts, and assumptions are associated with the term Qualitative research operates in a complex historical field of seven moments that overlap and are in the present. Their definition of qualitative research provi ded below, must work within the seven moments. Qualitative research is a situated activity that locates the observer in the world It consists of a set of interpretive, material practices that make the world visible These practices transform the world T hey turn the world into a series of representations, including field notes, interviews, conversations, photographs, recordings, and memos to the self At this level qualitative research involves an interpretive, naturalistic approach to the world. This mea ns that qualitative researchers study things in their natural settings, attempting to make sense of, or to interpret, phenomena in terms of the meanings people bring to them (pp. 4 5) Further, there was no single theory or paradigm in qualitative researc h but researchers claim us e of qualitative research methods and strategies fr om constructivis t to cultural studies feminism, Marxism, an d ethnic models of study It does not belong to a single discipline (Denzin & Lincoln, 2003, pp. 910)

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63 Qualitative research involves a variety of empirical materials such as case study; personal experience; introspection; life story; interview; artifacts; cultural texts and productions; observational, historica l, interactional, and visual texts that serve to describe routine and problematic moments and meanings in individuals lives (p. 5) No single method can grasp all the subtle variations in ongoing human experience. Consequently, qualitative researchers deploy a wide range of interconnected interpretive methods, always seeking better ways to make more understandable the worlds of experience they have studied. ( p. 31) Denzin and Lincoln describe d the five phases of the research process which work their wa y through the biography of the researcher The five phases are: 1. the researcher as a multicultural subject, 2. theoretical paradigms and perspectives, 3. research strategies, 4. methods of collection and analysis and 5. the art, practices and politics of interpret ation and presentation According to the authors, the researcher phase consider s the history and research traditions in which the researcher is located while guiding and constraining the work, that persons conception of self and of the other and the ethi cs and politics of research. The text lists and details the theoretical paradigms The research strategies such as case study and life history/testimonial, are reviewed along with the methods such as interviewing. The final phase of interpretation and pr esentation consider the criteria for judging adequacy, practice and politics of interpretation, writing as interpretation, policy

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64 analysis, educational traditions and applied research Detailed reviews of the phases are beyond the scope of this study J anesick (2000) provided a n outline for qualitative study design, which s he compared to a dancers warm up, exercises and cool down and the choreographers preparation, exploration, and illumination/formulation as the researcher makes a series of decisions throughout the study. Just as dance mirrors and adapts to life, qualitative design is adapted, changed and redesigned as the study proceeds, due to the social realities of doing research among the living (p. 395). The researcher must stay in the setting over time and by doing so the researcher has the opportunity to use crystallization, whereby he or she may view the approaching work in the study through various facets to deepen understanding of what is going on in the study. This allows for multiple w ays of framing the problem, selecting research strategies, and extending discourse across several fields of studyQualitative research design is an act of interpretation from beginning to end. (Janesick, p. 395) Summary This chapter presented the theoretical framework of the study, introduced qualitative research, and reviewed a brief history of adult education, continuing professional education, a histo r y of medical education and continuing medical education and reform and repositioning initiative s in CME Recommendations for future research i n CME from the literature demonstrate d the need for continued research and the dynamic state of continuing medical education. Chapter 3 outline s the research meth od, describe s the role of the researcher, c onsider s ethical issues, review s the pilot study, present s the

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65 interview questions, details a timeline for completion, discuss es participant selection, describes data collection and preservation, and lists review documents

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66 CHAPTER THREE METHOD The previous chapter reviewed relevant literature related to the history of adult education, medical education, and continuing medical education as well as reform and repositioning initiative in CME and recommendati ons for future research. The chapter provided the theoretical framework for this study and a brief overview of qualitative research This chapter describes the research methods, including the purpose, r esearch questions, problem statement, theoretical fram ework, rationale, role of the researcher, ethical considerations, a pilot study, i nterview questions, timeline, participant selection, data collection and preservation, member check discussion, and review documents. Purpose of the Study The purpose of this study was to describe and explain selected participants perspectives on continuing medical education. Research Questions The research questions that guide d this study we re : 1. What are the major elements of CME? 2. What influences CME? 3. What are the most sig nificant issues in CME? 4. What is the future of CME? Problem Statement T ension exists regarding the future of CME in the United States.

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67 Theoretical Framework Constructivism guided this study because it was the theory that best fit my personality and unders tanding of how learning occurs and develops. Since one must consider the impact of others in the construct of knowledge social constructivism also guide d the study placing a strong emphasis on dialogue and interaction with others, and negotiating meaning or refining understanding by contrasting personal perspectives with others. Constructivism and social constructivism relate to the learning process observed in continuing medical education, and to the act of interviewing where in the researcher and the par ticipant dialogue interact and negotiate meaning or refine understanding by contrasting personal perspectives. Method and Rationale The current research is a descriptive case study that utilize d i nterviews with national experts researcher observations documented in field notes, a reflective journal and review documents as data. The results offe red the most complete descriptio n of CME in the United State fro m the experts perspective. The four data sets allow ed crystallization ( Janesick 2004) of the data into a final set of conclusions Janesick (2000) discussed Richardsons 1994 explanation of crystallization, as Crystallization recognizes the many facets of any given approach to the social world as a fact of life The image of the crystal repl aces that of the land surveyor and the triangle. We move on from plane geometry to the new physics (p. 392). A qualitative approach unveil ed essence and ambience and refer red to the meanings, concepts, definitions, characteristics, metaphors, symbol and descriptions of things (Berg, 2007, p. 3) Janesick (2004) describe d the characteristics of qualitative

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68 work as holistic, focused on relationships and the social setting, refer ring to the personal and imm ediate interactions in a given setting, requir ing equal time in the field and in analysis, incorporat ing a description of the role of the researcher and consider ing the researcher as a research instrument, incorporat ing informed consent responsive to ethic al concerns and acknowledg ing ethical issues in fieldwork, and considering participants as co resear chers. In th e latter case, the most important questions would be about the participants views of his or her life and work. For the current research, the i nitial i nterview design was approximately one hour in duration with a range of 30 to 80 minutes. The researcher conducted all but one interviews in person, with one conducted via telephone due to scheduling conflicts. Professional meetings provided a good venue to meet with the participants Prior to the intervi ew, the researcher provided the eight participants with the i nterview questions. Participants gave permission to use a digital audio recorder with a back up digital recorder during the interviews. The interviews had professional transcription with one hour of recording equaling approximately 15 pages of interview data. The researcher compared the transcripts to the digital recording, making corrections as needed. P articipants had the opportunity to review the transcripts (See member check form in Appendix E) with one participant editing his transcript to correct names and text. F ield notes were maintained which include d observations made before, during and after the interviews. Th ese notes assisted in recalling the specifics of the interv iew setting, the participants characteristics and demeanor, how I felt about the experience and other relevant i nformation. A researcher journal was also utilized to track progress, or lack thereof, describe what was happening during the research process talk about my

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69 destination for each interview and what was happening in conjunction with the interview, professional meetings that we were attending, f or example. A journal can also be used to reflec t on personal experiences and feelings throughout the life of the research project that may influence the next step, the next selection of literature, what to do about barriers to completion etc. In this c ase, my researcher journal was weak and I realized that memory does not serve one well during the dissertation journey. Establishing the habit of journaling daily would have offered a rich description of the entire journey, helped in the decision making process, given opportunities to reflect on later, and so on. ( Excerpts are included in Chapter Four with the presentation of data.) Maintaining a researchers journal is highly recommended for any study undertaken. Peer Reviewers read drafts of this manu script, discussed content, and questioned the researcher about everything f ro m the theoretical concept to sentence structure and always found typographical er r ors Their ability to offer another perspective and confirm understanding of the material presen ted was priceless Some of the peer reviewers are students at University of South Florida in the Adult, Career, and Higher Education program who participate with this researcher in an ongoing support group. This is an invaluable opportunity to help maint ain focus, obtain feedback, provide in kind support to fellow students and remain motivated to continue with the dissertation journey. The process used to analyze the interview data, code and develop themes was based on the works of Merriam (1998) and Rubin and Rubin ( 2005) Merriam stat es Data collection and analysis is a simultaneous activity in qualitative research. Analysis begins with the first interview, the first observation, the first document read. Emerging insights, hunches, and tentative hypotheses direct the next phase

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70 of data collections, which in turn leads to the refinement or reformulations of questi ons, and so on. It is an inter active process throughout that allows the investigator to produce believable and trustworthy and findings rigor in qualitative research derives fr om the researchers presence, the nature of the interactions between researcher and particip ants the triangulations of data, the interpretations of perceptions and rich, thick description (p. 151). Merriam describes that dat a analysis had been a mysterious metamorphosis until analytic techniques in a number of publications had recently described She not ed that it is a highly intuitive pr ocess and that she would only try to introduce how one might proceed based on what had worked for her and presented techniques that had been commonly used in educational research. Of those, the current study use d a blend of narrative analysis the study of experience is through stories as participants used stories or experiences to better explain their perspective s, and the constant comparative method to constantly compare (pp.155159) It is suggested that data be m anag ed and organized through the use of coding assigning a short hand designation to various aspects of the data for easy retrieval The codes, created by the researcher to be relevant to the data at hand identify theme s as illustrated by quot es or occurrences (Merriam, 1998). Rubin and Rubin (2005) suggest that analysis occur throughout the research project and that systematic examination must be completed by immersion in the data to code and extraction of information from the transcripts ra ther than looking for confirmation of initial ideas or r elying on memory to recall and report on the data. In addition, a reminder that qualitative data analysis is not counting or numeric

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71 summarization, rather it is to discover variation, portray shades of meaning, and examine complexity (p. 202). The authors review the initial stages of analysis which may include searching for concepts and themes suggested by literature in the field of study or in the interviews themselves. Within the interview transcr ipts, concepts and themes may be found based on the questions asked or those raised and/or frequently mentioned by the participants. Some may be indirectly revealed by statements or expressed emotions, and those that arise out of comparing interviews and new related themes from those the researcher has already identif ied by grouping concepts refining them and considering what they may imply. They also recommend considering figures of speech, slogans, symbols and stories to suggest concepts and themes. Once you have found a concept, theme, event, or topical marker and worked out what you think it means you look for these same ideas elsewhere in all the interviews. You compare instances of the same idea and progressively define, refine, and label these e merging concepts. You continue doing so until you are comfortable that you have worked out a consistent understanding of each concept and theme and have noted most. You put all the concepts, themes, events and topical markers you are going to use in the analysis on a coding list, and then use that list to guide your coding, or marking of the text (p. 216). In the current study, codes were embedded in the raw data (transcripts) and built upon as the analysis progressed and themes emerged across the aggrega te data. A constant comparison to responses for each interview question was made to check for consistency in the development of themes.

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72 The initial phase was a review of transcripts consist ing of simply reading and taking notes shortly after the individual interviews The second pha se included a detailed review of individual transcript s and assignment of initial codes created as short hand descriptors For example, [e ACCME] quickly identified responses that were related to accreditatio n as a major element of CME Mr. Green in response to my question regarding the major elements of CME stated So, obviously those are some of the major elements of CME but can you describe for me what you feel those elements are in terms of CME? sta ted, Yeah, the major components of what this thing is called? Called CME? (Laughs.) Ive talked to people in the past about this, and I still believe the same basic things t hat you saying something i s CME you just cant get away from an adherence to the ACCMA criteria [e ACCME] T hat has to be referenced, to tell people what youve done and saying that you are going to be accredited or youre going to produced a certified CME. Each of the codes was identified according to the research question to be ans wer ed with the data. Therefore a let ter before the code represented a category created to identify general answer s to an interview question which, in turn, was associated with the research questions e represented elements of CME I for infl uences s to describe significant issues/barriers to advancement f to identify response s regarding the future of CME, and ? corresponded to closing question responses to, What havent I asked? Or, is there anything else you would like to add at this time? See Appendix J for the O riginal Categories and C odes and Appendix K for the Final Categories and Codes which represent the final themes.

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73 Guidelines for efficacy of categories for the constant comparative method include the following : Categories should reflect the purpose of the research In effect, categories are the answers to your research question(s) Categories should be exh austive Categories should be mutually exclusive Categories should be sensitizing Categories should be conceptually congruent (Merriam, 1998, p. 183184). Merriam (1998 p. 169 170) describes the use of qualitative software programs and office software such as word processors as appropriate tools for managing data Word process ing applications are popular due to researchers familiarity with the format and the text editing strengths. Rubin and Rubin (2005) also address software programs and refer to a wor d processor programmed specifically to hel p retrieve codes (p. 221). For the current study, a wor d processor was utilized to manage the data. All of the transcripts were combined into a single document and t he embedded codes were identified as needed using the command Find in Microsoft Office Word 2007. This allowed for easy retrieval of relevant interview transcript passages Once the categories were developed and the coding was complete, the raw data was reviewed over and over again to ensure all relevant data had been captured Passages from the interviews representing t he categories specific to the research questions were selected for inclusion in Chapter Four by searching for the associated codes with the Find command T he data was constantly compared to check and re check categories, identify

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74 themes as well as locate direct quotes for placement into the data analysis section of this document. Data analysis is the process of making sense out of th e data. And making sense out of the data involves consolidating, reducing, and interpreting what people have said and what the researcher has seen and read it is the process of making meaning. Data analysis is a complex process that involves moving bac k and forth between concrete bits of data and abstract concepts, between inductive and deductive reasoning, between description and interpretation. These meanings or understandings or insights constitute the findings of a study (Merriam, 1998, p. 178). D ocument Review A document review is an unobtrusive method rich in portraying the values and beliefs of the participants supplement s interview data, observations, and the reflective journal Documents may include meeting minutes, logs, announcements, fo rmal policy statements, and letters to help develop an understanding of the setting or group. A rchival data can further supplement the data. Content analysis is a systematic examination of the communications to document pattern, which creates an unobtrusive and nonreactive method. The researcher determines where the greatest emphasis lies after the data have been gathered Also, the method is explicit to the reader Facts can therefore be checked, as can the care with which the analysis has been applied (Marshall & Rossman, 1995, p. 86) In th e current study, the documents suggested for review initially include d the followin g: Macy Conference monograph, Conjoint Committee on CME 2005 Reform and

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75 Rep ositioning recommendations, AHRQ Report on CME, ACGME Competencies, ABMS Maintenance of Certification requirements, ACCME accreditation standards and associated correspondence regarding proposed changes, ACCME Standards for Commercial Support, and other documents recommended by the participants or appropriate based on data analysis After gathering the data, the review documents selected were two Institute of Medicine reports, Resigning Continuing Education in the Health Professions and Conflict of interest in Medical Research, Education, and Practice, the Lifelong Learning in Medicine and Nursing Final Conference Report, ACCMEs CME as a Bridge to Quality: Leadership, learning, and change within the ACCME system, AMAs The Physicians Recognition Award and credit system: Information for accredited providers and physicians Websites for National Commission for Certification of CME Professionals and the ACME were included In addition, I reviewed articles by Bridget Kuehn, Susan Nedza, Robert Orsetti, and Pat rick Kelly. Findings from these review documents were relevant to the current study and were presented as data in tandem with the transcript excer pts se lected to demonstrate how participants r esponses answered the research questions. Selections from th e review documents supported the themes identified in the analysis phase. For example, Question One asked about the major element s of CME. O ne theme identified in the participants responses was accreditation. The materials in ACCME s publication CME a s a Bridge to Quality: Leadership, learning, and change within the ACCME system describes the import ance of offering accredit ed CME as an essential component of physician continuing professional development. T he purpose of the publication was to assist CM E providers share that fact w ith their stakeholders. Th e examination and inclusion of th is

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76 review document data support ed interview data analysis and findings that accreditation is a major elem e nt of CME R ole of the R esearcher My path as a student and a s a professional circumvented a pre designed curriculum and established career ladders. I spent my m iddle school years at an independent private school, reminiscent of A.S. Neills Summerhill School where letter grades were non e xistent and self discipline was the key to success in an open learning environment. The school encouraged c reative solutions and dreams became realities as we explored topics of our choosing Transferring to a public high school was a challenge; however, I was able to enroll in advanced placement courses, opted out of physical education and substituted competitive figure skating jazz and ballet Involvement in a Mo ntage production was one of my most memorable high school experiences because it was an all student production reflecting the popular Carole King song Tapestry T he first verse follows: My life has been a tapestry of rich and royal hue, An everlasting vision of the ever changing view. A wondrous woven magic in bits of blue and gold A tapestry t o feel and see, impossible to hold. (King, 2008) D id I know then that a tapestry, in the form of text, would be something that I would want to produce as a doctoral dissertation? No, I did not ; however, as noted by Denzin a nd Lincoln (2003) a text montage producing such a tapestry or quilt was the goal of many qualitative researchers.

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77 The qualitative research er may take on multiple and gendered images: scientist, naturalist, field worker, journalist, social critic, artist, performer, jazz musician, filmmaker, quilt maker, essayist The many methodological practices of qualitative research may be viewed as soft science, journalism, ethnography, bricolage, quilt making, or montage The researcher in turn, may be seen a bricole ur as a maker of quilts, or, as in filmmaking, a person who a ssembles images into montages (p 5) The researcher as a bricoleur uses the tools or strategies that are at hand or invents them and fits t hem together as needed The practice is not necessarily set in advance because it depends on the questions and what the researcher can do in that setting. Montage and pentimento, like jazz, which is improvisation, create the sense that images sounds and understandings are blended together forming a composite, a new creation (p. 6) It also invites the viewers to construct interpretations that build on one another A qualitative researcher using montage does the same thing as a quilt maker who stitches, e dits and puts together pieces of reality together. This creates imagery with different voices, perspectives, points of view and angles of vis i on, creating spaces for give and take between the writer and the reader The use of a variety of methods leads t o crystallization in an attempt to obtain an in depth understanding of a phenomenon. Denzin and Lincoln describe these montage s or quilts as crystals Unlike triangulation where validation uses different methods to locate a fixed point, t he central imager y for validity is the crystal, which c ombines symmetry and substance with an infinite variety of shapes, substances, transmutations, multidimensionalities, and angles of approach.

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78 Crystals grow, change, alter but are not amorphous Crystals are prisms tha t reflect externalities and refract within themselves, creating different colors, patterns, and arrays, casting off in different directions What we see depends upon our angle of repose Not triangulation, crystallization In postmodernist mixedgenre text s, we have moved from plane geometry to light theory, where light can be both waves and particles crystallization provides us with a deepened, complex, thoroughly partial, understanding of the topic. ( Richardson, 2000, p. 934) There are several types of bricoleur researchers i ncluding methodological, theoretical, researcher as bricoleur theorist, interpretive, political, and narrative. The gendered, narrative bricoleur also knows that researchers tel l stories about the worlds the y have studied. Thus the narratives, or stories, scientists tell are accounts couched and framed within specific storytelling traditions, often defined as paradigms (e.g., positivism, postpositivism, constructivism ) (Denzin & Lincoln, p. 9) I am an interpretive and narrative bricoleur researcher because I wish to tell a story The product of the interpretive researcher is a complex, quiltlike bricolage, a reflexive collag e or montage a set of fluid, interconnected images and representations. The interpretive structure is like a quilt, a performance text, a sequence of representations co nnecting the parts to the whole (Denzin & Lincoln, p. 9) Returning to my path, undergraduate studies took place at a small liberal arts college. After struggling with the pre med curriculum I pursued and graduated with an individually designed major in Psychobiology which was in its infancy as a field of

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79 study Again I took the less traveled highway to my destination. In addition to the required credit hours, I took advantage of a variety of volunteer opportunities Aside fro m the wonderful liberal arts foundation, many of the extracurricular experiences prepared me for the world of work. Once there, however, I found that a Bachelors degree was not enough. The completion of a Masters degree in Guidance and Counselor Education led me to a job in private sector vocational rehabilitation with now defunct organization where I honed my skills in medical case management From there my career in healthcare began as one of the few non nurse case managers in a hospital setting Shortly thereafter, I became a manager and interim director in the rehabilitation department, then practice support manager in the outpatient clinic and currently in a position that initially combined two jobs, conference center coordinator and continuing medical education coordinator into one management role Subsequently, I gained the assignments of librarian budget management of our two residency programs and Medical Staff Services ; another montage. I am a professional who oversees the provision of accredited continuing medical education programs I researched mandato ry continuing medical education as well as repositioning and reform in CME I witnessed significant changes in the accreditation process changes in the utilization of commercial support for CME and the development of a certification process f or CME professionals designed to ensure some consistency in the qualifications of CME professionals In fact, I earned the Certified Continuing Medical Education Professional (CCMEP) designation As a result, I entered this study with a set of bi ases that became evident to me while reading the interview transcripts.

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80 When I reflected on my practice as a continuing medical education manager I decided to hone my skills in this particular area via enrol lment in the Educational Program Development program at the U niversity of S outh F lorida in 2004. The result s were delivery of more creative activities making t he program popular both in the hospital setting and in conjunction with external groups. As progressed through my doctoral cour s es and watched m y field evolve, I became keenly interested in learning about the perspectives of experts to appreciate their live d experience, and further my knowledge about the field and its future The acquisition of researcher skills is in part the goal of attaining an advanced degree. Berg (2007) discussed what Yin ( 1998) identified as the five researcher skills a ssociated with good case studies They were 1) to have an inquiring mind, 2) to have the ability to listen, including observation and sensing (and to assimilate large amounts of new information without bias), 3) to be adaptable and flexible, 4) to have a thorough understanding of the issues bei ng studied, and 5) to provide an unbiased interpretation of the data (Berg, 2007) In completing this study I have developed these skills. Ethical I ssues The generic ethics of research include informed consent and maintaining the anonymity of participants, but there may also be situation specific ethic a l considerations and dilemmas (Marshall & Rossman, 1995) Denzin and Lincoln ( 2000) describe d a Code of Ethics as the conventional format for moral principles adopted by professional and academic associations The principles overlapped in four areas : i nformed consent, deception, privacy and confidentiality, and accuracy. Marshall and Rossman (1995) discuss ed the need to anticipate issues such as negotiating entry into the lives of

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81 participants, reciprocity (if appropriate ), role maintenance, and receptivity while maintaining ethical principles The researcher is responsible for demonstrating that the research is feasible and ethical and must demonstrate an awareness and appreciation of the ethical principles of research. Janesick (2000) noted that qualitative researchers are attuned to making decisions regarding ethical concerns, because this is part of life in the field From the beginning moments of informed consent decisions, to other ethical decisions in the field, to the completion of the study, qualitative researchers need to allow for the possibility of recurring ethical dilemmas and problems in the field (Janesick, 2000, p. 385) One of the collect ive identity characteristics of a profession is ethical practice. Once established, a profession should refine its ethical practice and develop a code of ethics and rules The ethical tradition must be strong enough to prevent violation from practitioners or employers yet flexible enough to accommodate a variety of problems. Providers develop opportunities to discuss and debate ethical issues and practical applications via inquiry, instruction, and performance. Ethical problems in continuing professional education stem from a conflict of values between the professionals and the professions they serve As the field of continuing education changes, so do the ethical problems facing i t (Lawler, 2006) Decisions about whose interests will be represented, what aims will be pursued, how the learner community will be defined, how resources will be allocated, what instructional approaches will be used, how the program

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82 will be financed, and how success will be determined all involve making moral commitments. (Sork, 2000) One of the most prevalent ethical issues confronting continuing education in the healthcare professions is the provision of commercial support for C M E programs. In sum, it is unethical for academic institutions and educational organizations to accept any support that is explicitly or implicitly conditioned on industrys opportunity to influence the selection of instructors, speakers, invitees, topics, or content and material of educational sessionsmedical education providers and medical professional societies should avoid all industry interactions that might diminish, or appear to diminish, their objectivity or concern for patients best interests To do otherwise i s to endanger the integrity of the profession and the public confidence it enjoy s. (Coyle, 2002, pp. 405 406) In researching the use of commercial support, Herber t (2003) calculated the cost of Grand Rounds if the hour or more spent weekly equated to time spent in compensated clinical activity at a billing rate of $325 per hour, each was worth about $9750. He also looked at the sources of funding for the pharmaceutical industry, department s of medicin e, hospital s medical school s, and other facilities, and found that 49% of the funding came from the p harmaceutical industry (Herbert & Wright, 2003) Th e organizations that accredit continuing medical education (A CCME) and continuing pharmacy education (ACPE) addressed t he ease of obtaining funds and industry influence on the content of programs in their guidelines for providers and by the

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83 Pharmaceutical Research and Manufacturers o f America (Ph RMA). However, Brennan et al (2006) propose d a policy to implement more stringent controls to eliminate or modify the provision of small gifts, drug samples, CME, travel funds, speakers bureaus, ghostwriting, consulting and research contract s The proposal included psychol ogy and social sciences research on receiving gifts and giving that indicated current controls will not satisfactorily pr otect the interests of patients ( p. 429) In 2007, the United States Senate Com mittee on Finance, which has exclusi ve jurisdiction over the Medicare and Medicaid programs, noted increased federal spending on prescription drugs Their interest in drug marketing and utilization patterns, which include d funding of educational programs, was clear Of particular interest wa s use of educational grants to encourage physicians to prescribe products for uses beyond their Food and Dru g Administration (FDA) approval (p. 1) Another concern was that the ACCME and FDA did not provide real time monitoring of CME activities A survey of 23 pharmaceutical manufacturers revealed that, In 2004, expenditures by commercial sponsors to support CME exceeded $1 billion (p. 9) ACCME reported to the Committee that spending on accredited CME in 2005 equal ed $2.25 billion with $1.12 billion represent ing commercial support Steinbrook (2005) commented that if the standards released by ACCME in 2004 m a de support for CME seem less valuable to industry, companies m ight decrease their support If so, the medical profession might have to assume more of the true cost o f its own continuing education. The use of commercial support for continuing medical education is particularly contentious an d produced an ethical dilemma considered i n this study The government, t he pharmaceutical industry, academic medical centers and CME providers we re in the

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84 midst of deciding how to resolve this issue The use of pharmaceutical monies in the form of educational grants to support educational activities c ould be just another way to market a product. Many commercial support and conflict of interest guidelines are in place with PhRMA ACCME, and ACPE in an effort to eliminate bias in educational activities. The ACCME requested comments in August 2008 regarding their position that the manner of interaction between potential commercial supporters, or their agents, and some Accredited P roviders may need to be altered (p. 4) The CMSS submitted comments in several areas via a letter to ACCME dated August 15, 2008. Specific to this dis cussion was the response to commercial support for individual activities only under certain criteria [CMSS] does not support the new paradigm in its current draft formatbut rather recommends modifications to ensure the separation of bias fr om commercial support of CME, and further recommends a process for debate and discussion of the proposed new paradigm, so that it may ultimately come to be as universally accepted as are the ACCME Sta ndards for Commercial Support. (p. 5) Further they offe red the Conjoint Committee on CME as a veh icle for forwarding discussion and proposing a national solution ( Council of M edical S pecialty S ocieties 2008) Pharmaceutical companies have changed the ways in which they provide commercial support in order to be compliant with PhR M A guidelines and government regulations Of particular interest wa s Pfizer s July 2, 2008 announcement that they would no longer provide direct funding for Continuing Medical Education/Continuing

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85 Educat ion ( CME/CE ) programs by commercial providers including medical education and communication companies ( MECCs ) Pfizers decision marked an effort to address ongoing criticism of conflicts of interest in industry supported CME/CE. They also announced ther e would be stricter criteria to qu alify for commercial support fro m Pfizer In a July 2, 2008 e mail to CME/CE Providers, Joseph M. Feczko, Senior VicePresident and Chief Medical Officer of Pfizer Inc. said : We continue to believe in the value that indust ry supported CME/CE provides to healthcare professional s and ultimately to patients, and we will still support continuing medical education programs at many of the worlds leading academic medical centers and teaching hospitals, as well as programs sponsor ed by associations, medical societies and community hospitals, in keeping with the shared goal of improving public health. Continuing medical education/continuing education improves healthcare provider understanding of disease, expands evidencebased treatment, and contributes to patient safety However, we understand that even the appearance of conflicts in CME/CE is damaging and we are determined to take actions that are in the best interest of patient and physicians. (Personal Communication) Pilot Study In preparing for the current study, the researcher used a semi structured interview technique with and observations of David A. Weiland, II, MD on two occasions in September and October, 2007. The interviews with Dr. Weiland aided in understanding hi s role and lived experience as the Medical Director of the Hospice of the Florida

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86 Suncoast in Clearwater, Florida and served as the pilot for the current research Each interview was one hour in duration and recorded using two digital recorders Observati on notes became part of the final report to describe the inter view settings and to supplement the interview transcripts. After transcription, a professional transcriptionist forwarded the data electronically to the researcher, who compared them to the digi tal recordings to ensure accuracy. Data analysis aided in locating themes as they related to Dr. Weiland s role and lived experience ; this information and documents and photographs from the Hospice of the Florida Suncoast website made up the final report Dr. Valerie Janesick provided guidance for the assignment, incorporating her Rules of Thumb for conducting qualitative interviews (Janesick, 2004) Although I ha ve known Dr. Weiland for approximately nine years as a colleague and friend, the experience of interviewing him and the results that the data provided were in greater depth than I could have anticipated. The detail he provided, along with the emotional component he described, were moving and revealed a side of him that I would not ordinarily be able to hear, see, feel, or comprehend. The concepts and practice of hospice and palliative care became much clearer The importance of communication with the care team, the patient, and family was obvious based on hi s description of conversations and interactions in his daily work. In addition, the opportunity to write a descriptive was refreshing and enjoyable. The overall experience encouraged me to pursue a descriptive study of expert perceptions and lived experience in the field in which I work

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87 Interview Format Having confirmed the participa tion of eight experts and agreeing on a date and location I use d a s emistructured (Rubin & Rubin, 1995) / semi standardized (Berg 2007) interviewing for mat The interviews were in person for one hour in and audio taped Each participant responded to the interview questions listed below and included probing questions to digress, guide the conversation, clarify an answer, request ad ditional information, or delve more deeply Following transcription and content verification each participant had an opportunity to review their transcript and correct any errors Follow up interview s were not necessary due to data saturation. Interview Q uestions 1. From your perspective, what are the major elements that define CME? 2. Please describe your current role in CME. 3. Based on your experience, what factors influence CME? 4. Please describe the issues in CME that are most relevant for the advancement of the field. 5. What, from your perspective, is the future of CME? 6. Is there anything else you would like to add at this time? Timeline and Costs Review of literature March 2008 August 2009 Complete Proposal Chapters 13 September 2008 March 2009 Protection of Human Subject training November 2008 Proposal Submission to Committee and Oral Defense April 2009 IRB Application April 2009

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88 Interviews/Observations/Data Collection May September 2009 o Travel Cost $3000.00 o Office Supplies $100.00 Researcher R eflective Journal March 2008 to completion Data analysis May 2009 to January 2010 o Transcription Cost $720.00 Preparation of Chapters 4 and 5 October 2009 to March 2010 o Copy Editor $1600.00 o Drafts and Final Copies (FedEx Office) $325.00 Protection of Human Subject continuing education March 2010 IRB Progress Report March 2010 Dissertation Defense April 2010 Publication After August 2010 o ETD Fee $100 o ProQuest Fee and personal bound copies $354 TOTAL $6099 Purposeful Sample Qualifications for the deliberate selection of participants included their having acquired an advanced degree ( masters or doctorate) or professional degree in medicine and being employed in t he field for at least ten years as experts, opinion leaders, researchers, academics editors, or officers of professional or academic associations The rationale for selection wa s that participants were active in the field in a leadership capacity of some type, and had an impact on CME or might have an impact on the future

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89 of CME These criteria constituted experts in the field; as defined by Merriam Webster an expert is one with the special skill or knowledge representing mastery of a particular subject ( Merriam Webster O nline D ictionary 2010) F inally all participants were willing to participate in th e study and signed an Informed Consent. Names have been changed to ensure confidentiality. Invitations were extended to representatives from the various facets of CME which included the following : Officer or Committee Member American Medical Association Officer or Committee Member Association of American Medical Colleges Editor/Associate Editor/Consulting Editor Medical or Professional Journal Officer, Accreditation Reviewer of Committed Memb er Accreditation Council for Continuing Medical Education Senior Manager or Director, Medical Education Grant Office Pharmaceutical Industry Officer or Committee Member Alliance for Continuing Medical Education Participant 2007 Macy Conference In formed Consent Each participant signed an i nformed consent form (see Appendix A) prior to the interviews Th e version incorporates IRB requirements at the University of South Florida

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90 Sample Consent Forms developed by Janesick (2004) and a modified versio n of the one used prior to the interview with Dr. Weiland Methodological A ssumptions A descriptive study gathers information about the lived experience and perspectives of the participants which, in combination, offers rich description. Critics of the approach may say that the selection of the participant group is too purposeful that t he method is the least efficient way to collect the necessary data, or that telephone interviews or questionnaires are more appropriate. However, t he meth od of interviewi ng provide s the richest data when supplemented with the researchers observations and re view of documents Neither a questionnaire nor a telephone interview c ould yield the type of data needed to present a complete study Locke, Spirduso, and Silverman ( 1993) suggest ed that qualitative research require d an open contract During the proposal phase the researcher m ight need to move back and forth between data sources and ongoing data analysis during the period of data collection. Initial questions are pro gressively narrowed or, on occasion, shifted entirely as the nature of the living context becomes apparent through preliminary analysis ( p. 111) This was true in th e current research as I went back and forth between data sources both during and after data collection and reviewed the data multiple times Delimitations and Limitations According to Locke, Spirduso, and Silverman (1993) delimitation described the populations to which generalizations can be made. Delimit literally means to define the limits inherent in the use of a particular construct or population (p. 17) L imitations refer to limiting conditions or restrictive weaknesses They occur when all factors cannot be

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91 controlled as a part of t he study design, or sometimes the optimal number of observations simply cannot be made because of problems involving ethics or feasibility (p. 18) If problems occur and the information gained is valid and useful the researcher can proceed but needs to c onsider and note the limitations to assure the reader of the studys validity. Delimitations in the current research include that generalizations to other populations are not possible because of the individual lived experiences described. However, other researchers could replicate similar results with similar experts in the same field. Limitations included the inability to obtain sufficient interviews due to illness, travel delays cancellations, or other uncontrollable problems. Other issues may include the inability to access desired documents for review, and funding problems for travel and transcription services, among others. Data Collection and Preservation The researcher recorded the interviews using two Olympus Digital Voice Recorder s with the dat a transcribed verbatim by a transcriptionist. The interview transcripts were stored electronically and as hard copies to ensure the data w ere not lost. Field notes include d researcher observations ideas for later consideration descriptions of the intervi ew settings, reflections o n the interview s and immediate impressions During the interviews the researcher noted ideas for the second set of protocol questions The researchers journal became part of the final report T he data analysis involve d the iden tification of themes which in conjunction with the literature and document review s, aided development of the final analysis and conclusions Participants had the opportunity to read the transcripts to ensure accuracy Transcripts will be available to the transcriptionist, the primary investigator, the

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92 individual participant s, and the major professor for two years after the completion of the program Summary Th is chapter presented the purpose of the study, the problem statement, a nd the theoretical framework that guided the current study. The qualitative research design and method were outlined; the role of the researcher explored ethical issues considered particip ant selection described, and the interview questions were stated The goal s of this study we re t o examine the perspectives of CME experts, review recent literature and documents describe participants lived experience, identify themes and provide conclusions Ancillary goal s were to hone my skills as a qualitative researcher, improve my creative and scientific writing, and contribute to the larger body of literature in continuing medical education.

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93 CHAPTER FOUR PRESENTATION OF THE DATA Int roduction The purpose of this study was to describe and explain selected participants perspectives on continuing medical education. This chapter includes descriptions of the participants, the interview settings, and selected excerpts from the interview tra nscripts in tandem with review document data and recent literature that parallel the interview data analysis and findings Excerpts from the reflective journal and field notes are included. Participant Overview The researcher selected n ine individual s as prospective participants based on their educational level and national involvement in CME as described earlier E ight experts accepted the invitation Upon receiving permission from the USF IRB, I contacted nine prospective participants and all agree d to participant except one and, as of June 13, I have not heard from her after two attempts Two of the 7 have not been scheduled as yet I was delighted and surprised that they would say yes so readily My friend Suzanne said that the doctoral club is not very big and they are willing to support me as a result ( Reflective Journal June 13, 2009) To protect the identity of participants, the composite view provided in Table 1 below includes no individual identification. T he selected experts had many yea rs of experience, achieved advanced degrees and met the criteria set forth.

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94 Table 1 Participant Demographics and Interview Details Alias Meets Professional Criteria Education Years of Experienc e Interview Interview Duration (in minutes) Informed Consent CV/ Bio Mr. Blue Yes MD 40 June 29 56 X X Mr. Gray Yes PhD 33 June 25 56 X x Mr. Green Yes EdD 30 June 25 41 X x Mr. Red Yes MEd 20 June 30 54 X X Ms. Amber Yes PhD 18 June 30 telephon e 30 X X Mr. White Yes MD 37 July 22 80 X X Mr. Black Yes MD, MS 20 July 2 45 X X Ms. Brown Yes MA 13 July 15 60 X X Upon interviewing the experts and reviewing vitas resumes and biographies a long list of professional positions and a wide range of work settings emerged These are presented below in Table 2.

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95 Table 2 Participant Work Settings, Work Roles and Leadership Roles Work Settings Professional Associations Leadership Roles Employment Roles Other Designations Medical School University Pharmaceutical Industry Government Regulatory Agency Medical Association Medical Specialty Societies Acc reditation Agency Private Companies Entrepreneurial Ventures Health Care Military Voluntary Health Organizations Professional Societies Medical Communication Companies ACCME ACME AMA AAACE AATD NAAMECC GAME ABMS SACME PACME Committee Chair Accreditation Surveyor Committee Member IOM Committee Member or Reviewer Board of Directors Physician CEO President (private company) Medical Director Professor Assistant Dean Associate Dean Associate Vice Chancellor Consultant Project Evaluator Assistant Director, CME Director, CME CME Provider Director, Professional Development CME Dean Executive Director National Director Senior Consultant Executive Vice President Director of Education Senior Director Director Training Advisor Special Advisor Accreditation Manager Reg ulation Specialist Author Editor Presenter Fellow, ACME CCMEP Distinguished Service Award, ACME Presidents Award, ACME Frances Maitland Award, PACME Precepts of Hippocrates Award, GAME Six Sigma Fellow, RCPC Fellow, ACPE

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96 The Interviews T he following section describes the settings and the interviews Participant introductions are in order of appearance and described in detail in the field notes The interviews of Mr. Gray and Mr. Green were in the same location while we attended a profe ssional meeting w h ere the y were speakers Because of a last minute change in reservation s we moved from a semi private dining area just off the main restaurant to a concierge room, which was more conducive to conversation due to the unanticipated noise le vel in the semi private space. The concierge room was essentially a hotel guest room with a small sitting area where we were able to make ourselves comfortable. There was a large curtained window and the room was furnished with dark brown tables and dress ers accented by colorful Mediterranean decor Fortunately the hotel dining staff and management were accommodating about the change in location and brought coffee for Mr. Grays meeting We had lunch outside during a break fro m the conference and the inte rviews. On June 25 and 26, I attended the [state] CME Providers Conference in [city] I interviewed [Mr. Gray] and [Mr. Gree n] who presented at the conference. [Ms. Amber] also lectured but I interviewed her via telephone on June 30. Interestingly, both [Mr. Gray and Mr. Green] repeated some of the same opinions expressed in the interview in their presentation A s it turns out, they know each other pretty well and have similar perspectives about ACCME and PI CME as w e ll as where they think CME is going I am looking forward to finding themes to see if they are that similar. Of course my arrangements for a private dining room fell apart, but the staff was able to offer a guest room (concierge room) so that the interviews were conducted in a very quiet plac e just a little weird to be in a guest room. The dining room would have been too loud anyway. Mr. Gray did not want breakfast, so we had coffee Mr. Green had already eaten lunch, complaining that the break fast offered was not adequate for his needs. (Re flective Journal July 2, 2009)

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97 I interviewed Mr. Blue and Mr. Red during the course of a professional meeting where they were both meeting attendees and speakers My conversation with Mr. Blue took place during lunch in a private dining room in an hist oric hotel in the northeastern United States The staff was very attentive and tried to be quiet coming and going However, as we sat down, the fire alarm went off and was so loud that we had no other choice but to go outside until it stopped. We even watc hed the firefighters arrive axes in hand! Luckily, it was a small problem and we were able to enjoy our lunch. Mr. Red and I met in a small meeting roo m during breakfast on the following day ( Note: In the future, I would avoid interviewing during a meal due to the constant interruptions and the challenge in transcribing the interview) Once more, the staff was very gracious and accommodating The room was a simple one large enough to hold about 12 people comfortably around a conference table. I noticed the deep blue paint, wide white trim and floral wallpaper accents It was quiet and we were able to converse easily. On June 2830, I went to the [Conflict of interest] in [city] at the [ Hotel ] very nice! [ T hree participants] presented the CME component on Sunday. I then interview ed [Mr. Blue] on Monday and [ M r. Red] on Tuesday [Mr. Blue] and I met in the [r oom ] a small private dining room which was wonderful until the fire alarm when off for about 10 minutes We ordered lunch, stepped outside to chat a nd saw the arrival of the firefighters with axe and pick in hand! There was no big emergency thank goodness Trying to have a meal while interviewing is a little difficult due to the constant interruptions and extra noise, but [Mr. Blue] appreciated the lu nch I interviewed [Mr. Red] in the [ room ] a small conference room on the lower level We used room s ervice for our breakfast which was also appreciated and there were fewer interruptions ( Reflective Journal July 2, 2009) Ms. Amber was a speaker at o ne of the professional meetings as well, but with her schedule we were not able to talk in person Instead, she was interviewed via telephone using an ear device to record the conversation. While attending the conference in late June I found an historic lounge with carved oak wall panels and trim, beautiful

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98 chandeliers, f urniture befitting the 1900s when it was built and huge floor to ceiling windows graced with beautiful red window coverings overlooking the commons. According to the hotel description, the room is reminiscent of a British Officer's Club in the Orient. The dark wood paneling and mirrors that flanked the dining area we re offset in the bar by smooth marble. O rnately gilded and painted coffered ceiling displayed coat s of arms and related sy mbols. I selected this space to conduct my phone interview when t he dining management assured me the large lounge area would be quiet during that time of day H owever, as it turned out it was anything but tranquil The only other person in the lounge w ho was at least 40 feet away, was a very loud patron with plenty to say The conversation was further interrupted by the clamor of the bar staff while they completed their mid afternoon tas k of unloading clean glasses, plates and silverware My stress lev el escalated and the transcriptionist ha d a difficult time discerning the conversation. I interviewed Mr. Black in his very cool corner corporate office with wedge windows overlooking a large Midwestern city His assistant initially greeted me in the mo dern lobby and shortly thereafter Mr. Black es corted me to his office. I am en route to [city] to interview [Mr. Black] at his officethis will be interview #6. I am very excited to hear his perspective. I heard him speak at the [ conference] present ed by the [organization] on [ month the 28th specific to CME. (At Starbucks) Arrived in [city] at [organization] and of course the [related organization] is in the same building! Could have tried to set something up thereoh well [Mr. Black] will try to meet with me early as the airport is expected to be jammed at 4pm ish The security lady said to get there two hours early! [Mr. Black] was awesome and had different perspectives all together He was able to see me early so that I was able to get back to the airport early Note to self : Dont travel right before a holiday for school stuff !! This does make for a long day but better than an overnight stay I guess.

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99 He was dressed casually (short sleeve dress shirt) Corner office literally wit h couch and chair, conference table and desk Nice size Cool metal flower sculpture and mobile Grand view of [city] [ Assistant ] came out to introduce herself the receptionist was also very nice. [ R estaurant ] is next door and, apparently that is the c orner where baseball fans congregate prior to baseball games then take the train to the game. (Reflective Journal July 2, 2009) The only participant who travelled to see me was Mr. White He visited for several days with a friend and dropped by my off ice. My work space is small and sports an interior window offering a view of the library It was decorated about fourteen years ago with teal gray modular furniture in an L shape against the walls and an oval desk. I have two guest chairs and the usual c omputer set up along with several filing cabinets Other th a n the window, my favorite view is of a large Banyan Tree water color On July 22, I interviewed [Mr. White] in my office He has so much going on and so much information at his fingertips especially about the history of CME and AMA, etc It was a little difficult to stay on track because the information he provided was very interesting to me and we went off on many tangents He was delightful The book he is editing sounds very interesting as w ell it is about the history of CME. (Reflective Journal August 5, 2009) I interviewed Ms. Brown in a small meeting room on the first floor of her office building. The receptionist greeted me, and I waited in the lobby for a short time enjoying a pictorial history of the state. We sat at a beautiful round table in a colonial style room with red carpet, robin egg blue walls and white trim. It had a very high ceiling The lofty window allowed the morning sun to drift in. Interviewed [Ms. Brown] at her office building on July 15th in [city] which went very well She has a very interesting perspective since she is an accreditor, a provider and a site surveyor A s expected she had a lot to say I was a little surprised about the fact that the Medical As sociations were not involved in the most recent changes in the guidelines She seemed to be quite frustrated about that lack of involvement or lack of input But she attributed it to [the fact that ] they [ACCME] wanted to make a change without having to w ait and it made for a clean cut change. (Reflective Journal August 5, 2009)

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100 I am really very excited about my research and the outcomes thus far I am hoping to conduct the follow up via telephone just because of the time and expense Everyone has been excited about what I am doing, is eager to see the final product and ha s been complimentary of my background and experience indicating that I should be able to find a job fairly easilylets hope so! (Reflective Journal July 2, 2009) Research Questions The research questions for this study were: 1. What are the major elements of CME ? 2. What influences CME? 3. What are the most significant issues in CME? 4. What is the future of CME? Summarized data obtained from the interviews follows along with direct quotes fro m the participants As described in Chapter Three I reviewed categorized and coded the answers for each question from the transcripts to search for general themes. I have read through four of the eight interviews and listened to two [so far] to be sure t hat the transcription was accurate especially [Ms. Amber s ] as there was a lot of background noise and [the transcriptionist] ha d a hard time with ithowever, she did a great job capturing 9095% of the entire conversation I just ha d a few corrections. Now I need to refocus on looking for themes in the four transcripts I keep going back and forth about how I should do it and am VERY distracted by the absolutely beautiful weather Today it is clear as a bell with a nice breez e Am about ready to take off for the Beach !!!!!!!!!! Will need to get up earlier tomorrow and get to the WiFi place so I can do a little research in the Qualitative Weekly, etc. Rubin and Rubin is OK, but I think I have other books to use as well they are due back at the library! (Reflective Journal August 5, 2009) Question One What are the major elements of CME? Accreditation and physician involvement were the themes identified by the participants. ACCME was the short hand code representing the accreditation element

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101 and physician involvement the code which was inclusive of physician participation in the planning process, attendance and support of CME initiatives ( Please refer to Appendix J for the original categories and codes and Appendix L for the final categories and codes. ) Even experts in the field have difficulty narrowing down the answer to this question because there are so many components as exemplified by Mr. W hite. I dont know how to answer that I think CME has got to be committed to one cause which is helping physicians stay current and not only in clinical knowledge, but in the developments around them. Thats the CPD [continuing professional development] part so its working with themes, its working in the systems, its exemplified by the maintenance of certification programs of the ABMS Boards [American Board of Medical Specialties ] The ACGME is now enforcing residency training requiring these various competencies. CME has to stay focused on these new directions and not get hung up on any one area. But it really needs to keep doing many things including research. Without research and without publication, its never going to achieve the academic respect it needs. Accreditation Providers must have the accreditation component in order for the American Medical Association to accept CME, for it to meet state and federal requirements and to maint ain certification. In its publication, CME as a Bridge to Quality ( www.accme.org ) the ACCME encouraged providers to take action and demonstrate the value of CME to their stakeholders. In his introductory letter, Dr. Murray Kopelow stated : It is a critical time for continuing medical education (CME) to address the competence and performance gaps of physicians that underlie deficits in the quality of US healthcare. Accredited CME is an essential component of continuing physician professional development in the eyes of the US organizations of medicine that comprise the ACCME member organizations. For almost 30 years, the ACCME system for accredited continuing m edical education has provided

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102 standards, criteria, and policies that define what it means to be a provider of CME. The ACCME recognizes that US healthcare is at a crossroads, and that accredited continuing medical education is being asked to provide solut ions to bridge healthcare quality gaps. The ACCME system is an essential link between the lifelong learning of physicians and State and Federal requirements for physician licensure and Maintenance of CertificationTM. Accredited CME connects current practice to best practice. Your stakeholders need to understand just how important this role of CME is to the healthcare mission of your organization. In this framework, accredited CME is one of our nations strategic assets for improving care and an important partner for change to your physicians and your community of practice. ( Accreditation C ouncil for C ontinuing M edical E ducation ,2008a ) However, the IOM committee in Redesigning Continuing Education in the Health Professio ns (2009) noted: Health professionals and their employers tend to focus on meeting regulatory requirements rather than identifying personal knowledge gaps and findings programs to address them Many of the regulatory organizations that oversee CE tend not to look beyond setting and enforcing minimal, narrowly defined competencies. (p. 3) The report further stated in Recommendation 6 that the new Continuing Professional Development Institute (CPDI) should work with stakeholders to develop

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103 national standards for regulation of CPD. The CPDI should set standards for regulatory bodies across the health professions for licensure, certification, credentialing, and accreditat ion ( Redesigning continuing education in the health professions Institute of Medicine, p. 90) C onsistent regulatory and accreditation approaches could further assist in the interdisciplinary team education en visioned by the development of the CPDI. Mr. Red was an eager participant. Dressed in business attire, he was relaxed and thoughtful In fact, he seriously considered my questions and had made notes in advance. He seemed very interested in my perspective as well and was complimentary of my skill set as a CME provider Interestingly, he wa s one of the first national figures with whom I identified early in my CME career He was an effective presenter and no t shy about sharing his personal opinion. The topics that stood out in our conversation included balanced funding, MECCs role in CME, Conflict of Interest, and PI CME Here, he shared his perceptions on the element of accreditation: Alright because what does define it today in my view and goes to part of y our other question is that its much too oriented around process issues. When I think of CME as a profession its all about process, which is very different that what in my view of what it should be The profession is very focused on outcomes and quality i ndicators For example, while I have great respect for the ACCME [he] talked about some process measures the other day. Someone asked him about medical education companies, and his defense of them is that theyre more compliant than the other provi ders. He was talking about how theyre more compliant basically. And if you look at process measures in terms of the activity files and consider the resources and personnel they have, absolutely theyre more compliant But thats completely a process measure that belies that fact, and I dont want to skewer them all because there are wonderful ones out there, but as a general statement from my experience they are far less compliant in a much more serious way than the provider types. So that for me is but one example of the system is driven by process measures And you as a provider are encumbered by an extraordinary expense around those process measures Extraordinary bureaucracy that you have to follow, that at the end of the day does not contribute to pa tient health. So when I think of the kind of

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104 major elements that define CME today, Im struck by it. Its much more process rather than outcomes oriented. What it could be is very different. MARTHA: What do you think it should look like? I think the inte ntion, and I think the ACCME has articulated this so I dont want to sound anti ACCME but I think the orientation towards being the strategic asset for quality improvement within a healthcare institution is absolutely dead on right. I believe very much in that. I think were too slow in getting there. I think we have too many legacy issues, like a lot of the issues around commercial support and MECCS and different provider types that will slow things down. Too much time is being spent managing those issues rather than moving faster towards becoming integrated within institutions like yours, where youre probably like many, probably politically marginalized more than you should be. So those types of issues are very much on my mind. MARTHA: So do you think a sort of bureaucracy issue with the organization itself ? I dont think youre alone in that in thinking that there are too many concerns about whats in the file and how many Ts you cross correctly, or which Is you forgot to dot. Well said T hat s exactly what Im talking about. (Mr. Red ) Mr. Gray is well known in the field and I have had the opportunity to meet him in the past He was easy to interview and he was funny He focuse d on PI CME and the quality improvement process. I lear ned during our discussion that he completed a qualitative dissertation and was very interested in my work. He dressed in business casual attire w a s very animated and a fluid conversationalist He expressed his opinions and bias unabashedly He is an excellent speaker and teacher The areas that stood out were PI CME, if I were King of ACCME , physician funded CME and mission driven CME. You can come at that from a lot of different directions. I always kind of take it from the physicians per spective. To me, physicians by training and by be nd have a particular interest in being sure they keep as current as they possibly can, given all of the constraints they have, to provide the best possible care. Continuing medical education to me is a resou rce system that physicians go to feed on that professional interest, thats one of their professional obligations. So when I look at defining continuing medical education and when I talk about it, I talk about it as were not the engine on the train of quality for health care; were just kind of coal in the coal car. Were one resource physicians can use. We have an

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105 obligation in continuing me dical education, especially now Weve been talking for many, many years in our domain of practice to really have a n understanding of what practice is. So one element of continuing education as far as Im concerned for your particular target group, whatever that is, is to have some sense of what practice should be, what should be going on. Then we have the obligation of working with our physician colleague to identify the difference between what is and what ought to be, the kind of old model that weve always used, and really specifying what we think are the gaps in there. As CME providers, one of the elements our resp onsibilities is clearly to find the practice gaps, and then engage ourselves as educators because it is continuing medical education, and identifying from those things what things can be changed by education. Not all of them can, in fact, most of them can t. Its not that the physicians dont know; its just that they dont do. So understanding our practice and understanding the practice of our constituents, and understanding the gap between the current practice and the desired practice, I think, is one of the elements of continuing medical education from a provider prospective and I think that when physicians come to us they should have an expectation that we know what were talking about, that we can demonstrate to them that we understand whats going on in their world a bit. We understand that there are some things in their practice that maybe because of advancements or slight changes or old uses or new uses of old products or new products, that we are actually able to engage them in an activity that fits how they approach problem solving and design our learning activities or design our learning resources so that its easy for them to look at and engage in and to learn from. From that side of continuing medical education, I think those are some of the majo r elements. Of course, we always want to know if we make a difference so theres got to be evaluation there But you know the components, when you look at the different elements, theres a whole way to look at it from a systems perspective, continuing medi cal education to be integrated when youre in a hospital setting, youre in a hospital setting. One of the things that ought to be a part of a hospital continuing education is the way you integrate themselves into the institutions efforts to improve their overall care theyre providing the patients. How do you do that? One element of that is collaboration. Youve got to collaborate with the quality people. Youve got to collaborate with the clinical people. Theres that whole collaborative thing. You bring something to the table to help them manage, so within an organization one element of continuing medical education has to be an understanding of this system and integration into the system And one way to demonstrate the value that you have in that organi zation by showing what you do makes a difference. It means you can actually qualitatively or quantitatively show that we did these things and we had this impact. So thats another element. Theres the whole external elements now, external requirements that are put on us by our accredited providers, understanding that, the stark [Stark Law], the PhRMA code, the FDA stuff so another element of continuing education is an understanding of all of those things and how they impact your practice wherever

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106 you ar e in terms of your own organization. Then theres that annoying litany that we have to go through with regard to disclosure and financial support, and all of those kinds of things so its kind of like physicians arent smart enough to know the difference b etween market driven education and a real good clinical education so you have to be their intellectual chastity belt, I guess you would saySo one element is regulatory, one element is education, one element is systems. From a personal perspective, its my responsibility, to maintain some capabilities to work in all of those areas, so thats an individual capability. When you talk about elements of CME, its all over the place. Its not an easy job. Its fun but its not an easy job. (Mr. Gray ) Mr. G reen also wrote a qualitative dissertation The key to CME from his perspective is to increase self directed study in CME particularly since younger physicians are the most self directed group ever seen However, he feels this group will remain independen t in the search for knowledge via technologically advanced tools He also anticipates a move toward physician funded continuing education. From his perspective, CME research is not necessary because it does not differ from other type s of adult education. Y eah, the major components of what this thing is called? Called CME? (Laughs.) Ive talked to people in the past about this, and I still believe the same basic things. That you saying something in CME you just cant get away from an adherence to the ACCMA criteria that has to be referenced, to tell people what youve done and saying that you are going to be accredited or youre going to produced a certified CME. Youre now engaged in a national definition of what this thing is. There is an old joke about the umpire, and the star hitter; and the ball being thrown by the pitcher and the umpire immediately announcing if it was a ball or a strike, and on the three and two count the ball thuds into the catchers mitt, and theres no word from the umpire for a few seconds so they all start whirling around saying What was it? It was a ball or a strike? The umpire says Sonny, it aint nothing until I call em. (Laughs) Your educational activity aint nothing in terms of CME if it doesnt address the criteria, so aside from that it kind of relates to the criteria, but beyond the criteria the CME should be about topics that are focused on particular highly identified needs of a particular physician audience Say you have particular need, [a] particular audience and there has to be a meeting, a juxtaposition of those elements. If youve got things that a physician audience has been shown demonstratively to need, they recognize that they need it, and theyre engaged in educational pursuit to close that needs learning gap, then thats CME. ( Mr. Green )

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107 Mr. Black attired in business casual, was prepared for the interview and clearly, it was not his first one Before we began he clarifi ed the purpose of the interview Its on continuing medical education and its directions and evolution. And you are talking to us because we contribute to those directions and evolutions We might have insights about the future and the past OK Thats the path that CME has taken. As described above, Mr. Black also generally defin e d CME as a set of resources The other thoughts I had immediately after the interview wer e accountability, strategic management and leadership, a revised credit system, and high expectations regarding the skill set of the individual CME providers A prima ry component of CME from his perspective is the need for strong oversight in an effor t to ensure that providers are wor king within the boundaries of appropriate behavior First some lingo. To me, continuing medical education is a set of resources that support the continuing professional development in physicians. So CPD is an individual journey and a journey that the whole population of docs go through starting with questions in practice, from getting new information, developing new knowledge, putting that knowledge in the presence of wisdom or judgment into new strategies and putting it into practice, testing it in a practice, and keeping it going. CME are the sets of resources that support that journey. So lectures, the web, and what you read is didactic in nature; going to get new information When you do a small group work and work with experts, youre doing analysis, and synthesis, and putting it into strategy. And when youre doing hands on educational activities, thats transferring it from your strategic strategy perspective right into practice. And you do that just before you use it in practice. So thats CME as a set of resources to put it into place I guess theres different ways to look at the CME system and the components of it, like the organiz ation of it. A s individuals and as professionals and as organizations, we need to have a manner of acting. We need to understand the difference between whats acceptable and whats not acceptable, whats good enough and whats not good enough. In society theres a proper way to behave so society doesnt fall apart. But as you move into having a task to do, theres deliverables. Theres a right way to do it. The fellow who fills up the dairy case in the store has to put his apron on properly, and wear his hat properly, and stack everything properly in order to

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108 deliver what the storeowner wants. Its the same with any professional pursuit, especially where theres heterogeneity of the people involved, and the values arent all recognized and shared. Theres a need for an external application of standards In society we have the law But mostly were not regulated by the law. Were regulated by our own personal value set and what we understand. CME is the same. Its a heterogeneous group. Most medical schools specialty societies, education companies; they dont really need our rules to do a good job, to do the right job. But there are always places where people dont know what to do, so they have rules to guide them. And there are people who dont know the di fference between right and wrong. If you get somebody who comes from automobile sales and is now involved in pharmaceutical sales, they dont necessarily understand the rules of this game, and you need a set of guidelines and rules to manifest it. And thats what accreditation is about. Its about reflecting whats right. Its not about creating whats right. Its about reflecting whats right. [ACCME] is made up of the seven member organizations that expect and require that we operate within certain constr aints, what our mandate is, and everything we do needs to be focused on clarifying and improving how people conduct themselves as facilitators of CME. Whatever resource you pick to be, there needs to be some sort of guidelines on how to behave. Thats what accreditation is (Mr. Black ) Ms. Brown was relaxed talkative and animated. Outfitted in business casual, she too was prepared for our conversation. She is an energetic woman who cares deeply about her role in CME Her insights were differen t from the others due to her role in CME Physicians should be the centerpiece of CME and it should be by physicians, for physicians. She expressed a genuine concern for training the state accredited providers and assisting them in maintaining their a ccreditation. She consider ed the ACCME a partner but reflected on the lack of input provided when there were significant changes mad e without comment from state medical associations and other providers. Every year the ACCME holds a state medical conference. We gather as a group of professionals, and its a meeting thats run by the ACCME but its content is directed towards state medical associations. I would have to say that the implementation of the updated criteria, the state medical associations have no voice at all. In fact the day that I learned about the updated criteria, its the same day you learned about the updated criteria. It was an email in September of four or five years ago. We were on our way to annual meeting, I opened up this email and thats the way that it came. I would say that

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109 was a surprise because in the past there have been a lot more opportunities for comment. I think the ACCME are always pretty inclusive of the whole CME community and so they usually would propose something, there would time for comment, discussion and review of any information that might come forth from that call for comment, and then they would make that final decision. That might be an 1824 month process. So I think that state medical associations, I think the way we view our relationship with the ACCME is a partner. Were an accreditor just like they are. Obviously, its a tiered system. Theyre more responsible for the defining policies, procedures and criteria, but in partnership with the state medical associations. I think the ACCME doesnt see it quite as a partnership. I think that to me was a defining moment in our relationship with the ACCME. Although I spoke to a few physicians on the accreditation review council for the ACCME at that same time, and they learned about the updated criteria on the same day as we did as well. Thats probably more indicative that the ACCME had made a decision that there needed to be a sharp turn in the direction that CME was going in, and I think the board decided that this i s the way were going to do it. And that was definitely a left turn or a right turn, or whatever. But I think that in general the ACCME is a partner with the state medical associations, and for sure that the understanding is that whether youre state accredited or nationally accredited its the same thing. The same expectations, the same quality, the same output of education if you will, and that is definitely that the [state medical association] takes very seriously. We should be the role model. Whatever w e want our providers to do, for sure we should be doing it times ten. So we really try to do that, and I think weve been fairly successful in being a role model or mentor for organizations located in [this state] (Ms. Brown ) Physician Involvement Involvement at the physician level is crucial to a successful CME program because their knowledge, expertise and front line work experience aid in developing educational initiatives that meet the needs of their colleagues and close knowledge gaps. At any rate I see a physician becoming aware that they need to learn things and then consulting with a CME office and putting together a learning plan that might include formal CME, some sort of mentorship, or Im going to travel now to Tennessee to spend th e day with Dr. Baker [referring to the researcher after graduation here] who is going to teach me how to do this particular technique, or to improve my practice with management skills, whatever the learning skills I might do some online kinds of things, I might do some patient simulation kinds of things, and then the CME office will be in charge of monitoring the quality of that experience and assigning the appropriate credit. Thats what I see. It kind of begs the question, who will pay for this? Marth a: Good question. Well, youd think it would be the physician.

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110 Its going to be the physician. I think the self directed kind of CME that I see coming will be physician directed and physician financed by and large. And do I think some hospitals will pay for that ? Will Bayfront pay for that ? Maybe CMEs can be more about physician practices than it will be about hospital needs. The kind of problem we have now with whose accredited? And what is their mission ? Is it their mission to make sure that every doc tor on their staff gets all of their little learning needs met? (Mr. Green ) I guess the way I view CME and its very much based on and the education that I received from our CME committee. I was mentored right from the very beginning when I got he re, and CME is education is planned by physicians for physicians. Sometimes I wonder if there arent other organizations, other people who have a different opinion of that but from my standpoint it is for physicians, planned by physicians, so physicians ha ve the instrumental role in defining gaps, planning, setting the objectives, choosing the speaker, setting the content. I think to me that is a sacred role. Physicians have to remain at the center of the system. If they dont, then its just professional education for anybody, for everybody. But I also think that its definitely based on principles of adult education. I recognize that, so I think that it is extremely important to recognize how adults learn. Physicians are no exception to that. For sure adult education, but again the role of physician to me, I cant overstate it is that too many times we try to take them out of the equation and thats wrong. And I also see the CME system that facilitates learning, rather than a system that just produces curr iculum. What I mean by that is that as a CME provider, Im not really teaching physicians as much as Im helping physicians to learn to teach themselves what they need to know. Thats how I view CME. So those are the elements to me. Youve got the physicia n role, the adult education, and then a system of not teaching but facilitating learning on the part of physicians, so they can change themselves. The thing about adult education is I think that because were adults, we know a lot about adult education. We may not know we do. We may not have the terminology, but we know from going to classes, or anything that we do we understand. I think subconsciously Ok lecture is not as good as whatever but I think they dont know that they do know what they know I t hink we have to really develop the talent of our CME planners. I think we also need to really develop our physician champions And that I dont know how to do. Again, one of the things weve talked about is the time crunch that physicians are under. We had a speaker at a meeting, I dont know if you were there, five or six years ago, Dr Trae Dunaway. You really have to date your doctor to get him to be that physician champion. That was his theme, You have to date a doctor to really encourage him or her to get involved in the process . Its kind of a wooing process; grooming, and I think thats really tough. And its physician leadership and understanding the rules, and just being involved in the process. That to me is the difference between a successful CME program, and a CME program that follows the rules but theres no enthusiasm, no energy, theres no magic. If you dont have a physician who is pushing, because the staff cant really do it. It has

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111 to be physicians because its their program. Its for them and I think the administrators listen to the doctors, listen to the physicians; not so much for the staff The physicians are the ones who make it happen, so thats the difference when you look at a CME program You can follow the rules, and review the paperwork and all that stuff but if you dont have some physicians that are on fire and committed; Were going to have this program, then its not going to work. Its just kind of there and theres not a lot of success. And so I think professional development not only for staff but for physicians. I think that providers need to learn to embrace the idea of partnership more. I think that we think that we have to do everything and be everything, do the evaluation, try to figure out how to measure change; technology. We cant be everything. And so I think we have to really start thinking about strategic alliances and partnerships, and reaching out to other organizations and types of providers who can help us become more successful. (Ms. Brown ) M r. Blue was an inspiration to me as a CME professional and doctoral student His work, like several of the participants, g enerously sprinkle s throughout CME literature and includes sentinel research He has employed qualitative research He seemed delighte d that I would be interested in what he does and was yet another animated and energetic conversational partner Dressed in business attire, he managed to stay focused over lunch and, of course during the fire alarm! As he pointed out, another perspective of physician involvement is the knowledge translation that occurs with the physician learners in the educational process The physician s practice environment also needs consideration in the planning and implementation of the educational activity. M ARTHA: You kind of mentioned though what youre doing now is some of the major elements that comprise continuing education in medicine. Well and/or across the professions it seems most recently that the performance improvement is where people think were going. I think so. There are a lot of things to say. I know you have other questions. The first thing to say is that primarily just thinking about CME that the thing that would change your behavior, learn pretty quickly, that wasnt true. That its other things I embarked on the change study with [co authors] and learned a lot through that. Part of it was ethnographic measures, quality of interviews, so I learned a lot. M ARTHA: (laughs) Imagine that!

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112 I learned a lot about what makes best change, and it wasnt just CME activity. Then lately in the last twenty years or so, Ive been involved in knowledge translation efforts, which are more comprehensive, which understand the setting of the practice environment. The uptake by patients as well as by professionals and policy makers, payment systems, reimbursement systems, so the whole package of how we go from heres a good thing to do to get the doc to do it isnt so simple So one of the efforts for me going into [this job] is to take this knowledge of thirty years of experience, and all the knowledge that we know about Continuing Ed and lifelong learning, and to be able to put it into place to make policies happen. Thats the excitement of it but thats challenge of it because its not easy to change systems. I never thought that when I came here that healthcare reform would even see the light of day. No matter who is elected president, were not going to see healthcare reform. And I didnt think wed see the amount of scrutiny about CME and conflict of intere st. I never thought wed see that. That was an elephant in the room that nobody would touch, just like healthcare reform. And I thought my challenges would be harder, because who would be listening ? Practically everybodys listening to the issues in CME, s ome of them in a negative way but mostly in a positive way responding to the challenges. MARTHA: And isnt the AMA is doing their transformation work too so it goes hand in hand with what Theres a lot of activity going on all in the same domain, all in the same time. So the CEJA efforts, the A M As effort, Im a big fan of the AMA and what its doingwere pretty collegial with almost every organizationthe Federation of State Medical Boards for example is also thinking of maintenance of licensure. The A merican Board of Medical Specialty thinking about certification in a meaningful waya long way off from where Id want it to be, but Im a big fan of the U.K.s system of revalidation which is pure chart audit I was part of something like that in Ontario. You could go in, watch another physician, look at his or her charts, give them some advice, pick out those people who might be drifting a little bit from best evidence practice and bring them back. Theres also a three year restricted license, you dont kn ow this in England. But as a GP for example which is 50% of the population, and even more as a specialist because its a long training pipeline for specialist in the U.K. You have three years that you have as a GP you have to practice with a colleague with a group. So youre a licensed physician, youve done your residency, been for three years under the supervision of a colleague or mentor MARTHA: A true apprenticeship. A true apprenticeshipmuch more of a true apprenticeship. Or you may be assigned or you can choose to go somewhere else Its a lot better training.

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113 MARTHA: Do you think thatll ever happen here? (Laughs) I presented the Ontario system to colleagues in Virginia many years ago And the Ontario system is the random peer audit. Its done by trained peers so dermatologists to dermatologist. I talked about it and mostly its been a positive experience with the odd physician who resents it; the odd physician who brings his lawyer in when a charge happens But somebody thanked me for the talk and said this, and I think this is true in the American setting. Here you wouldnt get past the front door because it would be restraint of trade. If you were to say to me as a GP, or general internist, or dermatologist Your practice is substandard in m y views and therefore you shouldnt be practicing and youll have to go back to school , thats restraining my trade as a dermatologist And that from what I understand (with the nods in the audience) was pretty sacrosanct in the American context. (Laughs ) That may be changing With the advent of healthcare reform, we heard some of that today, the elephant in the room is over utilization right. We were talking about that outside. MARTHA: Part of the factors that are influencing continuing education were br ought up pretty well in the last couple of days in terms of conflict of interest, the disclosure, and who can you get to speak if y ou only have five experts [to chose from] Thats right. If its a very rare disease for example, who are you going to get t o speak on that only has five experts universally ? I think disclosure is (not to digress from your questions), but I think disclosure is necessary but not sufficient. I think disclosure is all we can do in CME. I think part of the role of AAMC is to make i t easier for the CME provider, so theres an online resource where every faculty member has to go and it probably shouldnt be housed at the medical school Kept maybe by the AAMC, so if Im a Harvard person going to Duke, the Duke CME provider just has to go and check on the disclosures. (Mr. Blue ) You know I can reiterate the educational planning process, and my approach to pulling it together. Which means robust practice gap analysis and developing goals and performance based objectives, ide ntifying the correct format, and implementing the program in a way that its effective and efficient, and then evaluating it different ways. You know the overall gestalt of CME is to improve patient care, and ultimately patient health as difficult as it ma y be in our current environment, with the lack of data, the inability to access data. Its very difficult to demonstrate cause and effect, return on the educational effect both financially and in adult education. Youre are in line for challenge and Im pl eased to see the direction were going in which is not seat time, but maintaining certification which is very good for competency and the documentation. As much as everyones complaining about it seems to be the only rational and reasonable approach to improve patient care, which is our ultimate goal. Other countries

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114 spend far less for total care and have improved outcome, better outcome. (Ms. Amber ) IOMs Redesigning Continuing Education in the Health Professions Recommendation 8 suggested training health care providers as teams to facilitate collaboration, align communication, and share advances. Recommendation 9 encourage d physician involvement using portfolios and other development tools to document their educational pursuits and their progress This put the physician in the center of the learning experience. Recommendation 8: The Continuing Professional Development Institute should identify, recognize, and foster models of CPD that build knowledge about interprofessional team learning and colla boration. Recommendation 9: Supporting mobilization of research findings to advance health professional performance, federal agencies that support demonstration programs, such as the Agency for Healthcare Research and Quality and the Health Resources and S ervices Administration, should collaborate with the Continuing Professional Development Institute. (Institute of Medicine 2009b, p. 8) Summary of Themes Question One What are the major elements of CME? Accreditation Excerpts selected from the IOM report, Redesigning Continuing Education in the Health Professions (2009) illustrated the importance of accredited CME However, a s expressed by the IOM committee, providers are distracted from design ing, delivering and evaluating CME intended to clos e knowledge and professional gaps by the pressure of meeting regulatory requirements. While M r. White is very familiar with the history and importance of such regulatory agencies, he suggested that

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115 time w ould be better spent focus ing on the physician competencies outlined by the ACGME and ABMS to ass i st target audiences close those gaps and support physicians in their maintenance of certification The Joint Commission expects that these same competencies are met during ongoing professional performance evaluations of hospital medical staff physicians so it is a logical focus for continuing medical education. Mr. Red, Mr Gray and Mr. Green noted the expense of fulfilling the regulatory process and burea ucra tic requirements. From their perspectives, e xpenditures of resources should be directed to impacting patient care through educational interventions The perspectives of Mr. Black and Ms. Brown lean more toward the expectation the provider s will demonstrate adherence to accreditation requirements in order to maintain their status as accredited CME providers. The general perception is that CME professional s struggle to meet all of these expectations. Physician Involvement Here the IOM redesigning c ontinuing education committee recommend s interprofessional team learning and collabora tive patient care. Physician s can still center their self directed assessment of knowledge and performance gaps as well as identification of appropriate learning experiences in this interprofessional model. Mr. Green sees the CME professional as a facilitator to assist in the development of a learning plan inclusive of multiple types of interventions and based on self directed approach and to monitor the quality of thos e learning experiences. The inter professional team experiences would be yet another intervention to achieve the desired outcome. Ms. Brown and Mr. Blue reflected on the importance of physician involvement in the development and implementation of CME. Ph ysician champions are key to ensure the ultimate design and delivery of interprofessional team based learning and collaboration

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116 for team based patient care is consistent with guidelines, protocols and best practice. Mr. Blue reflected on knowledge transl ation in medicine at the physician level and the challenge of embracing the wealth of knowledge in continuing education and lifelong learning to design a nd imple ment policy and system changes. Question Two What influences CME? The most influential forces on CME are funding, physician involvement, and ACCME ( accreditation). Funding from commercial supporters is dwindli ng in the realm of CME, in part because of accreditation requirements to resolve conflicts of interest and demonstrate transparency in educational programs The involvement of physicians in assist ing with the identification of gaps and offering their expertise in discovering ways to narrow or close those gaps is crucial to the success of CME program s Funding The pharmaceutical and device manufacturing industries traditionally provided funding, in part, for continuing medical education, also referred to as commercial support and associated with conflict of interest. However, concern arouse that such funding might influence prescribing patterns and use of devices by physicians Also, the social component of CME programs was sometimes a la rger focus than the educational component Monies from these industries came from the marketing divisions or the promotional department. In recent years, management of commercial support from the pharmaceutical industry transferred from the marketing depar tment to the medical affairs department to reduce the chance of undue influence. In its report on Redesigning Continuing Education in the Health Professions (2009) the IOM commented on the current state of continuing education including funding.

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117 In medic ine and pharmacy and nursing to some extent pharmaceutical and medical device companies have taken a lead role in financing the provision of and research on CE. Such commercial funding has raised and continues to raise concerns about conflicts of interest and whether some companies are using CE to influence health professionals so as to increase market share. (p. 3) ACCME announced updated criteria in 2006 along with well defined guidelines for commercial support and insurance of the clear separation of edu cation and marketing. The ACCME system is focused on supporting physician learning and change to benefit the quality of care. In November 2007, the ACCME Board of Directors articulated that, the concepts of independence from industry and collaboration wi th industry in the development of [CME] content are mutually exclusive. Although commercial interests may provide commercial support for educational activities as defined by the ACCMEs Standards for Commercial Support: Standards to Ensure Independence, in the US in the context of independence, there is no role for ACCME defined commercial interests in the development or evaluation of accredited CME activities. 1 This defines the independence of CME. The CME community is not alone in its concern for improving health. The biopharmaceutical and medical device industries also seek to contribute to the improvement of public health. Although their products and services reduce the burden of disease and improve patient outcomes with

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118 innovations in therapy, thes e companies are ultimately responsible to the financial interests of their stockholders. Framed by the Updated Criteria, CME is an endeavor for medicine, by medicine. When CME fails to be exclusively oriented to measured gaps in the delivery of care, it ceases to be relevant to physicians in practice and, ultimately, fails patient care. Our most important stakeholder the American public demands that the CME system provide demonstrable value without influence from industry. In return, the ACCME is resolute in its efforts to ensure that CME is provided through a valid and credible accreditation system... independent of commercial interests and free of commercial bias in all CME topic selection, planning decision, and presentation content.1,2 (ACCME, 2008)13 The participants in the current study were also keenly aware of the current state of affairs regarding funding of CME and consider ed it an influential factor in the industry. Youre asking about some of the most influential things and this may sound strange, but I think one of the most influential groups in continuing medical education are the pharmaceutical, independent medical education grants people because these people in these pharmaceutical companies t hat are managing these independent medical education grants departments know our rules as well as or better than we do. And they know what ACCME requires, they know what AMA requires for credit. They know what OIG says. They know it all and they know it be cause their lawyers make them for compliance. So what they are doing when they are funding continuing medical education, is they are winnowing out the people who either cant write an educational grant like they know those rules, theyre winnowing out thos e that dont know the rules, and theyre funding the ones that do know the rules, that are pushing the envelope in terms of less traditional continuing medical education, getting into things that are blended learning kinds of things, and theyre getting into performance improvement kinds of things in continuing medical education, at least they say they are, theres not a lot of money in there right now. I think that they are pushing the field in a way that the field has been talking about going for years, not just doing a one off lecture, but doing a series of lectures that might have a theme to them, like a

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119 series of grand rounds on one topic, coming at it from different perspectives. Theyre pushing things like the use of audience response systems like we re going to have in our conference downstairs. Theyre pushing things like that, so in a very backhanded kind of way, they are under the gun for influencing medical education and all that They are the only people who are really pushing the profession and making the profession say, If you want money folks to do this, youve got to do it right. And to me, I think its great! I wish we werent as dependent as we are on pharmaceutical money, but we are, and that to me is one of the biggest influences in t he field right now The other big influence is ACCME and the new regulations and their attempt now in their thinking what the field should be, especially related to the commercial support thing we were just talking about whether you ought to label something commercial free or an author is a no commercial support author, which to me just piles on and piles on and piles on. Its ridiculous. And the other thing that could be very influential in the future depending on what ACCME does about it and their collective membership, is that they decide that this supe r pool of funds If they do that, its going to be huge but its not going to change one thing because people who know the rules are still going to be making the decisions concerning grant s. I think its a very bad idea. Its mission creep from ACCME That to me interferes with the enterprise within the field of continuing medical education. It intervenes between your relationships with a supportive industry that wants to do the best they can and most of them do. It creates another super entity and my guess would be that some pharmaceutical companies will not put into that pool because their compliance people say, We cant do that, because if you do that we dont know if our moneys going to something that would be off label for us. And some say, It doesnt matter because you dont know. But they do know. If their money is in that pool and all of a sudden something comes up, and a bunch of trouble comes from it, theyll come back to the super pool where all of the money is, and if my moneys in there That may be a negative scenario What ACCME is trying to do right now to push the field is very influential as well. With the current criteria, and with these efforts that they are involve d in trying to push the field, I think they are being very influential. I think in some small way from a public policy perspective not even in a small way, the A lliance [Alliance for Continuing Medical Education] is beginning to exert itself into the fie ld, taking on incoming public policy issues, representing the profession, and trying to be our spokesman out there when others have concerns. Its a tremendously varied membership. You have people out there that are totall y dependent upon pharma [pharmaceu tical] money, you know the MECCs and then others that dont get anything at all when youre looking at that issue. (Mr. Gray )

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120 You know all the ethical concerns, the funding concerns the acceleration of medical knowledge people dont have the time go to meetings. I dont see meetings going away. There will be meetings always, as people want to network. People say Im going to that meeting because I havent seen Dr. Baker [referring to researcher af t er graduation] and I want to ask her a question. O r, see you there! I just thought of this thing that I want to talk to you about thats fabulous But the technology people say you can recreate that But I think were hundreds of years away from people being comfortable with technology to actually do that But there will be fewer meetings Not as much funding available from external sources to pay for those meetings A friend of mine on the Alliance board told me about a brochure he saw from a specialty society that had two prices: one was the price with p harma support, the second box to check if you were of an ilk to disagree with pharmaceutical funding and continuing medical education this is the price you would pay. MARTHA: Really ? Was the price considerably different? Yes. Very considerably different. I havent heard the results of that but it was kind of a test case to see who would check the second box How many people actually would pay a lot more money to feel clear from pharma money ? But theres not going to be much pharma money in the future, so well have to come up with some ways to fund CME. On the state provider medical society provider level, the hospital has been funding CME for many years. I dont know if theyre going to continue to do so or at the same level. Can we have every Wednesday m orning Grand Rounds? (Mr. Green) Well clearly, the environment currently is for all of us both the regulatory environment, and the political environment. I think that most people understand that. What I would probably again compare and contrast, a little bit of what should be to what is. What should be influencing CME is very much that needs basis while the profession exists, how it contributes to improve healthcare quality that you as a professional within your own organization; that ideally should be the almost exclusive focus, the very data driven focus. But your reality unless youre different than most people, you have politics that enter into it, different departments are interested in referrals for example, deal with the issue of people wan ting things rather than needing it, so theres a gap between what should be and what is. When I think about what influences CME, resources influence it for some providers more than others. I think thats where the issue of commercial support certainly is problematic for a lot of people. If youre a department or an organization that does not have funding from your own institution, its problematic so unfortunately there is an influence about where resources come from. That remains a concern of mine. Ive be en an advocate of balanced funding for a long time. For institutions that are too dependent on the industry, I dont think should receive funding from the industry. In my view, it shouldnt be more than 50%. Weve only drawn the line at 90% currently. So I think that industry has to be careful of not setting standards. It should follow the lead of the

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121 profession setting the standards. But sometimes the profession is slow in setting those standards because of politics, especially the MECC community in partic ular wouldnt agree with this position. So resources certainly are the cons Yeah, its just between the environment, the politics, the resources; its a fairly broad brush of some of the influences out there right now. MARTHA: I dont know a lot about ME CCS, but from what other place would they get resources unless they had an owner who had plenty of money to spend? You must have some seed money to start with, but when you think about it that really is the only place theyd get money. Some of them have s tarted charging registration fees. What a novel concept. But by and large they are entirely dependent on the industry. I think that certainly raises a lot of questions that margins are very high. That is truly a growth industry from the 90s, especially w here there was so much blurring between education and promotion. There certainly are good ones out there You work with some in your own institutions. They serve you. They created the exit key well, great project managers, they do a lot of things well, the res a lot of wonderful people in that setting, but among those influences were talking about are conflict of interest inherent in an organization thats irrespective of what its mission statement may say thats 100% dependant on industry for funding. Tha t belies a different mission, and truly is a vendor in that mindset. If its not a healthcare delivery organization or professional association with a clear purpose caring for patients, if its only other purpose is to get money from industry and do what w e can get done because of industry funding. A process measure may have wonderful educational statements per ACCME requirements, but were not accessing the organizational conflict of interest thats clearly there. But I am in favor, I mean other than envi ronmental force that starts occurring is this idea of block grants. You as a provider dont have the time or resources to be applying for all these grants. (Mr. Red ) A discussion ensued regarding the researchers involvement with block grants provided by one of the stat e medical associations The association applied to one pharmaceutical company for a large educational grant to provide CME on a specific disease state and, subsequently, providers from the region had an opportunity to apply for a portion of the funds. Theyve had a real struggle to get industry to support that model but thats the future. Hopefully I dont want to see that effort die. I think that was an early attempt, and it shows innovation at the state. I think its interestin g right now. Were not seeing that with the national providers as much as with the state effort. Council of Medical Specialties saw it and is getting very interested in that

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122 approach, which could change the dynamic. So I think maybe to add to your list of influences, I mentioned the environment and regulatory issues, but I do think the recent I O M report calling for new funding mechanism to be proposed in two years, is a major driver of change and Im all for it. I think its a wonderful thing and the types of things Id like to see mandated today and from an industry perspective. There is just too much unresolved, and the system today remains too dependent on the competency within the industry around many of these issues. Thats always been a drag on the sys tem, because the best that you can hope for in industry is that we dont get in the way. I think to a large measure and I hate to say it this way I think the industry is a laggard in recognizing quality so people try to do innovative things, like your approach through Georgia. Its not recognized. Its different and it takes a long time for industry to see that as quality so the system needs to evolve in such a way that industry is not the one determining what quality is. My concern is that theres too mu ch of that today. Its not an intent to be biased, but theres a lack of recognition that people in industry, we dont know what we dont know. Industry people feel like we by and large know about these areas, and I think thats a real mistake for the syst em to be built where any dependency on industry competence or our view is part of the equation. As long as that many resources are coming So Im in favor of the block grant approach, I think it should be mandated. I dont think it should be updated. Indus try should not make that decision. Industry believes it has a role in this, and then this is the only way it will occur. If you choose to do it this way and make sure of that, theres too many loopholes and how that could be rolled out. (Mr. Red ) The interview with Ms. Amber, as noted earlier, was via telephone However, when I saw her give a presentation in June 2009, she was very professional and wore business attire The perspectives that she offer ed we re invaluable because she worked in al most every segment of CME, from the pharmaceutical industry to academia to consulting and several places in between. As a result, she was fluent in her responses and easy to follow. Based on my notes, her focus was on the importance of accessibility to dat a and tools in order to measure the impact of CME accurately and to demonstrate change in patient outcomes Accountability and adherence to accreditation guidelines were also important She envisioned CME becoming less a commodity and more maintenance of certification with points based on true needs. Here she discusses influences on CME followed by Mr. Black

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123 Well conflict of interest is a component, pharmaceutical funding, and the relationship between faculty and programs that are conducted and the relat ionship between the funding, the publications that are printed, and the content thats generated the type of clinical trials that are done. The conflict of interest is significant. Also, the lack of consistency in patient care, the overall the cost of heal thcare, the overall results of existing healthcare, the numbers of medical errors that are generated each year are really significant It tends to be addressed by some of the work we do. (Ms. Ambe r ) So there are all these forces. Then the other set of forces is the fact that medical education, graduate and undergraduate, and continuing medical educations funding is done totally differently. So the private universities do it this way, public universities the government pays for, graduate medical e ducation for some bizarre reason is paid for through Medicare. There are huge amounts of money that go from the government to medical residency programs because theyre so well funded; they can support a very large accrediting body. The ACGME has 150 staff people, [ACCME ha s] twenty. I dont know if theyre accrediting about 8,000 programs, but theyre probably not accrediting more institutions than [ACCME and there] 2,400 institutions in [ACCME] but theres not that many more in the ACGME All that money is golden for them. [CME] this is completely unfunded. The private sector funds a lot of it from commercial support, but in dollars perspective that might account for half of the money that gets recorded. If you think of the amount of infrastructure in teac hing and time thats donated by the profession, by all these institutions, theres a huge amount of money getting spent. Probably five or six billion dollars with only a billion dollars of income. And thats really a problem. As we raise the bar, a force a gainst progress is that as we make it more demanding in graduate and undergraduate medical education, they get more resources and more support, as students or residents have to do more and more In [CME] the resources get thinner and thinner. MARTHA: And thats the longest piece of their education. Exactly. The whole construct is a problem, and we have a world full of people that think we shouldnt take any commercial support, and we shouldnt have any drug company money involved in our system. And that s a firmly held belief; they really do believe it, and think it must have a negative consequence. But the jurys still out as to whether thats the truth or not. MARTHA: Right. And/ or that the physician should pay for it all themselves, thats another com ment that I heard. The physicians are contributing their time and fee forservice physicians stop generating income, and most physicians are feefor service physicians So from an in kind support perspective, theyre already kicking in two thousand dollar s per day for the educational activity. People need to recognize that. Yes, they

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124 might make $200,000, $ 300,000, or $400,000. Thats true. But that doesnt mean that theyre not paying for anything. And Im not opposed to, or I dont have a position on whet her they should pay for it or not pay for it. The medical residents dont pay for their education. And the undergraduate students that pay tuition, they come up with this enormous debt. They pay while theyre practicing for the first ten years. Theyre pay ing off for the privilege of being there. Its pretty complicated. Its a little simplistic to say that they dont pay anything. (Mr. Black ) Mr. White was the historian of the group with dates, facts, and names at his fingertips. In addition, he ha d knowledge from an international perspective because of his previous and current positions Somehow, without even asking specific questions, I was able to gather the data I sought. Portfolios, maintenance of certification, e learning systems based pr actice, and mission driven CME were the immediate categories of conversation. I was on the [state] Medical Association CME committee The interesting comment was for me that in several site visits ( of course you interview the C.E.O and they have all stopped taking commercial support ) t he C.E.O. has agreed with their CME coordinators who often arent very knowledgeable people about getting grants that this is too much hassle, and its not worth it, and we can do it in a couple of different ways The medical staff dues are often devoted to supporting the continuing education program and the library. I think thats very interesting as were going through the battles right now. Where will commercial support go eventually ? But I think the main focus for CME i s that it has to be embedded in the mission of the institution be it a medical school, or a medical center, like this one. (Mr. White ) Mr. White continued with historical data that pointed to the origination of the guidelines regarding commercial support I think that in 1997 the FDA issued their Guidance on industry supported educational activities Its an important document and it still stands. It was crafted after a lot of input from the CME community through the Task Force, and they had inter views with others but it was actually somewhere around that time, the task force first called on the ACCME to change their standards of commercial support which dated back to 1984 and were pretty general. Then in 1992 the Task Force made an offer by saying Dear ACCME and dear other accrediting agency including pharmacy and nursing, these are some improved guidelines for commercial support And then the ACCME, [ Sue Ann Capizzi was very involved at that point ] said no these arent guidelines; were going to make them

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125 standards. Then more recently, the inspector generals office is questioning things like can hospitals even provide CME for their medical staff ? Like this is some sort of gift. This is totally screwy. Pardon me but it is. They have no busines s in this, but we brought it on ourselves, I think, by our increasing dependence on commercial support. And in the old days, this support was often specifically directed. I know at [college of medicine] there were a few companies that I wouldnt even let i nto the office, because they wouldnt give you money unless you took their suggestions and used their speakers bureaus Get lost! We had the Upj ohns and other companies out there that didnt do that. Its perhaps a wishful spin but I think that they should have bigger fish to fry than worrying about us including incentives in CME including the Senate. But again, thats an issue totally mixed up with gifts to doctors. M A RTHA: It doesnt seem like the same thing to me but thats my opinion. It isnt bu t it gets lumped in because for them, and I dont think they live in their own world. Doctors are not all making these huge amounts of money that are heard about; pediatricians start with $100,000 salaries, and at least that much in medical school debt and so on. Well we dont have to go there anymore. I think a big factor though has to be dealt with, and thats the physicians dont pay for their CME. I think that were really off the deep end on that score. Now of course youve paid your medical school tui tion, and then in residency for the most part you got paid a pittance. In my case, my parents continued to subsidize me. I couldnt live in Baltimore on a residents salary in those days. Now you can because thankfully thats gone up a lot. Entering reside nts, Im not sure where they are nowadays but its ok. Not if youre married with kids, but its better. But doctors have not had to pay for CME, and this is antithetical in a sense to where it used to be I mentioned this 1932 publication from AAMC, their Commission on Medical Education, and the lead author, Willard Rappleye ... They lauded using extension services of universities as a place to put CME run by the university, using the outreach of these extension services. M ARTHA: As in the land grant universities. Yes and they mentioned several examples, where the university and the medical system provided the framework and set it up. The docs paid either dues or specific fees to help pay the cost of the faculty to get to their place, and some minor honor arium. But I think we need to, there are a lot of proposals right now that are looking at that. But its not wrong. My feeling is you dont value what you dont pay for. I know from many experiences in CME that youve always got to charge some kind of regi stration fee. Otherwise, everyone says theyre going to come but no one remembers or cares. Of course, it doesnt have to be much, but I think you value in a sense what you made a commitment to. I think that the local hospital model where the docs pay int o their medical library dues go into supporting their education; thats a little example, not a very big one. Most medical school faculty, of course would not like unless they were given it as a part of their academic

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126 privileges, along with other benefit s they get. But I think that docs have got to be guided into involvement by paying something. (Mr. White ) As heard from the experts, funding of CME is a significant influence on the field and will influence its future. Their thoughts were sh ared by the IOM Committee established to investigate continuing education in the health professions. Recommendations 1 and 7 from the 2009 IOM report Redesigning Continuing Education in the Health Professions referred to financing continuing professi onal development and direct ing the Continuing Professional Development Institute (CPDI) to coordinate and guide efforts to align approaches for financing of CPD to involve professional performance and patient outcomes The new institute should analyze the sources and adequacy of funding for CPD, develop a sustainable business model free from conflicts of interest, and promote the use of CPD to improve quality and patient safety (Institute of Medicine 2009b, p. 8) This certainly supports the perspectives of th e group of experts in the current study Kuehn (2010) reported on this IOM report in the Medical News & Perspectives section i n JAMA Her review of the conflict of interest recommendations i ncluded comments from the Chair, Gail Warden. At a briefing in December, Chair Gail L. Warden MHA, professor of health management and policy at the University of Michigan School of Public Health in Detroit, said the committee found major flaws in the conduct, financing, regulation, and evaluation of clinician continuing education programs. Among the most pressing concerns the committee identified was the potential for conflict of interest when makers of drugs or devices fund education for the practitioners who decide whether to use

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127 these products. Warden noted that in 2007, commercial entities contributed $1.5 billion to such education programs. The committees report, he said, took a hard line on the need to prevent marketing messages from being integrated into clinical education programs. ( p. 716) Another IOM committee had the primary responsibility for looking at funding in the 2009 publication, Conflict of Interest in Medical Research, Education, and Practice. The committee chair, Dr. Bernard Lo open ed the report with these comments: Hardly a week goes by without a news story about conflicts of interest in medicine. While this committee met, colleagues and friends sent me many news reports and journal art icles on the topic. These reports even if one expects that initial news reports may not always have the stories quite straightserved as continual reminders that conflicts of interest create deep concerns about the integrity of medicine and medical research and raise questions about the trustworthiness of physicians, researchers, and medical institutions. As I look back over our deliberations, several themes stand out. First, as with all Institute of Medicine (IOM) reports, the committee was charged with ma king recommendations that were based on evidence and convincing reasons. Although the committee members were aware of powerful anecdotes and had personal beliefs about the issues, we repeatedly asked whether the evidence supported our conclusions and recom mendations. If it did not, we developed a reasoned case on the basis of the committees experience and the judgment of the committee members about the arguments for the use of different approaches

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128 presented in the literature or in statements submitted to the committee. Second, it is a challenge to craft policy recommendations that strike the right balance between addressing egregious cases and creating burdens that stifle relationships that advance the goals of professionalism and generate knowledge to benefit society. The committee tried to consider the possibility that wellintentioned policies may have unintended adverse consequences. Third, regulation alone may have limited effectiveness in the absence of a culture of professionalism and other incentives that are aligned to promote professional behavior. The committee considered how a variety of organizations including those that accredit health care institutions and license health care professionals, publish the findings of medical research, use practice guidelines, and pay for medical carecan buttress the conflict of interest policies implemented by institutions that carry out medical research, provide education and patient care, and develop practice guidelines. (Institute of Medicine, 2009a p. x) The committee developed 16 recommendations with several specific to undergraduate, graduate, and continuing medical education. These will be in the data regarding the future of CME. Physician Involvem ent Recommendation 5 from the Redesigning Continuing Education in the Health Professions suggest ed that the CPD Institute enhance the collection of data that enable evaluation and assessment of CPD at the individual, team, organizational, system, and nat ional levels. Efforts should include: a) Relating quality improvement data to CPD, and

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129 b) Collaborating with the Office of the National Coordinator for Health Information Technology in developing national standardized learning portfolios to increase unders tanding of the linkages between educational interventions, skill acquisition, and improvement of patient care. (p. 7) While Recommendation 8 suggest ed that the CPD Institute identify, recognize, and foster models of CPD that build knowledge about interprofessional team learning and collaboration (p. 8) According to the participants in the current study physician involvement was already a significant influence on CME as was the need to focus on quality improvement and patient care. We are not getting t he buy in in some reasons because, let me just conjecture Continuing medical education credit falls off of trees. You walk by McDonalds and you can get one credit. Its just everywhere, so its not that they need the credits, so anytime we make it diffic ult to award somebody the credit for involvement in continuing medical education, they dont want to do it. They say, I dont want to go through all of that stuff, the performance But if you go to them and say, The hospitals involved and is trying to improve Sepsis care and you go to your medicine department or your surgery department and say We are involved in these missions as an educational partner, lets see whats going on and lets see if theres a way that we can help our staff, everybody that touches these things to know what we need to know to do, and make sure that they are doing these things and gauge ourselves there. Thats different than saying, Get out your disclosures and give us your performance gaps, and the minutes of your meetings and fill out the application, and all of that, so they just w ant off right away, Im not going to do that stuff. Go to them engaged in what were about and its different. (Mr. Gray ) A certain amount of formalized structured quality stamp of a pproval learning I think physicians are always going to want to have that Do they need as much of it? Theres not much to doubt theres too much CME. MARTHA: Required by state licensing? No theres just too much CME around. Physicians almost have to av oid getting CME. Its pushed at them all the time And we were talking last night about some experiences with workshops and online kinds of things. Well you know online

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130 CME, theres a large percentage of learners who finish the programs dont go on to answ er the questions for the certificate. They dont want the credit. They dont need the credit. CME is about credit, so CME as we know it may be great ly diminished in the future Is CME about anything other than credits? They really need to make the case it needs to be about something other than credits. Its adding value to the production of this educational material. I dont think theyve made a very good case for that and I think the increasing preponderance of guidelines dont help make the case that it s a value added concept You see this when you try to talk a physician into joining the CME committee. Well you start telling them whats necessary and their eyes glaze over. Then theyll tell you Ill get back to you on that . And there are a lot of se ttings where you wouldnt have anybody on the CME committee if physicians werent ordered to be on the committee. You I dont think well going to ever have the kind of CME system we want until we have a process thats honored and valued its supposed to serve which is physicians. Until you can explain to a physician what you do, and they think that is worthwhile were not going to be a profession. Were not going to have insurance about viability in the future. Thats what I think. (Mr. Green) Ac countability is an important aspect of physician involvement as described by Mr. Black. Yeah, this is real multiply layered. It gets flat in one, and then all these things stack on one another that create a threedimensional set of issues. In its simplest form as contributors in the healthcare system, there is a new wave of accountability thats emerged in the last two decades and even more so in the last decade led by all kinds of things But theres an enhanced accountability at the individual level, the individual person physician is more accountable for how she cares for patients, how she responds to bad information, how she works in groups, how she gets funded and paid. All of these things have changed. Around the individual person is a community of pee rs who have also been going through change, but variably. Its heterogeneous. The pediatricians and the anesthetists and a few family physicians down at the bottom havent had much salary change, fee change and people are sort of now talking about dumping all the work down on them where in fact for years its all been moved out to the specialties. So theres this mobility of reality where the individuals practice has really changed over the last decade. Then in a layer around that, were talking about the f orces of change that are affecting CME; the groups and organizations that people belong to that have an advocacy function are changing in response. (Mr. Black ) Definitely their preferences and desires as physicians, their willingness to participat e in the system, the availability of funding is pretty crucial right now. I think that also the commitment of organizations to remain accredited, I see that as huge. That really worries me because I think that organizations are washing their hands, this i s too much. I see accreditation to provide CME as an organizational designation. Youve got to have commitment from the top, down. It cant be from

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131 the bottom, up. Thats kind of where weve been and are. With funding being so tight right now, those are t wo major factors that are really influencing CME. I think the other thing that influences CME is the way that physicians practice medicine, the healthcare delivery system. I think thats why as providers were struggling a little bit. It used to be that ph ysicians would go to a meeting and they would make time for a weekly meeting, or a monthly meeting and it wasnt a big deal. Now thats not really what physicians are looking for, or are able to do right now. I think that it has everything to do with the w ay that the healthcare delivery system has changed It used to be fee for service, physicians were practicing very independently, they were in their own office, and they didnt have to answer to any higher authorities. I think even the society role; we mig ht have had one member of the family working. So basically I think that a lot of that has changed now. Just the preferences of physicians, I dont think theyre joiners. It used to be you just joined your professional associations; you just participated i n organized medicine because thats what we did. Thats not what physicians do anymore. So its really tied to how physicians practice medicine, how theyre reimbursed, and the way theyre employed now. I think theyre more employees rather than owners in a lot of ways I think that has really influenced the way CME is being delivered, and why a lot of us are really struggling with attendance. I wonder if the other thing with performance improvement CME maybe the physicians dont feel like theyve particip ated enough in the identification of the gap, or the data that indicates that well theres a problem here. Do physicians necessarily agree with what that measure is? I dont know a lot about performance improvement, in terms of what groups are measuring these things but I know that I hear a lot of our members talk about pay for performance bad. The hospital, bad. Physicians want to be independent, they want to be autonomous, they have their realm, and they really dont appreciate the government or any o ther organizations like HMOs, and PPOs infiltrating this realm. I wonder if there is concern that thats whats happening. Theyre telling me I have to do this, and I dont agree with that. I think theres some of that too, some reluctance. Which is ag ain why physicians really need to be inserted into the process because we need physician buy in And I dont hear a lot of people talking about that. The ACCME doesnt seem to be talking about that at all, and that I dont understand. Theres a lot of talk about what the public is saying about care and what the IOM is saying about care, but what about what practicing physicians say ? And theres a lot of blame to be shared, and one of my frustrations has been you do have to accept the fact that care isnt perfect. Lets not worry about is it 100,000 deaths per year by medical errors or whatever that number is It doesnt really matter, because we know its too much. So lets just forget that and focus on preventing medical errors. So doctors do need to be enc ouraged to take control and actually suggest proactive ways to prevent medical errors, improve care. I think that physicians are feeling very burdened right now and I think the CME system is reflecting that. I think that morale is low. I think that physic ians dont think they have control of the practice of medicine, they dont have control over what they love. They want to care for patients. Thats what they want to do, so CME should be a natural extension of that. I think that CME is getting lost in this shuffle in trying to figure out who is

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132 going to be in control of medicine I think its too bad actually, because I think that physicians should play a really instrumental role in defining their own gaps and setting goals for how to address those gaps and it seems like were relying more on gaps that are being thrust upon. That may be why physicians are resisting that PI CME. (Ms. Brown ) When docs see you involved in whats increasingly going to drive their well being, theyll participate in pe rformance improvement activities and so on. You know Ive never met a doctor who didnt want to be aware of how they did in comparison to somebody else. They like feedback. Unfortunately, that feedback has to be pretty confidential to them so they can rec ognize their learning needs and gaps, and then theyre motivated to change. [Name] was with the [ University ] first, and then the [ Hospital ] in [ City ] He, by example, showed how you could guide a medical staff to use gui delines and parameters, assess themselves; usually the unit, the urology department, or something in medicine, the gastroenterology unit or something like that. And what he also found which is also very interesting is that all these AMA practice parameters and guidelines, they dont mean anything to the physician unless the physician buys into it. And what he did and illustrated so well, is that when physicians sat around as a group and discussed the guidelines that came up, I use as an example the American Urologic Society l (AUA) guidelines on, managing prostate cancer. Then they had a debate. That makes no sense for us, but thats good learning They developed their own sense of what was important, and those were the criteria that was set up that they wer e measured against. And then the feedback was given to them. As a group, they could see the whole group but not where anybody individually was. There are certainly outliers but the physicians got the actual data. I remember Brent being crucified once on the pages of the New York Times for his insistence that this feedback is confidential to the doctors What do you mean? The public has the right to know. But its been a lifelong thesis of mine that if you give quality feedback to docs, they will accept it and use it to move to the next dimension. I think the factors influencing CME that we have to talk about are also is whats going to happen with this trashing , as I call it, of industry and their relationship to education But so often in the past all funds from industry came through the marketing units, and then were given to CME And yes the companies have set up separate medical education units, but then they have been watching and totally concerned with what is going on with the regulatio n from government I hear from my colleagues that applying for some of these commercial grants is an enormous hurtle. (Mr. White ) Mr. White discussed the importance of considering the processes involved within physician practice and how CME could have an impact there as well on quality patient care.

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133 Well I think theres a section thats called Systems Based Practice for the doctors to understand the systems theyre working in, and work within that. That leads me into the we versus them attitude of hospital administrators and sometimes the medical staff and thats been going on for ages. They dont trust each other and its crazy. But its true. And we were kind of brought up that way, separately, and cant tell you AMAs battles over the fact that economic credentialing was usedsomeone had lost their credentials because they didnt fit the hospital directors plan or whatever. Doctors have to be citizens of their community, their medical community first. I think that they in some way ought to be involved in their real communities because theyre leaders and can do a lot. But I dont think they have time to do it. MARTHA: Time is a big factor I think. Time off to reflect and so forth. Theres some interesting things going on in Europe now that were actually around in 1932 when the AAMC commission hinted at in Germany, a plan where the government provided educational courses free Of course doctor s are pretty much salaried there b ut there are other countries including the UK where theyre given two weeks and money to go to CME courses Its part of the national health system. That makes it a lot more palatable. The most important item over and over and over is gaining physician support and involvement. And by that I also mean getting physician s more than perfunctorily involved like on a CME committee Its interesting at SMCDCME now SACME, it used to be all docs that were involved as the assistant deans or whatever the title was. And over the years thats completely changed, well not completely but has changed to a significant percentage. First PhDs and then masters prepared people, and at some universities people with bachelors degrees or less And that means the docs dont care, theyre not somehow involved appropriately and they need to be ingenious to get that to happen in any local situation. All politics are local, and you have to deal with whatever situation is where you are, but I think buying into the medical staff deliberations is really important. At [a college of medicine] of course I had a role as Medical Director and Associate Dean of Clinical Affairs, I insisted on sitting in with the dean with his meeting with the department chairman. At medical schools the department chairman has the real power. The chairman of medicine, the cha irman of surgery I dont know at Bayfront how it is. But CME has to be right there. I remember one of our early battles was w riting guidelines for CME, and figured we better have them written down because the departments were doing their own thing. One o f them had two full time people doing their own CME thing. I fought it like mad but eventually the other department chairman bought into the proposal and we had a [college of medicine] policy. My feeling was I was going to let them (the 2 departments) wear themselves out It was first the department of anesthesiology, where the department chairman asked would you take over? because his people left o r got going into other things, so it took care of itself It was worth losing the war to win

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134 the battle And so I think it very important that CME be involved very closely (Mr. White ) Another perspective is the physician involvement as a member of the patient care team and how they can work together to improve patient care and ultimately patient outcomes The health care team is team is changing and the approach to CE should be an interdisciplinary one The IOM noted: The current approach to CE is most often characterized by didactic learning methods, such as lectures and seminars; traditional set tings, such as auditoriums and classrooms; specific (frequently mandated) intervals; and teacher driven content that may or may not be relevant to the clinical setting. CE is operated separately in each profession or specialty, with responsibility disperse d among multiple stakeholders within each of those communities. ( Redesigning Continuing Education in the Health Professions 2009, p. 3) Recommendation 2 from the previous study suggested a vision of CPD wherein stakeholders collaborated and foster ed an i nterdisciplinary approach to the design and evaluation of educational activities thereby improving its value and cost effectiveness. In addition, the result of CPD should relate to the quality and safety of the health care system (p. 6) The team is ch anging, so theyre more when I left practice, we had many more nurse practitioners and nurses, and we were just getting P.A.s And when I started practice, there were no nurse practitioner and theres a 30 40 year history, so the team was growing. The same with nurse anesthetists, and the big panoply, so I think the team is changing and the quality measures are changing. I think patients are changing too. I think patients are a little more prepared to say Ok on my next visit Ill see the nurse, and the di etician, and then Ill see you [doctor] on the next visit, is that right? Yes, thats right. I feel comfortable, they feel comfortable, and the notes were good. So thats changed I think. The next level up is that societys

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135 changing generally. We were tal king about individual patients but I think society itself is changing. And theres a little more awareness of I can go online, I have tendonitis, tennis elbow, Im going to go online, Im going to search this for myself; the informed patient; and its bimodal. Theres some patients that are the luckier, the better educated, and have the ability to afford better care. Those are people who come in; theyre prepared, they have internet capabilities, theyre online regularly, theyre colleagues that play gol f with the doctor. Then at the less educated, poorer, more disenfranchised end of the population, people who cant even spell computer , wouldnt know how to get on it, cant speak English. So we have that bi modal operation. I think that bi modality is a ctually growing. I would think the poverty level beginning with the recession in the U.S. and Canada is probably growing; and so are the large immigrant populations for example. Both countries do that. Whereas this is either growing or staying the same; th e luckier of the patient But thats a difference, I think. Our patients are growing older, were a graying society. We lived through SARS in Toronto in 2003. So theres a pan flu epidemic waiting at the doorstep, whether its going to come in this year or twenty five years from now we dont know. Diseases are changing as well. Now we have the big government healthcare reform, maybe capitation systems. All of that is going to play a role in continuing education I think. Conflict of interest is another iss ue we talked about. MARTHA: Right So what do you think will impact or whats relevant for the advancement of what were doing? We spoke about that for a few minutes outside, but is it going to be more interdisciplinary, is it going to look totally different, what do you think its going to push to change? I think thats a very interesting question Martha. Youll hear a lot about age today because my back is sore and I feel like Im one hundred years old! I think the change...youve probably seen this i n hospital management, its much more program management, so twenty years ago it was division of cardiology. Now its the program in cardiovascular health , [which] has surgeons, internists, dieticians I think that will drive it more. I think the more p rogrammatic initiative; the disease classification from the hospital environment will drive it. We have better data now than we did five years ago, even one year ago. Were getting better data, we can pinpoint it, and we make people accountable a little m ore. So I think those two things well be able to say, Hmmm, you know what? Our congestive heart failure patients do bounce back to the emergency department with a higher rate than they should statewide, and I think we should do something about it Were looking bad in the hospital state report cards, the state legislature is pointing at us. Several of our well to do Alliance patients are coming back and are complaining. Thats not good for us. Maybe its good for the bottom line in some ways, but you know what ? Were more than just the bottom line? So I think thats gonna drive us Patients [at discharge] arent either being told that they need it theyre not getting their prescriptions, or the doctors dont know to order it, theyre residents and dont know to order it. Or they go home on a Saturday and there is a failure in the system; so figuring out where that failure is

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136 and then fixing it. So if its educational, it means presenting grand rounds on the topic for example, or sort of a clinic day Better Congestive Heart Failure Management , or the CME office getting hold of the feedback data, the global data and feeding that back to the group and say Let s build something around this, whether more teamwork would do it. All those things I think are in t he purview, what isnt in the purview are the quality measures, determination, and payment systems. But much of this is in the purview of the CME provider this new smart, renaissance, the Martha Bakers of the world who understand it, who understand what it is and then can intervene, might intervene in a traditional way, ok well accredit rounds or medicine . Three times this year I can just about fit in. Well present the data globally on those three occasions and look for trends, and look for the barrie rs, and post a focus group; the hospital will pay us for that because our measures will improve. Thats the goal. It may be a bit idealized MARTHA: As opposed to in six months were going to talk about MRSA Well in six months, the information we might n eed to talk about something else, or how do you know what you need to talk about in a years time? Thats right. So we need to have more accurate and up to date data. I think thats a part of it. I think with an issue like MRSA, its a much more sort of onsite training Hand washing is a small example. And there the SWAT team that the CME provider would develop is a little bit different than if its an issue like congestive heart failure where its a lack of prescriptions, or a lack of understanding, or maybe we need a patient educator. Maybe its a nurse we did this in Toronto. We had a nurse patient educator and she was the discharge coordinator, so it was a little bit extra work for her. Twenty minutes to a half hour with every discharge on the cardi ac ward. But she was the knowledge broker , going through the file, determining what had happened to the patient, asking the patient what they understood, making sure all the guidelines were being met. So its a congestive heart failure patient. Here are the three things you need to go home. You have that prescription ? Do you understand why you need to take it ? Will you see your primary care provider within a week or two weeks? Would you like us here to make an appointment for you in order to do that ? Som etimes we can get through on a backline with the primary care provider where you cant. What about salt? How about making sure that its not just the medication, but you understand not to have a lot of salt like potato chips and what not. (Mr. Blue ) Accreditation Participants broached the role of accreditation by the ACCME throughout the interview s sometimes in a positive fashion and sometimes not. Each participant appreciated the role that accreditation plays in the industry and conside red it important, however, noted that a focus on regulatory requirements may interfere with the

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137 provider s ability to design and implement CME that is valuable and that will make a difference in competency and performance The IOM Consensus Report Redesigning Continuing Education in the Health Professions (2009) discusse d the role of accreditation and provide d recommendations for change via Recommendation 6, which was discussed with Question One. In t he meantime, the expectations and requirements of the ACCME persist. I have a chance to talk to a lot of people around the country and I think some people are having difficulty now with the accreditation requirements, not so much the administrative part o f it, but the whole part of understanding what a practice g ap is, and to specify what that is and to look at that gap and identify, as I mentioned earlier, what you can address educationally. A lot of people are having difficulty getting their head around that. And its probably in part because they dont have the kind of background you and I have. They dont have that educational background, they dont have that experience, they are people who are dedicated and committed and have been given CME as an added responsibility in addition to medical staff, directors, administrative assistant, whatever (Mr. Gray ) Mr. Grays comments on the influence of accreditation bear repeating What would he do if he were King of ACCME ? What ACCME is trying to do right now to push the field is very influential as well. With the current criteria, and with these efforts that they are involved in trying to push the field, I think they are being very influential. I think in some small way from a public policy pe rspective, not even in a small way, the alliance is beginning to exert itself into the field, taking on incoming public policy issues, representing the profession, and trying to be our spokesman out there when others have concerns. Its a tremendously vari ed membership. You have people out there that are totall y dependent upon pharma money, you know the MECCs and then others that dont get anything at all when youre looking at that issue Absolutely. Anything that doesnt add value to what we do, we shoul d not even have to bother with it and theres a lot of stuff in our systems now that add no value at all to what we do in terms of continuing education of physicians. For example, lets go back to the example of whether ACCME is asking whether you ought to label something commercialfree CME and commercial supported CME. Does that mean one is better than the other ? Absolutely not. One adds no value to what we do; its just another layer of friggin paperwork were going to have to do. Those kinds of things.

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138 A number of the things you have to do in the accreditation system where you have to document this and document that, put this in the file and that in the file, adds no value to what you do. If I were king of ACCME, I would say, Tell me what your mission is. We have to do that anyway. And I would say, Are you achieving your mission, yes or no? And if you say no, Show me the data that say why you are not achieving your mission. And if you say yes, Show me the data that say that you are achieving your mission. I dont care how youre getting there, but I do care that you are getting there efficiently and effectively and that you are in service to your client group, to your target audience, Bayf ront, your physician constituents, however wide you define that. But the bottom line is, as an accredited provider, Im responsible for being mission driven, what my CME mission says I should be doing if Theres one hospital system up in Pennsylvania. Their mission is perfecting patient care. My CME mission shoul d be contributing to their perfecting patient care. What am I doing to help them perfect patient care? Show me what Im doing. I dont care about disclosures, but we have to do disclosures and we have to do those things because of the external pressures, but I dont care about whether or not you have in the minutes of a meeting something that said you did this or that. Im concerned that you are mission focused and mission driven, where we ought to be. A lot of this other stuff that adds no value to what we re doing, we ought to just dump it. So we have to take the quality improvement tools called value stream mapping and look at what we do and look at whether it adds any value and if it doesnt add value, reject it, throw it out. Lets get lean, lets get mean, lets get effective lets get totally focused on what our responsibilities are, which is to support physician life long learning, anything else that gets in our way we should say, No thank you, we dont want to have anything to do with it. (Mr. Gray ) He elaborated on his perception of the most important aspects of CME : patient safety, quality of care, and systems improvement. He encourages providers to step up to the plate. We are probably uniquely positioned in the field of continuing medical education now, given the current criteria that were under, to integrate ourselves into the most important things that are going on in health care, and thats patient safety, quality of care, systems improvement, its the best of all times since Ive been in CME to be in CME, but it takes a whole bunch of talent I dont have it all.. I need the best of your strengths, your quality strategies; weve got to do this together. Weve got to get ourselves at the table in order to do that. You mentioned tha t you were there at the table with your quality coach. Weve got to be at those tables. Weve got to get them to our tables and show them that were interested in the same things that theyre interested in. Were not just hot coffee, warm donut passer out people, we are directly involved, we are valued If we dont do it now, we do not need continuing medical education to improve the care of patients in hospitals Quality departments can take that on quite nicely thank

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139 you, and they have very capable peopl e to do that. If we dont step up to the plate now and add the value to continuing education, in my opinion, we are at a point of innovation and everything in continuing medical education now has to be focused on performance improvement either performance in terms of competence, performance in terms of actual performance, performance in terms of patient health outcomes. We are now required to be performance improvement people. What a great place to be. Our accrediting body has forced us to be what many of us in the field have been talking about where we needed to be for years and if you cant do it, youre out of the ball game. You wont get accredited. What a wonderful place to be Youve got to step up and do it now. (Mr. Gray ) Another expert agre ed that providers and physicians should step up to the plate, be accountable and provide continuing education to support physician learning and change. So if you take the unions of General Motors as sort of a paradigm where the interests of their members are paramount and they fight for things that kill the industry. Thats an extreme example of what advocacy organizations are about. We are taught in business school, If you dont know what to do you ask your customer . Advocacy organizations, their membe rs are their customers. So theyre being directed. So the forces of the advocacy organizations have become huge in the last decade as change goes on and that affects CME. And CME is supposed to be supporting the physicians abilities and learning and change so they can do the right thing. In the days when we could drive it by what the doctors wanted because they werent accountable for anything, it was very easy. It was meeting planning, it was what do you want , this is what well put on and everybody l iked it. And what did we say ? As long as it looked right, and you werent misbehaving and it wasnt embarrassing, then its more power to you. So this business of accreditation expectations and accountability has come all the way up through to us, so its come all the way from the individual increased accountability, through all these advocacy organizations and layers of organization all the way up to the accrediting body t hats created rules that says education must support physician learning and change. It must support improvement. And thats been welcomed by the people who are looking for accountability and courses of change, and disparaged by the people who are taking advocacy positions for the physicians. Its too hard, they shouldnt be asked to do this, its too demanding, we shouldnt be measuring. So the forces are polar in the world that I live in, and to some extent going in two different directions Interesting right? (Mr. Blac k) Mr. White offered an historical perspective and sp eculated on which groups would lead CME in the future

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140 Meanwhile the ACCME is growing in numbers, and bureaucracy. I think its key to support your state system. Thats interestingly enough another battle you wont know about but if you have way back wh en in the 1975ish era, Dr. C.H. William Ruhe was the VP of medical education at the AMA. They had a vision of creating a Coordinating Medical Education Council to deal with all three areas of education So you had the Liaison Committee on Medical Education which still exists (from 1942 on) accrediting medical schools, you had the LCGME for graduate medical education, and you had the LCCME for continuing medical education. Theres some background personality issues involved that Ill not go into, but the LC CME was started up, staffed by the Council on Medical Specialty Societies, and very quickly they moved to establish Chicago national standards for everybody; all the local hospitals and so on. So in 1976 or 1977 the AMA pulled out of the LCCME. They rest arted their own accrediting system, in which theyd been accrediting providers. I went to my boss and raised the roof. And that changed, but that was again from the people of the green eyeshades out looking at everything else I think the major thing now is how CME will mature. With all the stuff, weve got a great amount of research on what works and now putting it into practice. And quite frankly forgetting about what ACCME is always pushing on us, which is more and more bureaucracy and paperwork and so forth. I have yet to see how all this stuff really helps the CME do their mission of getting good education to doctors My wife ran a small medical, still does. They dropped their accreditation from ACCME. It was on humanism in medici ne because for this little cited one annual meeting a year with 150 people coming, it was a $10,000 easy cost to get re accredited and then the assessment each year. So now, theyve gone to a joint sponsorship thing. But I think weve let ourselves, I mean Im sorry we cannot control down to the nth degree with the individual doctor what he perceives. Theres bias in everything we do and to try to wipe this out with documentation, thats baloney. I for one am sorry that the AMA didnt stand up and say enough of this . There were several, I dont know whats happening I havent talked to Al because I was in Lyon France at the GAME Conference. The AMA had several resolutions this year from state medical societies complaining about ACCMEs costs. I dont kno w what happened to them. I think they were adopted, but probably charged the AMA reps to do something about it. So the AMA walked out. I was at that time at Maryland having to make the decision to get LCCME accredited and AMA accredited, and said I can t. I need the AMA credit. I cant do both. Thats why I was so interested in the history of this thing. Finally, in 1980 they came to a meeting of the minds and created the ACCME, with the understanding that there would be a state medical society system to accredit local hospitals based on uniform standards, but administered through the states. Actually, the LCCME was also trying to replace the state medical societies with new regional entities, which would be under their control. But that was back before t he breakup. The AMA just marched out and stayed out for two and a half years. You wonder about some of this ferment now coming up

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141 will not lead to something like that. But I think the AMA still has got to reestablish themselves, and AAFP has to also. But t he AAFP has submitted a marvelous chapter on their history and accreditation. They were the first, 47 and its a wonderful story. There are so many current friends who were there all later on, Norm Kahn and Nancy Davis and so on, developed the concept of evidence base and changed that Those organizations are going to have to really come back in a big way. MARTHA: Who can you see as the group that can make that kind of stuff happen? Like who was it that met recently at Mayo and they were talking about t he importance of research and that was one group, and the Macy thing, and then the Council of Medical Specialty Societies that did the reform and repositioning of CME in 2005. They started, but I cant see the result from that. Its such a big task to take all of what they were calling stakeholders and make it happen. Who do you think should do that or can one group do that? My personal belief is that is two groups; the AMA and the AAMC Association of American Medical Colleges. They would have the clout to make something happen. The CMSS is too small; it doesnt have AMA as a member. Its a collection of specialty societies that relate to the specialty boards. And theyre big but they dont have the sort of clout. AMA because of its history, the AAMC because of who they are and what theyve done, what theyve done over the years is really important. (Mr. White ) Summary of Themes Question Two What influences CME? Funding The funding of CME via commercial support remains a hot topic as noted in the two recent IOM reports. The ACCME criteria are clear guidelines as to appropriate use of these funds separation of education and marketing as well as conflict of interest resolution Excerpts from six participant interview s highlighted and illustrated the theme of funding as an influential force in CME. The specific influences identified included: individuals employed by the medical affairs departments of commercial interests who review and approve/reject educational grant proposals; the rol e of ACCME and expectations of adherence to the guidelines for commercial support ; the anticipate d decline in the number of certified CME activities as a result of reduced funding; and the cultivation of alternative sources of support such as registration fees, contributions by

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142 organized hospital medical staff block grants, provider collaboration and pooling of r esources Physician Involvement The IOM committee on redesigning continuing education, recommended the establishment of a continuing professional development institute that would b e able to evaluate CPD at the individual team, organizational system and national levels and u ltimately foster models of CPD that support interprofessional team based learning and collaboration. The physician is an integral part of the team whose approach to patient care should be based on evidence provided by quality improve ment data. M r. Gray, Mr. Green and Ms. Brown encourage providers to engage with physicians and respond to their preferences for learning experiences. In addition, the y need to get buy in from physicians by explaining the value of CME in their practice an d patient health M r. Black pointed out the increase in physician accountability at various levels and that competency and performance need meet or exceed expectations at all of those levels Mr. White reflected on the importance of data feedback to phys icians regarding their practice patterns and reiterated the need to gain their support and involvement in CME. Accreditation The identification of accreditation as a theme for the element s of CME mirrors the identification of accreditation as an influenc e in CME The IOM Consensus Report Redesigning Continuing Education in the Health Professions (2009) addressed the role of accreditation and provide d recommendations for change via Recommendation 6, which was discussed with regard to Question One I t w as identified as an influence by Mr. Gray as providers are struggling to understand the underlying concepts of the criteria to be met T hey lack the background in adult education principles

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143 and practices. He believes that the administrative burden requir ed to achieve accreditation adds no value. Preferably the focus would be on mission driven CME whose foundation is built on quality data with the purpose of improving patient safety, patient outcomes, and health care systems. Mr. Black supports the value of the accreditation body as the rule maker for ensuring that CME supports physician learning, behavior change, and performance improvement. Therein lays the debate. The historian, Mr. White, talked about how accreditation has evolved, who has been involved and what groups need to revitalize themselves now to make a stand in this debate. How CME mature s, c onsidering the research that has been generated on what works and now needs to be put it into practice will im pact its future He does not see the value of what ACCME is always pushing on us more and more bureaucracy and paperwork He does not see how the bureaucracy helps CME achieve their mission of getting good education to doctors Question Three What are the most significant is sues in CME? T he interview question that helped to answer this question was Please describe the issues in CME that are most relevant for the advancement of the field. Data Analysis revealed one theme providers, those who plan and execute CME activities B ased on the influential factors mentioned above a naturally occurring significant issue is the actual provision of continuing education, specifically the role of the CME professional Ms. Amber offered an overview of her perspective. As I mentioned earlier we dont have ready access to the data. If you work in a community hospital and you make friends with the Q.I. department you might have access to the data, (hop efully you do) you can create programs and re measure something as simple as everyone entering the emergency room will be given an assessment for DVT with a goal of 90% assessment something like that. You can work on those things, you can measure those things, but the majority of

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144 the providers dont have access to those data points, and managed care organizations who have access to the data are not ready to give it up. Theres only one company that Im aware of thats affiliated with a managed care organiz ation and they struggle to get their own data So I think the barriers are access to data and the barriers with physician time. They dont have the time to collect the data, they dont have the time to attend educational programs, they dont have the time to spend with patients to do a quality differential diagnosis of history taking, and time is a barrier or lack of standardized CME platonic health record or medical record are barriers Lack of funding; the government is saying they want certain things done and they want improve care. Show me the money. How do they expect that to happen while simultaneously saying that pharma [pharmaceutical industry] is not doing right by supporting medical education? There is an inconsistency there. (Ms. Amber ) I t takes a different kind of CME professional to see that. So if you didnt have to do all of that file crap, you could be out walking the halls, talking to the head of this department, and talking to the head of that department, and saying whatever your s ermon would be But we are engaged, we are directly engaged in trying to improve the quality care of people in this hospital. We want to support you so that you can do the best you possibly can. I know you are involved in a lot of quality things. Lets lo ok at it and see if theres anything in there that you think we can support by our library services, by our educational services, or whatever it is, and in the meantime, and in doing that, provide the credit that the physicians need to report W e would mee t JCAHO requirements because it is engaged in what were doing related to the patient care. Thats an interesting concept. You do education related to the kinds of things you see in your hospital thats unique isnt it ? Rather than what they see at another hospital. So if you dont have kids in your hospital, you dont do pediatric programs. Thats profound JCAHO is profound. To me, those are the kinds of things youve got to be doing and its different than making sure the coffees hot and the rooms there, and the lightings good, projectors working, the attendance sheet is there, disclosures are in, and everythings in the file, and all that, although some of that is required to do a good business, not all that we are required to do make any differ ence. Do a value stream map and everything else, out the door. (Mr. Gray ) Yes, I think that our CME production guidelines as defined by the ACCME should be streamlined to focus only on the minimum necessary to produce an educational activity. Its my contention that people misunderstand those guidelines and theyre about achieving minimum standards; thats what accreditation is. Its not about excellence. The excellence in education is always going to be a local decision based on the standards of the people producing and consuming the activity at the local level. Its not going to be driven by some national organization. They act like they can, and thats their role Thats not their role. Their role is to make sure that it doesnt dip below the mini mum standards.

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145 They act like Jesuits instead of Franciscans. Theyre not Gods holy warriors up there in Chicago. I understand that they want CME to be the best that they can. I said that recently But I think that you do what you do thinking that youre doing the best for CME He was really kind of touched by that. He doesnt hear that very much I think they do, but I think they have gotten to where they think their role is s ome kind of cutting edge vanguard kind of thing and thats not what theyre about It should be providers taking the lead Instead what I see all the time are providers say What would the ACCME and me think about that? Who cares what they think about t hat? Go and do these innovative things that you want to, you can read the guidelines, you can see if you are adhering to the minimum standards, then just go do this innovative stuff I just dont see much innovation happening among providers Well thats what we want to do this brings us to the institute. We want to fund that kind of thing. Somebody wants to do something different than theyve been able to do before we want to help them do that. (Mr. Green ) Mr. Green explain ed that les s frequent, high quality impact CME wa s preferred to a frequent low impact didactic style CME. As in the movie industry, not every activity can be a blockbuster. He also discusse d the national certification of CME providers. M ARTHA: Now do you think that providers like me, a one person shop, I would love to do all those things. But I feel like Im filing too much, and dotting too many is, and like you said the more guidelines there are, the more difficult it becomes to do anything strategically But it seems to me the certification thing is a nice thing to get. It wasnt real easy either was it? MARTHA: No it wasnt It was harder than I thought it would be to get certified. But those folks are so busy doing everything else plus seeing me that its hard for them to lobby and to get their act together Is that accurate? I couldnt agree more You know its kind of like do you think your life is going to be one series of exhilarating adventures after another? MARTHA: Well no. Or is it going to be mostly kind of steady with peaks you know ? I think thats how you should think about your CME And for most things, putting a huge amount of effort into it isnt really necessary And just like every couple of years, do some slam bang, whammer jammer, you know, innovative CME thing Thats the kind of thing we want to get involved in. And so we want to bring these external resources to you, so you dont really have a staff of one, but a staff of four or five

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146 to do these things But thats not going to be your everyday reality, given the kind of shop that youre in. And you go and you talk to people at the academic medical centers with staffs of 14 16 and its kind of the same thing there too. MARTHA: Right its just bigger. (Laugh s ) Yes just bigger, but theyre subdivided out and their doing their little thing and its usually pretty much like it isbut you know with peaks every now and then they get to go to Dubai. They dont do that every week. Some of it I think providers have a thing special is special , and what I want to do is reduce the number of activities I do to a manageable number, have as many of them be meaningful as possible, and every now and again I want to do something thats really important. Then I feel like Ive made a contribution and a l egacy theyll look back and say He did some really interesting stuff . MARTHA: That sounds like really good advice. Plus financially more viable if you were to do it that way, and be able to plan more oh what am I going to do next week ? Oh gosh, they ve cancelled. Now what? You see thats the tyranny Your main concern is who is going to be in the ring next Wednesday morning, and the Wednesday after that, and the Wednesday after that, and the Wednesday after that As long as youve got your nose to t hat continual grindstone, thats not a good future. (Mr. Green ) Well I think that from my perspective the professional development of CME staff is crucial. Very crucial I think that I am very impressed with the quality of people who we deal w ith in terms of what I consider CME staff, CME coordinators. Im talking about the people who are the administrative people that work with the physicians to plan and deliver CME. Im impressed with them because I know that every one of them wants to do a g ood job, and they want to do it the right way. I think that usually however, this is not a profession at a state level so much as something youre thrust into. I dont think anyone wakes up and says I want to be a CME coordinator when I grow up. Its a j ob that they worked for. They find themselves there by accident. And its typically someone who really doesnt have any adult education training. The thing about adult education is I think that because were adults, we know a lot about adult education. We may not know we do. We may not have the terminology, but we know from going to classes, or anything that we do we understand. I think subconsciously Ok lecture is not as good as whatever but I think they dont know that they do know what they know I thi nk we have to really develop the talent of our CME planners. (Ms. Brown) I think you said it well earlier. I agree, I think a major barrier to advancement is the competency of the profession today By and large the majority of CME providers out there do not have CME professionals leading them. I do see

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147 someone alluded to it yesterday; the medical staff secretary [is coordinating CME] Its still in a community hospital setting as you know. Those are the people often doing the work, the medical librarian, or whoever gets assigned, or the physician who has attended lectures for years and thinks theyre now CME and theyre the one year rotating person responsible. There are still by and large too many involved who really lacked knowledge of the fie ld, the move towards more professionalism, people like you pursuing advanced degrees I think is very much needed. Until that happens, until a more professional competency is required I think it is a major limitation. Im one that has a view that either the professional ceases to exist, probably in the very near future unless it tackles some of these issues, or it will truly evolve into being that strategic asset embedded right in the core of an organizations mission to improve healthcare quality and makes the transition It may not be called CME in that environment, but it will involve people like you. Maybe its CPD, maybe its just quality, maybe CME as we know it weve got to completely eliminate it because people simply wont change their opinion about what it is I dont have a crystal ball on that, but its either going to be irre l e v ant and disappear, or really make this transition. And now is the time. As youre alluding to, the whole discussion around healthcare reform really fueled that, as its goi ng to be so increasingly clear for all of us that if youre not contributing in a cost effective way to improve health care quality and patient safety; if youre not doing one of those two things in a measurable effective way, youll be largely irrelevant. Youll be a cost to the system. We need to be an investment within the system. So itll be an interesting couple of years with a lot of opportunity. I think itll emerge. We talked about some of the barriers. Im not sure where the biggest barriers are bu t I sometimes think the current accreditation system is one of them. I hate to say it that way as people are so focused on process but it has so little do with what were talking about. (Mr. Red ) Continuing Medical Education providers come from a variety of backgrounds, are diverse in their education, may hold multiple roles in their organization, and represent an assortment of skill sets. The National Commission for Certification of CME Professionals, Inc. (NC CME) is a recent national certification organization. Certain criteria in combination, such as length of experience in the field, educational level, continuing professional development, and others are required to sit for the exam. At the time of this study, the organization wa s in the proce ss of determining how providers with the certification could maintain it, whether by exam or continuing education. An

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148 explanation of the organization as well as its Vision, Mission, and Goals and Objectives outlined on the website show the state of affairs for CME providers. The National Commission for Certification of CME Professionals, Inc. (NC CME) is a nonprofit organization founded in 2006 by an independent group of peers within the CME community for the purpose of establishing a definitive certifica tion program for CME Professionals. In July 2008, NC CME began designating qualified individuals as Certified CME Professionals (CCMEPs); within six months, more than 150 CCMEPs were listed in the National Registry at www.NC CME.org The overarching purpose of the CCMEP program is to raise the bar in CME. The public deserves assurance that CME (also known as CPD, CPPD, CPE, and CE ) is being managed by persons who understand principles of adult learning and professional development, know how to frame clinical content for maximum impact, and can wisely interpret the rules and regulations that define the field. CME Professionals are responsible for maintaining the integrity of activities essential for relicensure of more t han 600,000 practicing physicians and 60,000 practicing physician assistants in the US. The value of certification by an independent, self sufficient national organization is widely recognized by CME professionals and their employers. The mission of the National Commission for Certification of CME Professionals (NC CME) is to improve the quality of patient care by

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149 creating a standard of certification for the men and women who create, deliver, or support educational programs for practicing physicians and other healthcare professionals. Such a certification program will acknowledge, evaluate, and reward individuals for their achievements in the field of continuing medical education. [The goals and objectives were to] Establish an independent national program of certification for CME professionals, with input from stakeholders in the CME community; Demonstrate the value of CME as a career path to persons employed in the field of CME and to their employers, including accredited organizations, medical education and communication companies, commercial supporters, accrediting entities, and regulatory agencies; Establish criteria for acquiring knowledge and practical skills that are beneficial to practitioners and their employers; Create uniform standards of certifi cation against which CME professionals can be measured periodically; Define a curriculum of study and levels of experience required for certification; Develop a valid and reliable program of examinations; [and]

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150 Encourage the development of self directed le arning tools and resources to help professionals prepare for certification. ( National C ommission for C ertification of CME P rofessionals ,2010) The Alliance for CME is also concerned about the expertise of its members They provide professional development, educational opportunities and training products including webinars, publications ( Journal of Continuing Education in the Health Professions ) and other resources via their website ( http://www.acme assn.org ). The aim is to improve the provider skills of CME professionals, which will ultimately improve the quality of healthcare through evidenced based educational interventions for physicians and other healthcare providers and the syst ems in which they work. Summary of Theme Question Three What are the most significant issues in CME? Providers The NC CME and the Alliance for CME are the biggest proponents of continuing professional development for professional s who provide CME The N C CME has established a certification f or professionals to clearly demonstrate their expertise The Alliance is a professional organization devoted to supporting providers and CME professionals by offering continuing professional development opportunities, various types of training and education, guidance on obtaining and maintaining accreditation, networking, and through the publication of The Journal of Continuing Education in the Health Professions ( JCEHP ) The dilemma of not having access to qual ity data is a barrier for some providers. In a hospital setting, Ms. Amber suggests teaming up with hospital quality management departments otherwise providers may need to partner with organizations that do have the information. A different type of CME professional who can engage physicians, who are involved with quality initiatives and who are familiar

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151 with The Joint Commission requirements according to Mr. Gr ay. This perspective is shared by Mr. Green who adds that provider should go do innovative st uff that makes sense and reflects excellence at the local level while meeting the minimum standards Ms. Brown and Mr. Red share the perspective that professional competency amongst providers is a barrier to advancement of the field and that the developme nt of CME professionals is crucial to our success. Question Four What is the future of CME? This question generated three themes : funding, providers and technology The future of CME will look quite different than it ha s for the previous 30 or so years. The way in which it is funded, the skill sets of the provider s, and the use of technology will be re defined and re designed. Responses that specifically c ited technology are highlighted here. H owever, technology was found within the context of other responses an d was described as an important aspect of CME that will continue to evolve Funding The future of continuing medical education will be, I thi nk, will be defined on how well we are able to demonstrate that we can impact those three things Not only physician competence, but care provider competence, care provider performance, and patient health status. Care provider competence is the easiest to assess, its the easiest to impact because it deals with knowledge, but not knowledge alone, weve got to share it so that they know how to apply that knowledge in some way, that they either can or in performance that they actually do. What a great place for us to be as educators. Thats exactly what we are required to be doing So from an educators perspective or from those who are CME managers or coordinators or directors or whatever we call ourselves, its a great time to be in CME Thats the future. I dont know about other components of the future. I dont know about the regulatory future, because of the Senates concern about bias coming from industry funding. Im not sure industry is going to continue to fund continuing medical education in the long run because of all of this other stuff. They dont

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152 want the Senate breathing down their neck. Many of them are already saying Were not going to fund these kinds of providers. Several of them have. One company said, We will not directly fund a MECC . Youve got to be working with another kind, working with an organization that has a physician constituency With the way that things are playing out in the field that may end up being the death knell for the medical communications companies. Pharma will not fund them directly, and the MECCs cant rely on partners that have physician constituents and find ways to work with them directly or a lot will go away A lot of the MECCs do absolutely phenomenal work. They do great work; they charge great prices, huge prices. So I think thats part of our future in CME; how those collaborations can develop to do what we talked about doing in terms of the things that are impacting patient care. You know the legislative things; the funding things are going to be ver y important to us in the future. If physicians have to pick up all of the cost of their continuing medical education, and theres no free continuing medical education, I think well see a huge dip in the amount of money spent in continuing medical educat ion, and physicians have to carry it. What are we now, a billion dollar industry, a lot of that comes from pharma, when that goes away, and we become a half billion dollar industry over night. That will have a huge impact in terms of accredited or certifie d continuing medical education activities. That future is a little bit iffy I think youre going to have both, but to me, if youre trying to, if, as we are required to have a direct impact on competence performance or patient health status One off pro grams are not going to do that But a series of programs designed specifically to address an issue, might have the opportunity. You might be able to do one, but I think the series is going to be more important. We know this from the literature, youve read the literature about, and Davis has done these reviews he doesnt say CMEs not effective, he says one of CME is not effective, but if you engage in a solid needs assessment, if you engage in a series of activities, that those activities are interactive and basically engage a physicians mind and learning, then those things are the things that are effective. So I think that the pharmaceutical companies now since we depend on them for a lot of support, are funding those kinds of things I heard one pharmaceutical company person talking to a professional society on the floor of the Alliance exhibit hall, He said, We only save about 15% of our money to support the one of kind of continuing medical education; 85% of our money goes to other kinds of thi ngs, series, focus kinds of things, multiple intervention kinds of things. ( Mr. Gray ) But theyre going to see CME increasingly focused on what the strategy of the hospital is, and will be And so in the outpatient setting, in the physicians own practice I guess that will be the responsibility of the specialty society, and this kind of self directed scene. Id like to see somebody start to move in that direction. I dont see it happening, but I see it as a force that is going to become driven b y number factors, decreased pharma funding, continuing in ever increasing needs for physicians to learn new stuff. Thats not going to slow down. The scientific advance in medicine is just accelerating, not slowing. How are they

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153 going to keep up with it? Y ou have a new generation coming along that is probably the most advanced self directed learning generation ever (Mr. Green ) M ARTHA: So thats the other question the future You mentioned a few things like the self directed piece, perhaps phy sician financed CME Anything else about the future? I think therell be less education with credit. I do. I think thats a response to a number of the market realities, the demands of the users and the funding situation. Lots more use of technology Were going to get to a point where people are going to expect some kind of technology component, like is there something online I can do ? Something more I can learn, just like when LCD projectors start ed replacing slide projectors. At first, it was a novelty, and then it became a requirement When do you ever have a speaker now come and they dont have a PowerPoint presentation? (Mr. Green ) MARTHA: Id be really interested to see what people think about pooling funds. I dont think its going to happen. This morning at breakfast [a gentleman] was sitting with us, and somebody asked him that question. And he said he couldnt see [it] partly because youd get in trouble, and pa rtly because the regulator says to you gave money to this, you didnt know where it was going Somebody over here was talking about an off label use, and you supported that. So they need to have a little more control and rightfully so. If I were the company and was producing agents that help with diabetes care, thank you very much Id like all my money to go into a dye pack. Would it have to compare other medications to my own? Of course. Would it have to talk about prevention, screening, weight loss and a ll the other things? Of course, it would have to do that, but I think we should be able to label it. So maybe it goes into the deans office or CME office in kind of a blind trust but tagged in some way so this goes to cardiovascular health, or womens hea lth. I can see them doing that. I dont think anybodys donated to the Blind Stanford Pool. I dont think anybodys donated to that because thats a donation. And as he said yesterday its 5% of the total amount of money that theyve got so you can use that up pretty quickly every year ( Mr. Blue ) But I am in favor, [of] this idea of block grants. You as a provider dont have the time or resources to be applying for all these grants. I think that Van Harrison was the first person to really address that issue in his article in JCEHP back in 2003. And he was dead on then, and its largely an issue for the profession. As he said the issue of commercial support is not industrys problem that those funds are available. Its the profession, its organizati on, its hospitals, its academic medical centers that havent stepped up to the plate, and potentially funded these areas in the manner in which they should. Theres so much blame for industry for those resources, although you can clearly hear it ought to be done differently. But its not industrys fault that the profession has more fully funded this and I agree with you on that. I also agree with the concerns about topic bias with funding available

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154 for specific areas. Everybody knows what they are from industry, and yes, many of those align with interests that organizations have so its a wonderful resource but we also see far too often and consider a lack of a priori needs determination, its really going in the direction of where the money is. As Ive hea rd, what is the joke and Ive heard this from the MECCS. Why do we pursue topics of interest to industry ? Who is the famous bank robber ? Or maybe its Jesse James, someone like that, youve probably heard it quoted. Why do I rob banks ? Because thats where the money is MECCS use the same analogy of that, why do they hit the industry for funding. Its those topics. That is a concern. Back to that article, one of the reasons I took an interest personally in the whole issue of health care disparity to the poi nt that Murray made it the other day, a variety of topic areas that are not today addressed. I agree with that. There are many not addressed, and I too worry that industry has a responsibility; so long as we are in this space of being aware of that potenti al downside of industry support that it might drive people away from other areas of need. Now is that fault of industry? I dont really think so. I think its the fault of profession, the lack of balanced funding frankly, but I think industry too needs to be aware of that. Its a negative environmental influence. We need to help with those issues too. Either provide a percentage of funding and or be more clear about provider qualifications. If you for example were less than 50% dependant applying for grants you should have a many time leg up over the 90100% dependant on industry support, because it would be clear that you are pursuing whats needed by your institution. I think the future, a huge need of this issue of balanced funding, other sources of funding come into play. (Mr. Red ) MARTHA: I have my standard questions but that all sort of leads into what is the future and what does it look like. I think you hit that one right on the head. As you have said before, theres a place for an update but theres also probably more of a place for hands on work group type of stuff that can really make a difference and then blend that with the learners that we have now who will be more comfortable going online just in time to find out what they need to know And based on the self reflective stuff, there are lots of possibilities of how it could be done. I think it just depends on how creative people want to be, and how much support they have. Thats right. I think we used to think of a hundred people in an audience, all at the same level. Im going to teach them. But some of the guys and gals have already done what Ive suggested they do. Some wouldnt consider it in 100 years. And some are doing their Blackberry, or reading the morning paper, or not paying any attention. I think one of the big breakthroughs for us in CME is that by changing the culture of CME also change the audience. So if the question is, theres a brand new discovery or theyve never heard of thisa new form of anti depressant for example, or a new screening test then maybe the lecture or online learning, or disseminating by means of newsletter to all your 500 to 600 docs maybe thats good enough. If they know about it but they dont agree with it because there are guidelines created for cardiologists, and Im a family doctor or general internist,

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155 then there are other things we can do. Maybe thats peer groups, maybe thats grand rounds, and maybe thats workshops. If the issue is that Im aware of it, (this isnt my model by the way) it s somebody named Pathman. Do you know the Pathman model 96, medical care 96? He talked about how people adhere to guidelines 100% of the time. He had a four phase model. One was awareness of it. One was agreement with it. One was adoption of it. So not all the time, but enough that I felt pretty comfortable, to adherence which meant everyone did it And so the issue is agreement. Were talking about small groups, peer pressure, maybe an opinion leader, in the ward or in a community setting. If the question is adoption, that is A l l right I should be using insulin more. Im so used to prescribing something thats been many years that Ive prescribed intramuscular subcutaneous insulin. I think I should go to a workshop so I can learn how to do it better . That s the adoption question. The adherence is Should I do it every time its needed? And the interventions are different. On the front end, its more like the lecture, the newsletter, the online thing. On the back end, its more like reminders at the point of care so it pops out. Sixty five year old lady diabetic needs flu shot. Have you given her the flu shot? Yes, no. If no, click here and the nurse will bring it in. So I mean that much more point of care learning will happen. I think just understanding it that way is the way we need to proceed. And theres a big question there about where we do all of that. You were talking about the extent to which your hospital would be able to support you. Thats a question isnt it? Its not just you convincing the C.E.O. that you need the monies. Its looking at the data to say Look weve got a problem here. Weve got a gap in the perception of our patients, or a gap in care (Mr. Blue ) The Institute of Medicine (IOM) study Conflict of Interest in Medical Research, Education, and Practice published in 2009 was through support from the National Institutes of Health, the Robert Wood Johnson Foundation, The Greenwall Foundation, the ABIM Foundation, the Josiah Macy, Jr. Foundation, the Burroughs Wellcome Fund, and the endowment fund of the IOM The Abstract provided an excellent overview of the study. Patients and the public benefit when physicians and researchers collaborate with pharmaceutical, medical device, and biotechnology companies to develop products that benefit individual and public health. At the same time, concerns are growing that wide ranging financial ties to industry may unduly influence professional judgments involving the

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156 primary interests and goals of medicine. Such conflicts of interest threaten the integrity of scientific investigations, the objectivity of professional education, the quality of patient care, and the publics trust in medicine. This Institute of Medicine report examines conflicts of interest in medical research, educatio n, and practice and in the development of clinical practice guidelines. It reviews the available evidence on the extent of industry relationships with physicians and researchers and their consequences, and it describes current policies intended to identify limit, or manage conflicts of interest. Although this report builds on the analyses and recommendations of other groups, it differs from other reports in its focus on conflicts of interest across the spectrum of medicine and its identification of overarc hing principles for assessing both conflicts of interest and conflict of interest policies. The report, which offers 16 specific recommendations, has several broad messages. The central goal of conflict of interest policies in medicine is to protect the in tegrity of professional judgment and to preserve public trust rather than to try to remediate bias or mistrust after it occurs. The disclosure of individual and institutional financial relationships is a critical but limited first step in the process of id entifying and responding to conflicts of interest.

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157 Conflict of interest policies and procedures can be strengthened by engaging physicians, researchers, and medical institutions in developing policies and consensus standards. A range of supporting organiza tions including accrediting groups and public and private health insurers can promote the adoption and implementation of conflict of interest policies and promote a culture of accountability that sustains professional norms and public confidence in medicin e. Research on conflicts of interest and conflict of interest policies can provide a stronger evidence base for policy design and implementation. If medical institutions do not act voluntarily to strengthen their conflict of interest policies and procedure s, the pressure for external regulation is likely to increase. (Institute of Medicine, 2009a pp.12) Recommendations 5.1, 5.2, and 5.3 we re specific to conflicts of interest in undergraduate, g raduate, and continuing medical education. Among other directives, Recommendation 5.1 call ed on academic medical centers to prohibit faculty, students, residents, and fellows from making presentations controlled by industry (a direct violation of the ACCME guidelines). Recommendation 5.2 suggested academic medical centers and teaching hospital s provide education on the avoidance of conflict of interest as well as the management of relationships with commercial entities. It directed accreditation organizatio ns to develop standards accordingly

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158 Recommendation 5.3 was specific to CME. Questions about conflicts of interest have been particularly visible in continuing medical education. Most physicians are required to participate in accredited continuing medica l education as a condition for relicensure, specialty certification, or granting of hospital medical staff privileges. Many commercial and academic providers of accredited continuing medical education receive half or more of their funding from industry, wh ich raises concerns about industry influence over the selection of educational topics, the content of presentations, and the overall scope of educational offerings (e.g., whether they provide sufficient coverage of such issues as prevention and physician patient communication). Although individual continuing medical education providers and the accrediting organization for continuing medical education have taken steps to limit industry influence, the dependence of many programs on industry funding raises doubts about how successful these steps can be. Recommendation 5.3 calls for a broad based consensus development process to propose a new system of funding accredited continuing medical education that is free of industry influence, enhances public trust in the integrity of the system, and provides high quality education. Some members of the committee supported a total end to industry funding, but others were concerned about the potential for unintended harm from such a ban. The committee recognized that change s in the current system likely would substantially reduce industry funding for accredited continuing

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159 medical education. Even if education providers trim their expenses, the costs of accredited continuing medical education would likely increase for many physicians, which could be an economic burden for some physicians, for example, those in rural areas. (pp. 1112) These recommendations will shape the future of funding in continuing medical education and chart the course for ways in which undergraduate, graduate, and continuing medical education manages conflicts of interest. The accreditation organizations for these entities should design standards in an effort to ensure compliance. Providers Ms. Amber spoke of the future including what CME providers would need to do in order to keep pace and demonstrate the types of skills necessary. MARTHA: What does the future look like? Moving away from CME as a commodity that is accrued in a haphazard sort of fashion, to moving towards maintenance and certification in order to enable board and licensure continuation, accruing points based on true need, not perceived needs, and based on data points from your own practice. Not something thats designed by some national group. Theres a question running in evidence ba sed guidelines that sometimes is not realistic to the healthcare system. So I see us moving away from CME and towards MOC and [CME providers] as facilitators for MOC. The C stands for certification now, but it may stand for competency in the future. That s my perception. Thats a tough angle, because you have to demonstrate competency not only in knowledge but also in skill set. And all the way up that paradigm of knowing what to do, knowing how to do it, and integrating it into your practice in a daily f ashion. I see where theres going to be a need for professional educators to structure the education for the learner, to take the new science and pull it together in a way that can be taught and understood and translated, translational practice So there s still going to be a need for educators. I think were going to need a higher skill level, and were going to need access to the data in some standardized way or at least train. Im kind of interested in concepts that theres a couple of groups that trai n practice enhancement coordinators, who are nurses or other health professionals who go into different practices and really hand hold them. They do chart audits, analyze, and determine whether outliers practice, direct them to different resources, a range of resources, and then go back and re measure, and keep motivated all of the way. I think thats

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160 an interim step until we have an electronic health record system. So Im kind of intrigued by practice enhancement coordinators. MARTHA: W here do you think people like me in terms of providers or skill sets will need to be as we move forward? I think youre in the right place as far as developing your skill sets in education and all that, with an understanding of andragogy and continuing to do research and ad d to your body of knowledge around continuing education and adult learning. I think that learning from other disciplines, learning from other training and development organizations and associations is good, because theres a lot of work on transferring kno wledge to practice. We just happen to have been very insular in medicine, not looked beyond teaching and learning, and I think theres a lot to be gained looking outside of the profession for ways to do things, ways to do them better. (Ms. Amber ) Mr. Black also anticipate d a change in the type of providers that will survive as we move ahead. I think the process that the individual physicians will go through will be one where each doc has their sort of measured needs in hand. Everybody will know and carry it around like a smart card what it is that they dont know and what they do know, what they need knowledge on, what they need new strategies for, what performance they need to change. That there will be information for them that will be usef ul, interpretable, there will be assistance in interpreting it, so people are thinking about their learning all the time. Theyre thinking about their improving, that it will be safe to say I dont know to yourself and in public and there will be time an d rewards for people who pursue new information and changes of practice. And that the delta slope of improvements will be markedly increased, people wont be doing it in mass or in synchrony, theyll be doing it as a million points of light. Together the p ediatricians will all be engaged in it, and they will find synchronous in group things to do together and it might look sort of the same. But theres an incremental and measurable improvement and theres going to be data to show that this continuing profes sional development is occurring. And those CME people and resources that dont contribute to that delta will be gone because they arent going to matter. Theyre going to be a waste. I think that the providers will be as close to the patients as it can ge t. I dont think that the model of an education company that is; there are multiple roles for the education companies as brokers, sort of putting the buyer of information and seller of information together But if the need is really driven from patient need, the closer to the patients you are, the closer to the needs gonna be, and closer to the application of the measurement is and if you can measure what youre trying to change like your performance then youll be better off The learners are going to come to you more and more. Now the education companies overlap when you talk about any educational format. Like the specialty societies. The specialty societies are more like the education companies, than the specialty

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161 societies are like the academic medi cal schools. All right? The specialty societies are distant from where people do their care; they dont have access to the patient information. Just like the education company, theyre distinctly different in that theyre physician sort of run, owned, crea ted. Their mission is to help the physicians care for the patients better But the way that you can do CME because there is commercial support for a certain topic therefore youre going to do it, if those topics arent linked to practice based need then th at education is going to dry up and go away. I think there will be differences in the types of educational providers as we go forward. (Mr. Black ) From the perspective of a state accr editor, there is a significant challenge to train providers s tatewide. Theres so much that I need to teach these CME coordinators. But if its going somebody up there for four hours, and they would say it was too much. So I think that even with CME that is a lesson that needs to be learned We do still have a lot of speakers who have PowerPoint with slide after slide after slide with so much information. We have to be very specific in what we want the physician to do or not do after the activity is over. That is the assessment of whatever the gap is and the desired result We really have to get better at what do we want to accomplish with this one hour lecture , which apparently we are going to do lectures because theyre still going on. But what else are we going to do to go along with that? We havent gotten very good at that yet. Thats where the future is going to have to take a sharp turn. We cant just keep going We had static, nothing for such a long time. I think that forces are really driving the CME system right now to change dramatically. Im excited abo ut it. Im a little scared because Im not sure exactly how were going to get there, but I know that physicians have to want to do this. And right now, I dont know that physicians know that anythings going on! Of course that the physicians that we talk to do, but there again theyre involved in planning. Its the audience, so we have to bring them back to the equation a little bit and get them involved. (Ms. Brown ) The IOM report on redesigning continuing education pointed out that the CME/C PD provider skill sets will have to be broadened significantly and that clinical faculty need training i n effective CPD methods Those in roles similar to Ms. Browns will eventually have techniques, methods and support systems to assist them with th is task.

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162 In a comprehensive CPD system, proven techniques and methods would be identified and disseminated systematically to provide the greatest benefit for the investment. Mechanisms for spreading effective learning methods could take a number of forms. Descriptive reports detailing these methods could be distributed widely to CPD providers and health professionals interested in advancing training. Alternatively, effective CPD methods could be taught by qualified CPD providers to other providers. This would require a much more coordinated effort of training and evaluation than currently exists among CPD policy makers, planners, and evaluators, but such coordination would greatly facilitate the dissemination of CPD advances and eventually be of great benefi t to patients and clinicians. With a framework of CPD research and practice improvement, CPD providers will progressively increase their adherence to evidencebased CPD and surveillance data and contribute knowledge regarding CPD, improvement, and patient safety. An innovative e health infrastructure can provide this opportunity through a variety of methods. For example, multimethod educational materials and electronic newsletters could support just in time learning; social networking environments such as Facebook and Twitter could promote tacit knowledge acquisition and cocreation of clinical knowledge, increasing opportunities to engage in electronic communities of practice. Simulations could also be used to train

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163 individuals and teams in disease manageme nt techniques. As technology advances, so, too, do to the opportunities for e learning. In a better CPD system, schools, universities, and colleges would offer professional degrees or certificates with curricula designed to dramatically improve health professions education. Continuous learning a much more dynamic approach to evidence development and application would take full advantage of newer information technology to implement innovations. Programs and institutions dedicated to continuous learning and health care improvement would help the CPD system develop by providing a stable infrastructure and learning environment. Such institutions would house faculty expert in CPD. It is conceivable that many health professionals would want to learn in a specia lized institution dedicated to developing comprehensive and integrated CPD programs, rather than collecting credits in a piecemeal and disjointed fashion. If these CPD programs were structured to provide premier educational opportunities, the professional drive to achieve excellence would likely also spur health professionals to enroll. Further, involvement in a community of professional learners and teachers to help individual practitioners advance would be a strong incentive for clinician enrollment, espe cially if the knowledge and skills they gained could be tied to improving the economics of their practice and improving the value of their care. As centers of CPD activity and scholarship, these institutions would be ideal vehicles to pilot test and assess effective CPD curricula by providing reliable contexts for

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164 implementation and evaluation. Additionally, institutional structures for CPD could provide new levels of visibility and accountability for CPD and its resultant outcomes for learning, although he alth professionals would be responsible for their own learning and performance outcomes. (Institute of Medicine 2009b, pp. 8081) MARTHA: What about the providers themselves, in terms of now we have our certification ability, and someone mentioned that why isnt education pushed in with the quality improvement department or whoever is doing that. And like you said a lot of us arent trained, or wouldnt know about content. Were just there to make sure that the file is complete so when we have our survey, we pass So I think thats sort of an interesting piece too in this particular field. Yeah, first thing to say some departments and offices have begun to merge; so CME and CQI. Kaisers don e it. Kaiser Northwest has pulled it together. I cant remember what they call the unit. But it takes their details about their community based docs, and are they prescribing too many antibiotics for upper respiratory tract infections where they dont work. And if thats the case, they send a detailer out. The detailer says I looked at your profile doctor, and it seems to me youre prescribing a lot of penicillin to five year olds with viral throats. Did you do a throat swab? The doctor says, Well no I dont. Well if you think of these five signs of strep throat for which penicillin would be useful. Heres a little reminder card so you can look for those five signs And heres a strep kit. So if youre really interested and feel you need it, this is a 2 4 hour return. Heres a tool for you to use. And Im going to come back in three months and visit with you. This is educational, doesnt count for anything, but its educational. And Id like to have your feedback. I hope you dont feel like Im intruding in your practice. Im a pharmacist and Im trained to do this. Its beginning to happen, nowhere near the speed I think it should happen of course. But its not. (Laughs ) I think a part of it is to make sure that folks like us go to the Alliance for CME m eeting, and the Society for Academic CME and all the other things like this kind of session, and the quality improvement one we did two weeks ago. So theres a lot more like that, and I see more and more people doing it We on our part are doing a lot more of that so I think thats useful. I also think you dont have to do it all. I never did it all. I had a little team around me, and the team would include the quality improvement person for my local hospital. So we had our quality assurance data kind of pr esented to us, and we developed the rounds and the informatics person there. So it was a little logistical committee. But you also need buy in for you (Mr. Blue )

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165 The Lifelong Learning in Nursing and Medicine Final Conference Report Executive Summ ary review ed their vision for continuing education and lifelong l earning with an overview of the 30 recommendations put forth. The four key areas for analysis and recommendation were continuing education methods, interprofessional education, lifelong learn ing and workplace learning Of greatest interest here was the continuing education methods that CME providers wi ll be tasked to implement and facilitate. While the Expert Panel and writing groups reviewed the literature, discussed the implications of their findings, and developed extensive recommendations, a vision was created for the future. This future for health professional lifelong learning places greater emphasis on interprofessional education and practice, preparation and assessment of graduates with skills that support lifelong learning; increased diversity in continuing education methods and self learning opportunities; greater use of technologies to deliver evidence based information and assess changes in practice; and a focus on ways in which this vision could be applied in the workplace setting. The recommendations that arose from this process provide a path for achieving this vision which we believe is necessary to address many of the issues currently facing the countrys healthcare system. Cont inuing Education Methods Classroom education (meetings, conferences, rounds, courses, and inservice training) is a tradition among health professionals. Most of these programs employ didactic methods, demonstrated to be effective at

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1 66 transmitting new know ledge or delivering updates, but with little evidence that they produce change in the practice of health professionals. Newer and possibly more effective models are explored. Beyond classroom education there is a host of broadly defined but under utilized educational interventions that exist which employ pro active methods and strategies to effect learning and change in health professionals. Support from the Expert Panel for these methods was widespread. (Association of American Medical Colleges and the American Association of Colleges of Nursing, 2010, pp. 56) Technology The Lifelong Learning in Medicine and Nursing Final Conference Report also discusse d the role of technology in learning. They refer red to the IOM 2003 report Health Professions Education: a Bridge to Quality which call ed on the health professions to look at how professionals w ould be educated in the futur e. Despite the promulgation of these and other reports and their recommendations, work remains to be done regarding the methods and formats of continuing education, interprofessional education, and preparing future practitioners for lifelong learning to ad dress the shifts in the nations patient population, growing complexity in the healthcare system, and exponential growth of knowledge and advances in technology, biomedical, and related fields. (Association of American Medical Colleges and the American Association of Colleges of Nursing, 2010, pp. 89)

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167 Recognizing that the overlapping, broad concepts of continuing education an d lifelong learning deserve a variety of perspectives, Expert Panel consensus developed around five major themes In addition to these five major areas of focus, several important, cross thematic considerations were agreed upon in broadening the conceptua lization of continuing education and lifelong learning. These considerations are presented here as necessary ingredients in the reconceptualization of CE and lifelong learning: A broader definition of continuing education in particular the acronyms CME a nd CNE used by medicine and nursing respectively appear to lead the reader to a more traditional and less broad understanding of the field including only formal or traditional CE appears to limit the use of the term, leading to confusion relative to c redit systems, and impeding innovative thinking related to CE specificity is needed regarding the type of educational/learning method or intervention; Incorporation of the principles, recommendations and messages of this report into basic or undergraduat e health professional training; and Application of information technology to each of the five focus areas. The need for ongoing learning throughout a health professionals career was widely supported; however, there was consensus among the Expert Panel that a simple readjustment of current polices and thinking regarding CE was insufficient to address healthcare system needs, reforms critical to improving care gaps, and concerns about the state of American healthcare, matching the conclusions of others ( pp. 1617)

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168 The e xpert panel from the conference envisioned that health professionals lifelong learning would encompass in part [n] ewly developed and tested technologies are used to deliver upto date, evidence based information directly to health pr ofessionals in all practice settings and to document changes in practice and patient care outcomes (p. 23 ) E xperts in the current study concu rred with the conference panel and are represented by the perspectives of Mr. Green, Ms. Amber and Mr. White in the following excerpts. Lots more use of technology Were going to get to a point where people are going to expect some kind of technology component, like is there something online I can do ? Something more I can learn, just like when LC D projectors started replacing slide projectors. At first, it was a novelty, and then it became a requirement When do you ever have a speaker now come and they dont have a PowerPoint presentation? Could you do something else interesting? (Laugh s ) Bring s ome props, or do a demonstration. I saw a demonstration a few weeks ago, a virtual patient Theres this company, a CME company thats working with a gaming company This was fabulous You enter the doctors office, you go back to the examination room, and you see the patient, and you see the patient in 3D in various angles, and you can query questions to the patient. Theyve already programmed in the patient answers; all sorts of responses to questions that are likely to be asked. Then you can click a button and hear an expert comment on what the patient just said. Then you can check out what peers have suggested might be the diagnosis and the treatment, whatever. (Mr. Green ) Technology ; there seems to be some very cool dynamics, electronic del ivery. There are a number of companies out there with some really interesting technology that have virtual offices, and vision trees and patients coming in and out, access to data, well hypothetical data, but still technology is really important for learni ng Aligning with hospitals, academic medical centers, and associations are probably the key areas of employment or opportunity because I dont see where medical education communication companies will have since they dont have direct access to patients, data or care, they become facilitators and important ones. But it behooves those groups to really think about aligning with those other organizations that do have direct contact with patients. So I think positioning yourself as you are with hospital or me dical center, learning as much as you can about the research to medical education. We just got the new JCEHP in. I myself am just devouring it, two or three times taking it with me on every plane ride, and trying to learn from the experience of others. Tha t would be helpful. (Ms. Amber )

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169 Another factor here that we sort of talked about is our CME leaders developing the types of media approaches that are going to work in the future; thats the younger generation coming out Its moving toward e learni ng I dont think we want to get away from group meetings. I think theyre very important for a number of reasons, and theyre very cost effective for getting information out, and the tradition of going is a good one because you never know when you might f ind a pearl somewhere even though you dont care about that subject at Grand Rounds this month or week. You broaden your knowledge. I think for any internist thats terribly important. I was a gastroenterologist by training and internal medicine was my bac kground. If I didnt know what was going on at least a little bit in hematology and endocrinology, I couldnt do my job as well either. So I think that the conferences have a role, but getting ready for a new generation and leading our current docs into this I think its a different era now than when I last looked at it because doctors probably know how to use computers. (Mr. White ) Technology was addressed in the IOM report on redesigning continuing education and described it as an effect ive tool not only to collect data but also to create a platform for educational interventions Recommendation 5 involved the use of data in CPD as well as the creation of standardized electronic portfolios. Recommendation 5: The Continuing Professional De velopment Institute should enhance the collection of data that enable evaluation and assessment of CPD at the individual, team, organizational, system, and national levels. Efforts should include: a) Relating quality improvement data to CPD, and b) Collaborating with the Office of the National Coordinator for Health Information Technology in developing national standardized learning portfolios to increase understanding of the linkages between educational interventions, skill acquisition, and improvement of patient care. (Institute of Medicine, 2009b, p. 7)

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170 Summary of Themes Question Four What is the Future of CME? Funding A successful CME program will be defined on how well we affect physician competence and performance as well as patient health status according to Mr. Gray. However, the anticipated decrease in commercial support will make it difficult to provide the accredited CME required to impact physician competence and performance We m ay see more CME offered without credit. With the advance of technology, the resources to fund it for point of care educational interventions are in question. Mr. Blue says we will have to convince administrations to expend monies to assist with education based on data. I ncreased block grants, but not blind pools, are likely to increase as collaboration increases among providers. Mr. Red recommends balanced funding using a variety of sources in combination with commercial support. The IOM conflict of interest report was presented to further reveal the influence that funding f ro m commercial support and the association conflict of interest will have on medical research, education, practice and development of guidelines based on the available evidence. The recommendations specific to CME were presented. Providers The future of CME providers and CME professional s from Ms. Ambers perspective, may be toward facilitators of maintenance of certification or competency who will need to be professional educa tors able to structure leaning activities that will translation into practice This will require a higher skill level, ability to research and glean information f ro m other successful professions. Mr. Blac k agree d t hat providers will change as the respons ibility to effect change in

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171 physician competence an d performance increases. The ability to absorb new information and coach CME faculty will also be essential according to Ms. Brown. The continuing professional development of providers was mentioned by M r. Blue as an important initiative. The IOM committee for redesigning education reiterated the n eed to continuing professional development not only for providers but faculty too as mentioned by Ms. Brown. S uggestions for systematic identif ication and diss emina tion of effective and proven educational techniques were outlined. Recommendations for implementation methods to effect change in learning and change in the health professions wer e also provided in the Lifelon g learning in Medical and Nursing Final C onference Report Technology Technology is vital in the reconceptualization of continuing education. The lif e long learning conference report places technology in all five of its focus areas Further, the IOM report on redesigning continuing educa tion described it as an effective tool for data collection and t o create platform s for educational interventions Experts in the current study anticipate technology to be implemented for simulations, virtual patient experiences based on hypo thetical data reflec ting todays and tomorrows professional practice, and a variety of e learning applications. What havent I asked? Or, is there anything else you would like to add at this time? A n openended closing question was posed to ensure that significant perspectives from each participant had been captured. The three themes that emerged accordingly related to Performance Improvement CME, CME providers and accreditation

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172 Performance Improvement CME Performance Improvement CME (PI CME) is the gold standard that CME providers are expected to demonstrate in order to maintain their accredit ation. The problem, as mentioned by the participants, is the ability of the CME providers to grasp the concept of PI CME, implement CME activities that incorporate performance improvement, identify objectives develop and measure changes in physician compe tence, performance, patient outcomes or, ultimately, changes in population health. This can include PI CME related to process in an office setting or in the inpatient arena. That to me is one of the greatest opportunities we have as CME providers is to eng age somehow in our CME activities ways to say docs you need to see how you work. You need to look at your work, how you do your work, and change the way you do your work. So maybe when a person with diabetes comes into the practice, for a while when they pull that file out and they put it into his file you put a blue sticker on something and everybody knows blue sticker means do a foot exam. Or you tell them to take their shoes off when they go into the room. Or you have them bring the patient monitor for their blood sugars using a red chart where they plot it. You draw lines on their chart showing where they should be and theyre up here and you show them where they are and they begin to say Oh, Im supposed to be down here. Not that the doc doesnt know it, but there are other things in the system. We kind of need to get ourselves involved in those things. Its a great opportunity for us to help look at how work is done, not only what you know, but how you go about what youre doing. So if you have a CME activity that is a series of conferences on a particular point, treatment of hypertension, then what part of that program needs to be Doc! Look at how youre doing this Look at your work. Heres how they say the work ought to be done. What work are you doing? Sit down with your staff and have a 30minute brainstorm about what youre doing and actually map what youre doing. You dont even think of doing that. Im doing one right now in an OB/GYN practice and one of the partners theyre young shes co ncerned that shes not doing her screening for osteoporosis in women of 65 and over that had the risk factors. She knows she doesnt do it. Why arent you doing it, Amy? I just dont think of it. So I said were going to sit down and map what happens i n your practice, or you do this: have your nurse follow three patients through your practice, say when they come in. Were going to figure out a way she can do that. She cannot not get that bone density screening done. MARTHA: Could it be as simple as a c hecklist for patients?

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173 It could be as simple as a checklist It could be something more major where they buy a piece of equipment for their practice where theyd actually be able to do their testing themselves. It could be that they do a better contract w ith the people who do the bone density scans and tests and you get your reports back. And not only do you get reports back, but they get where they belong. They get an electronic medical record that actually gets on the record. It could be any number of th ings, if you think about it to cue them. I had some surgery done on my hand, and they had their papers and they checked this off and youre breathing and you dont smell, you dont have body odor whatever all of those things are, and on the right hand corner of his form he had highlighted in magic marker, somebody highlighted the corner with a magic marker and I looked down there on the chart and it said PQRI [Physician Quality Reporting Initiative] I said Doc, why are you doing a PQRI? and he said, W ell this is all part of our process. Im on Medicare and a supplement. He said, Were involved in trying to meet these incentives. This way when they pull your chart, they see that mark, and they have where theyll sign highlighted in orange. I sign tha t box, theres no way I can sign it without making sure everything in that box has happened. He knows it all needs to happen or they wont get reimbursed. He wont get their incentive money unless its documented. They didnt go off to some continuing medical education activity to learn about documentation, what they did is they marked their form with an orange box and highlighted it and he has to look at it when he signs it. That is brilliant and they are meeting their incentives. They almost got their in centive last year except for making that one change. Now if you were a CME provider and you came in and saw that Look at your practice. Look at what youre doing. Look at what youre not doing. Well, you know, I forget to do that. So what can you do s o that you will not forget it? Why dont you highlight that in a magic marker? Oh, thats a good idea. MARTHA: It would depend on the individual as well. Its like trying to get all of the protocols and the standing orders in line. Doctor A has to have it this way and Doctor Z has to have it this way. Sometimes they have the standing orders just for this group because thats how they do it. If they can get them to include everything that needs to be included then thats okay So when you go into Dr. As group practice and you find out that theyre not doing something as their CME provider or quality, your question is How are you doing your work? What are you doing? Is this stuff you dont know? Are there some things that you can think of that might make i t so that you just couldnt get away with it? Once we as CME providers engage in those conversations theres a different playing field. To me thats where we need to be going. Its going to take somebody other than the medical staff directors secretar y to do that Theyre not dumb. They could do those things. They can monitor whether it is happening, whether they can engage

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174 in it or not and some doc says I dont know how to do that and he comes over to the CME director whos just had that appended to their title because theyre the medical director and says We cant figure this out. And the coordinator is sitting there and he says, Why dont you guys do a process map? And heres how you do it. So what do we need CME providers to think about doing? About how we can inject ourselves into quality patient care, patient safety, and what we can do to support physicians efforts in those areas in terms of patient safety and quality care. Those are areas as CME providers we havent traditionally been engaged in because weve been doing our one of meetings with hot coffee and good donuts. (Mr. Gray ) Its not supposed to be about documentation of activities, its supposed to be about activities resulting in learning that took place, or behaviors t hat followed. I dont know how youd substantiate anything without writing it down, but I dont know it needs to be more than that. For a lot of people its not much more than that. Just let me get the sign in sheets, get the evaluation form, put it in th e folder, put it in the right order, have tabs filled out the right way. It makes me crazy. MARTHA: As a provider then, if Im supposed to be able in the long run to show a change in patient outcome, how are we going to do that? I would never put that d own as part of my mission statement. The day they require that will be the day that CME ends, that CME ceases to exist. MARTHA: How far can we go do you think? What you can actually document? It can definitely go to physician self report of behavior chan ge. Theres actually in the educational literature quite a bit of research that supports the commitment to change kinds of things that professional groups say that Im going to do it. Then they will do it to some extent. So youre looking at proxies for c hange We definitely can do that. Occasionally we can have real data that shows the change in behavior like in prescription patterns Now if youre in a closed system like Kaiser, you can show actual changes in treatment of patients and in some cases infor mation about their health status following In open systems right now, I dont think we can show that So patient outcomes are very iffy to focus on; physician behaviors, you can do proxies. To go much beyond that, we know chart reviews are very accurate and time consuming, expensive, and invasive You have all physicians paranoid if it comes to that, you have your IRB stuff to deal with. Thats hard. Population outcomes, never go there, never go there Sometimes you can do patient outcomes. Sometimes you c an show physician behaviors [colleague] and I both agree that performance improvement is the ultimate form of CME And I like to call it the most powerful learning technology there is Its the most advanced form of self directed learning there is, to the extent that people actually do performance improvement work. I think you can nail it there The question is what is acceptable in the mix ? And so from an accreditation

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175 standpoint, how many of those do you have to do? The ACCME has been mum on that. They dont say. Are these proxy things enough? I dont know. They wont say, and it makes people very nervous (Mr. Green ) And thats one of those areas thats a classic example of when you take th e performance improvement approach to any clinical area, youve got to include that as in so many cases as one of the elements. But todays world of funding things one grant at a time, one activity at a time, rather than a program level type of grant. Ofte n those things are not understood and/or overlooked by commercial supporters. Thats a concern to me. Thats another reason that I think people outside of industry need to decide more about how those funds are used. The issue for the near future remains de fining as we think about education differently, the role of the medical specialty society compared to the duty of care provider; you being a hospital, an academic medical center or a medical school. I think Marcia Jacksons article in JCEHP a couple of years ago where she defined a medical specialty society, I forget the other co authors, but they had a very much curriculum based approach in terms of a medical specialty society appealed to me, because I thought it defined the role for the future of the medi cal specialty society which today I see at times medical specialty societies competing with your efforts. Competing with medical schools in a way in the CME world doing the same thing in different settings, but in the new world of PI CME, it seems like those roles could evolve a little bit differently. I dont see how a specialty society could ever be integrated with local care and quality initiatives that are at the heart of this new world of CME, CPD. So I dont have the answer, Im just reflecting out loud. Im interested in how that evolves, how the specialty societies might be more involved in identifying the competencies for specialists for example. But they can only carry that so far. It seems to me that in this future state, much more coordination, m uch more cooperation between different organization types. Because theyre in a better position to define competencies than you would be, but youre in a better position to incorporate that into actual data driven activities. Those have got to go hand in hand. I dont see much of that currently. Do you? That would be interesting so that maybe in the future the alliances become more what the societies working, be they state or national with organizations like yours, and the MECC type world as it declines, as I think it will, becomes much more of that project management execution arm, and a lot less of a cognitive piece. Today its still the cognitive, more than it would be in that future state. So I think about things like that. Itll be interesting in the future to see how that evolves. Even your own state is working with one of your state chapters and a national specialty society would be interesting. Like a cardiovascular one, I think the ACC has state chapters. Maybe theyre regional the American Colleg e of Cardiology. Its possible they just have regional chapters. It would be interesting to incorporate their competency work, Joe Greens work for that type of initiative, in the future efforts like that. (Mr. Red )

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176 Providers As evidenced by the response to other interview questions, the experts were concerned with the caliber of CME providers traditionally viewed as meeting coordinators and file clerks A s the road to maintenance of accreditation becomes more difficult to navigate current providers will not be prepared to meet the challenge. As stated earlier, the National Commission for Certification of CME Professionals (NC CME) offers a certification exam for those who meet the eligibility criteria Well lets imagine what would happen i f CME just went away You know the basic question I think is CME valuable. Yeah, I dont think we want CME to go away. I think we want our physicians to know the latest information, the latest evidence based information. There are a lot of people now who a re saying that pharma is going to pull out of funding of CME, theyre going to stop funding, and theres going to be marketing like youve never seen before. And I think that doctors will go to that. I dont think thats good. Weve really got to win this battle and not have them completely exit the scene in terms of funding really good evidence based clinical information for physicians. While there might not be the onrush of every month of blockbuster drug being introduced, doctors have a real need to know how to prescribe medications and use them appropriately. And they shouldnt be getting that information in a marketing based content in the absence of CMEs. We cant lose this battle for CME and I really hope that CME wont become so complex and so burea ucratic that people stop wanting to do it. There are people downstairs in the state of despair. You may be one of them. Theyve really kind of convinced themselves that this is all too complex now, and they cant do it What do you think has caused people to become convinced they can no longer do CME? MARTHA: Well I think what Im looking at is how to do it differently so you can demonstrate that youre meeting the minimum standards I cant do that with the program I have now So my barrier is support, both financial and people. The physicians who serve on committees just let me do my thing, and they say thats great, go ahead . Its a blessing more than anything else. Theres no active participation. And to change the culture of the grand rounds and case conferences and that kind of stuff will be difficult without some sort of other support or buy in by my customers. (Mr. Green ) Its an exciting time though. You feel like you can almost see it. Its the emergence of truly a redefined or new pro fession. To be a part of that is exciting. Ive been always been an advocate of that when I was on the board of the Alliance. I was one of the few who voted in favor of that in the late 1990s because maybe its some of the influence from someone like Ron Cervero and his writings about the politics of all this so its influenced me. That certification is not

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177 needed by leaders of today they are there and well known. Its needed by all those folks who are ma rginalized in their own association or whatever setting they are, even in industry. Its simply whether the exam is relevant or not, in terms of actual any relevance to competency. But nevertheless its something that helps you become less marginalized, a s its recognized in your own institution for no other reason than that even if it doesnt contribute to improve competency. Just the move away from being so politically marginalized I think is healthy, so I am in favor of it even though we all might think of ways we can improve and all the politics with that. But yes, Im generally in favor of it, although a lot of people have not been. Even in the industry world, Ive thought that there probably needs to be mandated if youre in industry. What so often happens in industry is somebody right out of leaders thinks they can put somebody out of marketing directly into one of these roles with no knowledge, because they have a different orientation about what this all is. If you put that in as a job requirement you immediately build in some safeguards, so at least people with some level of knowledge wont be replaced with somebody who shouldnt be in that role. (Mr. Red ) One of our barriers to success and to change, one of the ACCMEs problems is althoug h I love them, the people in the CME system, the heterogeneity of their backgrounds and their skill sets is a real hindrance to the evolution of CME, it really i s And we either have got to stop that and have a better admission process, training process, a nd preparation process, or we have got to address it and say Weve got to bring the skills up of everyone, make us more homogeneous from an ability to deliver, to evaluate, to measure, to participate, to do research, to be strategic, to deal with and have management skills. We havent done a lot about that over the past, in the time since Ive been in this job. We cant get any better then, who we are, and we roll out new rules that arent rocket science, theyre not really hard, but the world has a seizure over them. W e could say Lets dumb down the expectations. But well dumb down the expectations, and then organizations like ABMS and Maintenance of Certification or Maintenance of Licensure and the government will all say To hell with you. Well just blow you out of the water. If we diluted the standards of commercial support, if we took out independence and identification in resolving conflicts of interest, CME would be out of business overnight. The system just wouldnt tolerate it anymore. So a s I know personally what the struggle and the battle is, I came in as a CME dean and didnt know anything about it. I had to do strategic management, I didnt know how Ive done a leadership institute for continuing professional education in the mid 80 s at Harvard there was a week long program that I went to, and some of the big leaders in CME (and I didnt know who any of them were) were there. I went back as faculty the next year, and the year after that and went I came here to take this job because I needed to enhance my skills to do this job. Then I did a certificate in management at [ university ] then I started a certificate program in conflict management because

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178 of a lot of things were dealing with. So I have the right to say we need to improve ourselves in order to do these jobs better. We need to get better And I dont see that as much as I think we should. Ive been seen people who have been in the business forever doing things exactly the same way forever, and I dont see the quality. Theres a glimmer of it, in that the quality improvement people are starting to appear more often at CME meetings and inside CME there. Theyre getting dragged over from quality into CME by some people who have insight. What that is just the diluting of the people who havent changed. The people who havent changed havent changed and the minute when we dilute them out 100% then I dont have anything to worry about. But we need to have expectations of people that are higher. What often happens is because the people who theyre accountable to dont understand it or get it or dont know what anything is about. They say, Well shes ok, shes acceptable, she makes noise, she gets her accreditation every time, and shes presentable so Ive got no comment . But they dont really say Why isnt she publishing 23 articles, why isnt she a leader, why isnt she on any committees? I think anything that creates expectations that just gets people to understand that there are expectations is terrific. Its a little bit of a cop out in that the world of credentialing of professionals that most of its done for immigration purposes where Can this architect be an architect in this cou ntry? There are tests and performance demonstration things that people have to pass but they started with training and credentials from the country that they lived in. In this system, all theyre doing is starting with a pulse, and the fact that they have a job. Thats the criteria. Theyve survived with this pulse, in this job long enough to be here when its time to do this test, and thats not really certification or credentialing. They usually come hand in hand as Well give you a test to see if you have the knowledge but theres so much imbued in you by training they dont just let you learn internal medicine and say go do it, and were just going to give you a test if you pass the test. You have to do a residency program, demonstrate in the residen cy program, then go write the test, and the two things together certifies you (Mr. Black ) Accreditation Although there are many components or elements in CME, providers must adhere to the criteria of the ACCME in order to maintain an approve d provider status Mr. Green and Ms. Brown commented on ACCME at the conclusion of the ir interviews. Theres this thing in CME that whatevers in the fol ders is what CME was. You know from way back when I worked with a consultant group, we used to talk to people about their cultural statements and in hospitals where they say we strive to treat every patient with respect . (Laughs) They probably have that on the back

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179 of your name badge. We used to say so if youve got that framed and on the wall, and youve got that laminated on the back of your card, that means that it cant breathe; that no oxygen cant get to it and its dead And all of that happens in the living behaviors, interactions between people. Its not words on a certificate somewhere. But the whole thing about accreditation ACCME if its i n the folder, it happened. [A colleague] and I have talked before about setting up a dummy provider and just presenting the ACCME with file folders that represent activities that never happened but meet all the criteria and see if we could get this organization accredited that doesnt exist anywhere. I dont see why it couldnt be accredited ? I think theyd pa ss it. MARTHA: Yeah, based on what they require. They no longer require site visit. So just have a video, interview, some Kinkos somewhere and they are looking the pieces of paper MARTHA: Your point is well taken indeed. (Laughs ) I dont know where w ere really headed. Its not supposed to be about documentation of activities, its supposed to be about activities resulting in learning that took place, or behaviors that followed. I dont know how youd substantiate anything without writing it down, but I dont know it needs to be more than that. For a lot of people its not much more than that. Just let me get the sign in sheets, get the evaluation form, put it in the folder, put it in the right order, have tabs filled out the right way (Mr. Green ) Thats the other thing thats happening at the national level is the ACCME is significantly raising their fees, like 100 times a crazy raise in fees, in terms of the fees that the state medical associations are going to pay for each of the organiza tions that they accredit. So thats a huge deal in CME right now is the cost. Again thats the funding I think that the way the ACCME looks at it is that you pay for value. You pay for quality. People only value what they have to pay for. Do we want to ke ep giving CME for free? I dont know I think certainly other professions pay for their continuing professional education, and doctors have gotten used to not doing that. Free CME is great but do physicians really value it? The value proposition is theyve never had to pay for it, so its not that valuable to them. Now they need it, but theyre used to getting it for free. I think the ACCME thinks this is expensive. If youre going to do CME and do it well, youre going to have to sink some finances into it It will be interesting to see. Probably fees will go up. I dont know how much, well see. The ACCME used to be three or four people. Now its twenty five people or so, I dont even know how many employees they have now. I think its good because its elevating, its an important thing. Sometimes I think we have to be careful about creating busy work. To me the accreditation system should be less about documentation and more about results.

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180 Less about the paperwork, and more about what actually happens. Whether its the educational room, or the computer or whatever the learning setting is going to be. I know theres a lot of concern that were not focused enough on best practice, and were more focused on how we document it I probably wont be able to re member the quote but Dr. Kopelow from ACCME said Well were concerned about best practice, but documentation is the I cant remember how he said it. He said that best practice is what we want to focus on, but documentation is the way to get to best prac tice. It was almost like, that really doesnt make sense. So it is a balancing act between the output and how we got there. And of course we as accreditors have to look at is the documentation which is not always exciting. But it is important. It is a ba lance. We have to be real careful about that balance because we can get too reliant on forms. There needs to be a passion, and enthusiasm, a sense of oh gosh Im learning something . Doctors are turned off by filling out a form, or Oh I have to do a eval uation form at the end of every activity and if I dont do it I dont get my credit . Well, that is a turn off Its a turn off for any educated person. You want the za za zoo, but you dont want to do a form. I think thats the best way to kill the enthus iasm. Its very difficult. What I like to do is learn all the rules so you can forget all the rules. Just make it happen. If youre going to make great music you have to know the notes and what all the signs and symbols mean. But then you have your passion and have to do it that way. I think thats a problem that people are having a hard time with, going from focusing on the rules to lets make the magic happen now. Thats the future of CME. Weve got the rules, weve got to learn them all, but then we can f orget them and focus on doing great CME, best practices. Thats where we want to be. Its tough because you have turnover but we have to get there and we will get there, but its a question of how long its going to take. I think that its going to take lo nger than the ACCME wants it to take. (Ms. Brown ) Summary of Themes What havent I asked? Or, is there anything else you would like to add at this time? Performance Improvement CME PI CME can be completed in outpatient or inpatient setting s, in a hospital, in a health care system, or in a group or individual practice. The AMA requirements to earn CME credit for PI CME are to complete three stages learning from current, from the application of performance improvement and, finally from an evaluation of the performance improveme nt effort. In terms of funding, Mr. Red notes that educational grants are awarded for one activity at a time, rather than at the program level. The programmatic systems based approach is not understood and is, ther efore, overlooked or simply not considered by

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181 commercial supporters Mr. G ray sees this a s one of the greatest opportunities for providers to connect with physicians and look at how they p ractice medicine with a focus on quality patient care and patient s afety. Mr. Green goes a bit further to sa y that it is the ultimate form of CME the most powerful learning technology there is. Providers As presented earlier, the role of CME providers will become very important in the design and delivery of more sophisticated CME. Mr. Green hopes that CME is not so complex and bureaucratic that providers will give up the profession. However, as M r Red points out, it is a redefined or new profession and national certification is a very useful appraisal to guarant ee providers have the appropriate education and qualifications along with the expertise necessary to oversee quality CME programs Accreditation Mr. Green reiterated his view that CME should not equal what is in the activity file Successful CME brin gs to light the learning that takes place and the resulting change in behavior. Ms. Brown commented on the high cost of remaining accredited. Her perspectives are parallel Mr Greens regarding accreditation systems which should be less about documentati on and more about results with a goal of reaching best practice levels. Summary This chapter presented the data collected via interview s document review field notes and reflective journal and represent ed the perspectives of the experts in continuing medical education with whom I spoke as well as experts selected by the Institute of Medicine and those who participated in the Lifelong Learning in Medicine and Nursing Conference. Participant descriptions were in aggregate fashion to protect their ident ity.

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182 The chapter illustrated each interview setting and the experience. The elements of CME were identified as accreditation, and physician involvement. Factors seen as the most influential were funding, physician involvement and accreditation. The most s ignificant issue facing CME is its providers and the future will revolve around funding, providers and the role of technology The final question posed was what havent I asked or what else would you like to tell add at this time? Responses foc used on PI CME, providers, and accreditation. Chapter Five summarize s the findings, provide s conclusions, outline s implications to practice and suggest s recommendations for future research.

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183 CHAPTER FIVE DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS T he field of medicine bolstered by clinical r esearch, advances in pharmacology and innovations in both technology and information technology systems has accelerated faster than practitioners can keep pace. In an effort to ensure the competence and performance of practicing physicians providers accredited by ACCME offer CME Physician participants rely on these providers to produce educational activities that meet their needs and assist in maintaining or improving competency and performance That improvement can ultimatel y enhance the health of their patients and, eventually, the health of the general population. As a CME provider I have witnessed significant changes in accreditation guidelines, commercial support, outcome measurement, certification of providers, reform and repositioning initiatives, and advances in technology However, t he perspectives of the interviewed experts and appreciation of their lived experience, as well as the review of document s and recent literature, has broadened my knowledge about the elements, influences, significant issues, and the future of continuing medical education Purpose of the Study The purpose of this study was to describe and explain selected participants perspectives on continuing medical education.

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184 I interviewed experts in t he field of CME to obtain their perspectives on the current state of affairs of CME and the future of CME The research questions developed for this project were : 1. What are the major elements of CME? 2. What influences CME? 3. What are the most significant issues in CME? 4. What is the future of CME? The design of the interview questions elicited information to answer these questions The researcher summarized the data obtained from the interviews along with direct quotes from the participants As described in the Ch apter Three, the researcher reviewed and coded answers for each question from the transcripts to search for general themes and infused the data with r eview documents Document Review A document review, which is an unobtrusive method rich in portr aying the values and beliefs of the participants, supplemented the interview data, observations and reflective journal Documents may include meeting minutes, logs, announcements, formal policy statements, and letters to develop an understanding of the se tting or group. Archival data can further supplement the data. Content analysis is a systematic examination of the communications to document patterns. The strength of the content analysis method is that it is unobtrusive and nonreactive. The researcher d etermines where the greatest emphasis lies after the data have been gathered. Also, the method is explicit to the reader. Facts can therefore be checked, as can the care with which the analysis has been applied (Marshall & Rossman, 1995, p. 86) An overview of this

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185 method and references utilized as guides as well as t he final list of review documents are provided in Chapter Three. Theoretical Framework The theoretical framework selected for the cur rent study was constructivism inclusive of social constructivism. It matches my understanding of how learning occurs and develops Not only can c onstructivism explain how learning occurs it guide s teachers/instructors to the most effective instructiona l techniques Likewise, it guides providers in select ing techniques settings and learning experiences most likely to change physician competence and performance. Physicians learn by comparing outcomes, by discussing patients with their colleagues, by trying new techniques and combinations of medications, and by noting the results for the future. They also learn by listening to national and local opinion leaders, researchers, and their patients. Sometimes learning occurs during hands on workshops or on t he battlefield Self reflection and reflective practice are excellent learning experiences, and are especially complement ary to performance improvement projects. In short, physicians develop and refine their skills by the constant construction of new know ledge. The method of interviewing is reflective of social constructivism wherein the researcher and the participant dialogue and interact, and negotiate meaning or refine understanding by contrasting personal perspectives. This was demonstrated i n the pr esentation and analysis of data in the current study as there was a constant comparison of perspectives between the researcher and the participant s and between participants via the transcripts This framework consistently supported the research method and data

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186 analysis which reflects the learning that takes place in medicine and that which occurs in the interview process. T he perspectives expressed certainly ascribed meaning to the participants lived experiences and provided a more thorough understanding of their role in the continuing medical education community and beyond. As a result of the knowledge gained about the field within which I work, observation of qualities, characteristics and/or skills observed that I would like to emulate and ideas for fu ture pursuits as a CME professional and researcher, t his research m a y be termed as studying up . The experts were receptive to participating in the study much to my delight, and proved to be gracious, open, funny, insightful, opiniona ted, informativeand the list goes on. Not only that, but I have had the opportunity to see all of them in the role of instructor or presenter at pro fessional meetings. All of th ese were an open invitation to continue pursuing my professional goals and one day joinin g them in the level of expert. Summary of Findings Question One What ar e the major elements of CME? There are many segments of CME in terms of providers such as community hospitals, academic settings, professional societies, state medical associations, and MECCs, and many steps in the development and implementation of each CME activity that it was sometimes difficult for participants to answer this question. However, the themes were accreditation and physician involvement. Figure 1 illustrates these findings.

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187 CME Physician Involvement Accreditation Figure 2.Question One What are the major elements of CME? Either the ACCME or state medical association awards accreditation to providers at a national or regional level. The mission of ACCME is the identification, development, and promotion of standards for quality continuing medical education (CME) utilized by physicians in their maintenance of competence and incorporation of new knowledge to improve quality medical care for patients and their communities ( Accreditation C ouncil for C ontinuing M edical E ducation, 2008) Criteria are set for providers to become accredited and surveyed periodically to ensure they still meet the criteria This requires providers to keep detailed files on each activ ity, series or conference offered Although some participants considered this absolutely necessary, others deem ed the oversight unyielding thereby not allowing providers enough leeway to produce continuing education that was mission based and focused on patient outcomes via progressive methodologies. The IOM report Redesigning Continuing Education in

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188 the Health Professions noted this focus on regulatory requirements and suggest ed it would be preferable to concentrate on the identification of knowledge g aps and the development of educational interventions to fill th ose gaps Variations in regulation contribute to inconsistent learning and conflict with efforts to achieve high levels of competence and practice for every health professional (Institute of Medicine, 2009b, p. 3) The second theme was physician involvement inclusive of physician participation in the planning process, attendance, and support of CME initiatives Involvement at the physi cian level is crucial to a successful CME program because their knowledge, expertise, and front line work experience are necessary to develop educational initiatives to meet the needs of their colleagues and to close knowledge gaps The IOM recommended est ablishing a Continuing Professional Development Institute to assist in the redesign continuing education in the health professions ; the Lifelong Learning in Medicine and Nursing Conference findings also promote d team based education and practice. The Lifel ong Learning vision included using outcome based continuing education methods that linked education to delivery of care. Both initiatives should promote the direct particip ation of physicians in the educational process and promote interdisciplinary, team b ased patient care. Question Two What influences CME? The most influential factors in CME were identified as funding, physician invol vement, and accreditation The themes are represented i n Figure 2.

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189 CME Funding Physician Involvement Accreditation Figure 3.Question Two What Influences CME? T he method by which continuing medical education is financed ( physicians registration fees, educational grants, academic institutions, medical centers and hospitals, independent medical education companies or foundations ) served as the definition of funding in this instance. C ommercial support and the conflicts of interest that arise from that source of f unding have come under scrutiny by the federal government as a result of their concern for undue influence on prescribing patterns and use of devices by physicians thus increasing market share for the commercial entity Marketing an d accredited education need to be separate. Educational activities should be free of commercial influence and bias. Funding is influential because many accredited pr oviders depend on commercial support and are not going to be able to finance CME without it, consequently reducing opportunities for physicians to participate in this important aspect of their practice.

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190 A lthough the ACCME implemented updated standards for commercial support in 2006 in an effort to improve transparency and eliminate conflict of interest, the recent IOM reports on Conflict of Interest in Medical Research, Education, and Practice and Redesigning Continuing Education in the Health Professions t ook issue with the funding mechanisms and called for standardized procedures and conflict of interest guidelines. (Institute of Medicine, 2009a ; Institute of Medicine, 2009b) Recommendation 5.3 from the conflict of interest report specifically directed stakeholders to propose a new system of funding CME within 24 months of the reports publication that was free of industry influence, enhances public trust in the integrity of the system, and provides highquality education (p. 12) In turn, accreditation organizations should design standards in an effort to ensure compliance. Hopefully accreditation organizations in all of the health professions will work to develop parallel standards across disciplines. To further ensure this separation, Recommendation 6.2 state d pharmaceutical, medical device, and biotechnology companies should already have policies and practices in place that prohibit ed providing physicians with gifts, meals, drug samples(except for use by patients who lack financial access to medications), or other similar items of material value and against asking physicians to be authors of ghostwritten materials Companies should not involve physicians and patients in m arketing projects that are presented as clinical research. (p. S15 16) Combined, these efforts are 180 degrees from elaborate CME conference s financially supported by the marketing divisions of pharmaceutical companies in the not so distant past. Frequentl y these included food and beverage, resort activities and, as a sidebar,

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191 CME activities. Implementation of these recommendations along with others presented in the Conflict of Interest in Medical Research, Education, and Practice report will go a long way to assure lack of undue influence of physicians by commercial entities. Continuing medical education for physicians by physicians as described by Ms. Brown is a not a new concept Physician involvement is a necessity in the design, implementation, and e valuation of CME activities in order to be effective and valued by the target audience, physicians. Their preferences and desires are crucial to the CME provider in order to offer the kinds of activities that physicians find worthwhile CME can assist phys icians in providing better care for their patients to whom they are accountable and who sustain their practice Physicians are also interested in feedback and comparison of their practice patterns. CME and PI CME can play a critical role in providing this information to physicians Another uncovered aspect of physician involvement was the importance of their participation in the treatment team. The team has changed over time to include not only physicians and nurses but physician extenders (nurse practitioners and physician assistants) as well as pharmacists, dieticians, and a variety of therapists who must work together in order to provide efficient and effective care. Communication and continuing education are keys to their success The Lifelong Learning i n Medicine and Nursing Final Conference Report contained 30 recommendations in the four key areas of continuing education methods, interprofessional education, lifelong learning, and workplace learning, all of which include d physicians. Based on the litera ture reviewed, interprofessional education has merit and can have an impact particularly in primary care, geriatrics and other specialized areas Thus there is evidence to support simultaneous and

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192 collaborative education of new and practicing professionals (Association of American Medical Colleges and the American Association of Colleges of Nursing, 2010) IOM s Redesigning Continuing Education in the Health Professions called for a focused effort to provide interdisciplinary design and evaluation of education activities (Institute of Medicine, 2009b) Accreditation, by its nature, is an influence on CME Simply put, the American Medical Association does not recognize c ontinuing medical education activities unless provided by an accredited organization. The ACCME oversees accreditation in the United States, in a tiered style, by state medical associations. Within the United States, the AMA only authorizes organizations that are accredited by the Accreditation Council for Continuing Medical Education (ACCME) or by a state medical society recognized by the ACCME Committee for Review and Recog nition (CRR) to designate and award AMA PRA Category 1 Credit(s)TM to physicians. The AMA, on behalf of its physician constituency, also maintains international relationships for certain educational activities that meet AMA PRA st andards. In the 1960s, the AMA started to recognize CME programs in hospitals and other health care organizations for the purpose of encouraging quality CME. In 1977 the AMA responded to the rapidly growing number of accredited CME programs by inviting oth er organizations to form a national accrediting body, which eventually evolved into the ACCME in 1981. The ACCME currently includes seven member organizations: the AMA, American Board of Medical Specialties, American Hospital

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193 Association, Association for H ospital Medical Education, Association of American Medical Colleges, Council of Medical Specialty Societies, and Federation of State Medical Boards. Today the ACCME directly, or through the recognized state medical societies, accredits more than 2,500 U.S. based organizations to provide CME For accredited providers who choose to designate their activities for AMA PRA Category 1 Credit(s)TM high quality program content is expected, in compliance with the standards outlined in this booklet. The strength of the AMA PRA credit system depends on the complementary roles of the ACCME essential elements and standards for commercial support, and the AMA PRA requirements. Both organizations work diligently to coordinate the development of t heir respective systems in a manner that seamlessly serves providers and physicians educational needs. This effort ensures the integrity and effectiveness of the AMA PRA Category 1 Credit(s)TM system. (American Medical Association, 2006, pp. 12) Due to its mandatory nature, there are varied perspectives about ACCME. On the negative side some perceive it to be a micromanaging organization that views CME as whatever is in the acti vity files of the provider All the is must be dotted and ts crossed in order to maintain accredited provider status Providers do not have the skill set to understand the complexity of the focus on PI CME, physician competence, performance, and pati ent outcome expectations Within the confines of the field, it is too influential.

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194 On the positive side is the recognition the PI CME as introduced by the AMA in 2006, has been adopted as the highest degree of provider performance and can help providers achieve accreditation with commendation by the ACCME This focus also forces providers to practice their mission and adhere to their values One could describe the polarity of this situation as those who embrace the opportunity to be held accountable versu s others who say the task is too demanding and too difficult to measure. Question Three What are the most significant issues in CME? CME providers were the most significant issue at the time of this study based on a number of factors. First, they often have multiple roles which make it difficult to concentrate on the complexity of accreditation let alone implementation of quality educational programming aimed at improving physician competency performance, and patient health with the ultimate goal of a ffecting community health Second, providers have limited access to data, limited funds, lack of training in adult education principles and practices, and few professional development opportunities Although the ACME offers an annual conference and online resources for their members, some are cost prohibitive to those who are already working on a shoestring budget. Third, as pointed out by the Lifelong Learning in Medicine and Nursing Final Conference Report (2010), providers should use newer and probably m ore effective education delivery models that would produce change in physician practice. Many will have a difficult time transitioning from the traditional didactic method to these more advance d methods Fourth, the NC CME offers the new certification exam ; h owever, the experience, education, and continuing professional development required to take the exam are beyond the reach of some providers.

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195 The experts look beyond the current state of affairs to a time when providers will be professional educators who are motivated to pursue continuing professional development and engage in conversations with their constituents and their quality management colleagues to provide excellent education as measured by local st andards, not by national ones Providers would take the lead in offering innovative programming They would help institut e external standards while adding value As stated by Mr. Red, its going to be so increasingly clear for all of us that if youre not contributing in a cost effective way to improve health care quality and patient safety; if youre not doing one of those two things in a measurable effective way, youll be largely irrelevant. Youll be a cost to the system. We need to be an investment within the system. So itll be an interesting couple of years with a lot of opportunity. I think itll emerge Question Four What is the future of CME? In 1992, Davis, Fink and Watts contributed a chapter entitled What Lies Ahead? to the book Continuing Medical Education A Primer, Second Edition. T hey noted that traditional CME formats, including didactic lectures and reading, had such a precedent that they impeded efforts to introduce practice or problem based CME activities They anticipated that the physicians currently in training might support progressive practiceor problem based CME The authors noted several changes already underway that might drive important changes in the content and methods of CME over the years ahead (Rosof & Felch, 1992, p. 223) Those changes included: Quality Assurance Practice Arrangement and Cost Considerations

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196 Linking CME to Physician and Patient Outcomes The Definition and Scope of CME The Political Environment Davis Fink and Watts added, The future almost certainly holds more structured, more data based, more outcome related CME, and a growing understanding of the nature and context of physician learning and change. As this occurs, the concept of in dividual physician responsibility for professional, lifelong learning, integrated to practice, will surely be strengthened. (p. 226) T he outlook for CME is changing and the credit goes to the contributors and editors of that text along with their respectiv e colleagues and the stakeholders of CME who persevered and advocated for the changes they envisioned. The future of CME as envisioned by this group of experts in 2009 is in Figure 3. It will depend on technology, professional CME providers, and the funding available for the provision of CME.

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197 Technology Providers Funding Future CME Figure 4.Question Four What is the future of CME? As can be seen from responses to other questions, the funding for continuing medical education is at a major cross road The IOM directed stakeholders to create a new system for funding quality educational programs by 2011 that is free of industry influence and simultaneously earn public trust The experts in this study questioned whether industry would f und CME or whether stakeholders would embrace a model of pooled funds Perhaps block grants, especially useful for nondrug related topics not typically funded or PI CME projects, will become the primary avenue of commercial support Another scenario may be that we create quality education that does not offer continuing education credit. The question remains then how will interactive series, workshops, electronic newsletters peer gro up initiatives and didactic lecture f ro m opinion leaders or national experts be funded?

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198 In 2009, Robert Orsetti wrote an editorial for CE Measure in which he introduced Patrick Kelly, past President of Pfizer US Pharmaceuticals, whose paper was delivered at the 16th Annual Conference of the National Task Force on CME Provider/Industry Collaboration in 2005 as the distinguished Shickman Lecture The paper entitled Let Science Prevail: Embracing the Ultimate CME Strategy conclude d with the following thoughts: Conflicts of interest can always be found by those w ho look hard enough, but for the sake of patients and the healthcare delivery system that serves them, more time and energy must be devoted to looking for the confluences of interest between CME and the pharmaceutical industry. The greatest of these conflu ences is a shared interest in information, objective, insightful, and timely scientific and medical information that expands our awareness, increases our options, and advances the cause of quality healthcare. Recognition of shared goals and interests is cr ucial, because just as the success of CME depends on the free movement of the best information available, so too does our ability to shape a healthier US healthcare system. We must work together to ensure that sciencein the form of the free movement of the best information available does prevail. (Kelly, 2009, p. 15) Orsetti (2009) note d that the debate on commercial support continued for the next four years. His concluding editorial statement revealed that CME and patient care will surely benefit when debate and criticism of the appropriateness of commercial support

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199 cease and all parties agree to collaborate within the existing guidelines to improve content and delivery systems, while strengthening them as n eeded ( p. 11) Th e debate continue s as the various stakeholders (regulatory agencies, government agencies and their committees, academic medical centers, providers and their professional associations, medical specialty societies, state and national medical associations, etc.) jockey for position to sustain themselves and uphold the honorable intention of providing quality, unbiased, evidence based continuing medical education. Mr. Gray predicts the future of CME will depend on how well we affect physician competence, performance and patient health. Mr. Black and Ms. Amber, respectively summarized the future of providers One of our barriers to success and to change [is] t he people in the CME system, th e heterogeneity of their backgrounds and their skill sets is a real hindrance to th e evolution of CME, it really is And we either have got to stop that and have a better admission process, training process, and preparation process, or we have got to addre ss it and say Weve got to bring the skills up of everyone, make us more homogeneous from an ability to deliver, to evaluate, to measure, to participate, to do research, to be strategic, to deal with and have management skills. You have to demonstrate c ompetency not only in knowledge but in skill set And all the way up that paradigm of knowing what to do, knowing how to do it, and integrating it into your practice in a daily fashion I see where theres going to be a need for professional educators to s tructure the education for the learner, to take the new science and pull it together in a way that can be taught and understood

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200 and translated, translational practice So theres still going to be a need for educators. I think were going to need a higher skill level, and were going to need access to the dat a CME providers will need to be closer to patients, have access to data and engage physicians They will need not only to participate in the change process but also to facilitate it utilizing a soph isticated skill set. Practice based CME would be ideal perhaps along with working toward the maintenance of certification or competency CME as Ms. Amber pointed out They must meet Joint Commission standards Providers should design and implement innovative educational initiatives with measureable outcomes based on physician competence or performance and patient health. They should exhibit professionalism and competency on a regular basis accentuated by research activity and leadership roles T he value of accredited continuing medical education, as opposed to marketing based education should prove successful Technology is a component of CMEs future with the strength to make a significant impact on how, where and when CME is viable. There are only as many options as there are creative providers and information and communication technology professionals Learning can take place in a synchronous or asynchronous environment or in a hybrid situation with e learning and a classroom or face to face component Th e range includes P oint of care (Just in time learning) Virtual Office Simulations Computer based

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201 Web based Interactive w ebcasting with imaging Electronic newsletters Social networking Facebook and Twitter Pod casting Satellite Cable TV Closed Circuit TV CD/DVD Digital T he Lifelong Learning in Medicine and Nursing report encouraged the application of technology in all five of its focus areas They note d that technology can deliver upto date evidence based information to all practice settings and to doc ument change (Association of American Medical Colleges and the American Association of Colleges of Nursing, 2010) IOMs report Redesigning Continuing Education in Health Professions also urged the use of technology to collect data and as a platform for educational interventions. The committee members considered the ehealth infrastructure of the future for evidence based and surveill ance data. Examples they provided were electronic newsletters and multimethod education to support just in time learning, Facebook and Twitter for tacit knowledge acquisition and co creation of clinical knowledge, electronic communities of practice, and s imulations to learn diagnostic and management techniques (Institute of Medicine, 2009b)

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202 What havent I asked? Or, is there anything else you would like to add at this time? PI CME providers, and acc reditation were the themes uncovered with this closing question as shown in Figure 5. PI CME Providers Accreditation Figure 5. What havent I asked? Or, is there anything else you would like to add at this time? The participants in the cur rent study covered the role of providers and accreditation issues in previous research questions including responses to this question. PI CME however warrants additional discussion because it is where providers struggle to be competent to meet the expectation s of ACCME. Figure 6 below depicts the traditional and performance improvement levels of CME.

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203 Performance Improvement CME Traditional CME Level 7: Community Health Level 6: Patient Health Level 5: Performance Level 4: Competence Level 3: Learning Level 2: Satisfaction Level 1: Participation Adapted from Orsetti, 2009 Figure 6.Performance Improvement CME Mr. Green stated: You know its kind of like do you think your life is going to be one series of exhilarating adventures after another ? Or is it going to be mostly kind of steady with peaks you know ? I think thats how you should think about your CME And for most things, putting a huge amount of effort into it isnt really necessary And just like every couple of years, do some slam bang, whammer jammer, you know, innovative CME thing Thats the kind of thing we want to get involved in. And so we want to bring these external resources to you, so you dont really have a staff of one, but a staff of four or five to do these things But thats not going to be your everyday reality, given the kind of shop that youre in. And you go and y ou talk to people at the academic medical centers with staffs of 14 16 and its kind of the same thing there too

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204 The question is what is acceptable in the mix? And so from an accreditation standpoint, how many if these do you have to do? The ACCME has be en mum on that They dont say. Are these proxy things enough? I dont know They wont say, and it makes people very nervous. It is no surprise that providers are nervous about being able to meet accreditation expectations and have trouble embracing the concept However, the experts offered insight on what kinds of performance improvement activities might be doable and effective. For example, examining how physicians conduct their daily routine and making changes can affect not only their efficiency and effectiveness but can also improve patient health and promote patient safety Skilled CME providers can coach physicians in mapping out what happens in the office and determine what steps they miss, thus correcting the process and improving patient care. C oncrete examples are the diabetic foot exams and completing an osteoporosis screening exam The implementation of electronic medical records will enhance this type of process Another area where process improvement is to meet reimbursement incentives by pr operly documenting the patients chart based on guidelines and protocols as exemplified by the Center for Medicare & Medicaid Services Physician Quality Reporting Initiative (PQRI) Mr. Green recommended implementing PI CME by measuring commitment to change, behavior change, and in some instances change in patient health status . It can definitely go to physician self report of behavior change Theres actually in the educational literature quite a bit of research that supports the commitment to change kinds of things that professional groups say that Im going to do it. Then they will do it to some extent. So youre looking at proxies for change We

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205 definitely can do that. Occasionally we can have real data that shows the change in behavior like in pre scription patterns Now if youre in a closed system like Kaiser, you can show actual changes in treatment of patients and in some cases information about their health status following In open systems right now, I dont think we can show that. Going much beyond Levels 4 and 5, competence and performance, would require patient chart audits which are costly to perform, time consuming, and invasive. Another view was to employ the common PDSA (Plan Do Study Act) model for PI CME and obtain commercial su pport for the entire project rather than asking for educational grants for each activity Mr. Reds perception was that the pharmaceutical industry does not understand this approach to funding He questioned how medical specialty societies would be able to conduct PI CME since they are not close enough to local quality issues They may need to collaborate with local hospital and academic medical centers that would have data and could identify high risk, high volume issues This point was echoed by Nedza (20 09) Vice President, American Medical Association Clinical Quality and Patient Safety Member, in her article All Health Care Quality is Local: The Role of PI CME in Achieving Sustainable Change . Just as all politics is local, all health care is local and so is all QI. PI CME provides a model to enable such analysis and, more important, provides a flexible structure to facilitate changes at the practice level. Although there is room for improvement in the PQRI program, at the core of the PQRI program ar e performance measures that use Current Procedural Terminology (CPT) Category II Quality Tracking Codes TM

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206 to capture variation. This includes variation based on clinical judgment, patient preferences, patient specific barriers to compliance and/or system reasons that capture barriers to providing services (e.g., the influenza vaccine was not available to provide recommended vaccination). Work sheets and tools are available that enable the physician, the practice manager, the hospital QI department, and the professional coder and biller to support PI CME data collection. Although performance measures have been developed to support various federal programs offering individuals and groups incentives to facilitate QI, at the local level one thing remains the s ame: Physicians still find themselves working within a system that inhibits their ability to practice and provide quality care. The transformation of the health care system will only be successful if national efforts to improve quality enable QI where care is provided. Although policymakers can design systems that facilitate or reward performance measurement, the success of these programs will depend on the ability of physicians to identify opportunities for improvement, the availability of tools that make performance measurement a byproduct of the care process and a commitment that supports continuous efforts to transform care at the practice level. (p 2) Conclusions If taken as a whole, the interview data re vealed the themes of accreditation, funding and providers The experts weighed in on these themes by responding to interview questions which in turn, answered the research questions.

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207 As alluded to in the Introduction, CME has experienced little change in the past 30 years because its participants were happy with traditional formats of listening to one and done lectures that provided updates or introduced new technology or treatments These are still important topics and this group of experts does not expect them to stop. However, there has been consistent pressure to move forward into problem practice evidence based CME presented in a series with mixed interactive activities combined with didactic or other multimethod interventions that are effective and impact the competence and performance of physicians and, as a result, patient health. This pressure from certain stakeholders and individuals supported by reports released by the IOM and other influential groups resulted in directives to change what we are doing When paired with the ACCME changes in 2006, providers have no other choice than to move forward or lose accreditation. Providers, then, have a steep hil l to climb to prove they are competent and skilled professionals who can deliver quality education in an efficient and economical manner They may need to return to higher education to pursue college degrees preferably advanced degrees Obtaining nationa l certification from NC CME within in a certain timeframe could be a requirement for employment Providers need to take advantage of resources available from professional associations such as ACME, S A CME, AAMC, and the AMA as well as those in the adult ed ucation community. Accreditation is a set of guidelines and rules reflecting what is right Its not about creating what is right Its about reflecting what is right ... [it] need s to be focuse d on clarifying and improving how people conduct themselves as facilitators of CMC (Mr. Black) The experts, both in this study and in the greater community, would probably

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208 agree, but some say the focus should be on the provision of quality CME rather than following mandatory guidelines. The financial support of CME is in limbo, and the CME community ha d less than 24 months at the time of this study, to design a new system Of course, it is unclear what that system will look like and makes it difficult for providers to develop strategic plans In the interim, we struggle to obtain independent educational grants and prove to our respective institutions that CME is a valuable commodity in the world of health care. Although his article specifically addresse d conflict of interest, Dorman (2010) summarize d the current state of affairs in CM E and offer ed some remedies Vital signs: Temperature 100.3oF; blood pressure 160/95; heart rate 105 bpm; respiratory rate 28 pm In health care, providers value tracking a patients vital signs. It is these signs that provide a wi ndow into the present state of the patient and a quick way to assess if something is wrong. If one were to take the vital signs on most continuing medical education (CME) providers, planners and faculty today, one would likely find that the patient is febr ile, hypertensive and tachypneicthat is, the patient has signs and symptoms consistent with systemic inflammatory response syndrome (SIRS). A good clinician, suspecting something amiss and looking to dig further, would typically start by taking a history. In this case, the patient, a CME provider, would respond that he was enjoying his usual state of good health until media, government and regulatory agencies began to question the veracity of his work and the

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209 transparency of his process. To wit, the recen t investigations conducted by the Senate Finance Committee into relationships between physicians or medical researchers and pharmaceutical, medical device, and biotechnology companies have put a great deal of pressure on the entire CME community. A clinician might trace the true source of this patients malaise to these investigations, and the negative media attention that has splashed on CME as result.(p. 1) The remedies for such an aliment are: 1. F or the heal th care industry to embrace the IOMs recommendations in the Conflict of Interest report, 2. For those outside of health care to provide the time needed to collect da ta and begin to imple me nt the recommendations 3. Education must be acknowledged as the central c ore to the health care trifold mission of patient care, education, and research 4. Develop a national CME issues agenda and locate required funding Dorman concludes with Of course, if that doesnt work, then my best advice is to take two aspirin and call me in the morning (p. 3) Implications for Practice As a CME practitioner I see many implications for practice that emerged from this study especially in the hospital setting Although there are many facets of CME, such as : the physician involved in development but also the primary customer; commercial entities as a source of funding ; and regulators who ensure that everyone follows the rules, guidelines and laws However the CME provider is the one who makes

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210 it happen, managing the educational activities, the funding and the accreditation Practitioners, then, need to consider the following in terms of funding, design and deliver y of CME and c ontinuing professional development Funding As described in the current study, the availability of funds from commercial support for CME will continue to dwindle The health care industry as a whole will continue to struggle with reform and decreased revenues, especially from gov ernment entities such as Medicare and Medicaid. CME must be considered a very valuable asset in order to survive in the hospital setting and to receive financial support from the accredited institution CME professional s will have to demonstrate the abi lity to provide educational interventions that will support the initiatives of the hospital or health care system in order to request the additional funds that will be needed to support programming at current levels. As an alternative funding source, providers can request assistance from their foundations or request assistance in locating appropriate funding from external foundations Other resources to consider are hospital vendors outside of the pharmaceutical and device manufacturing realms who are sti ll able to offer donations to the foundation or directly to the institution In order to reduce expenses, some providers have discontinued giving honorariums to member s of their medical staff and have decreased the amount provide d to external faculty. S ecuring block grants granted by commercial supporters and administered by an independent group has recently become an excellent avenue for funding as well as assistance and guidance from the administrator for the CME project The Physicians Institute f or Excellence in Medici ne based in Georgia is one such administrator. One of their projects has included a partnership and with the Association for Hospital Medical

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211 Education to secure and administer the educational grant for performance improvement CME. A specific group of providers was then asked to apply for a portion of the grant for a local PI CME project of their choosing. This is an outstanding example of supporting hospital initiatives, using external funding and improving practice performance. Another implication based on the finding s in th e current study is to consider pool ing resources with local or regional accredited providers to deliver either didactic or innovative CME acti vities to meet the needs of th e local and regional physicians res pectively. This has been the practice called jointly sponsored CME when accredited providers work the non accredited part ners to produce CME conferences, review courses, webinars, internet CME, etc. The same type of partnership can be forged with accredi ted providers who share the workload and the cost. F or accredited providers in the same community with shared medical staff members this can have the additional advantage of being a physician satisfier when the education al intervention is convenient and applicable at both locations. Design and Delivery of CME Engaging physicians and involving them in all phases of CME development is the best way to ensure that the right topic is selected and offered at the right time to the right audience. It also help s in demonstrating the value of CME to the medical staff and administration Design ing creative and innovative educational interventions to replace some of the didactic lectures is another way to further engage physicians who may otherwise not participate D esign ing more programs that are truly interdisciplinary in nature will help to build collaboration within and between teams of health care providers. Utiliz ing the PI CME

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212 process to demonstrate excellence in CME is important but more importantly it can improve patient care and outcomes. Again, this supports the institutions mission and primary initiatives. Implementing Just in Time/Pointof care CME utilizing accredited institutions inpatient and outpatient electronic medical records as platforms to launch internet searches of evidence based sites will be a satisfier to physicians and their patients C onfirmations regarding treatment choices and subsequent decision s are made more quickly and are made at the bedside or exam room. Simply teach ing phy sicians how to use the internet for Just in Time/Pointof care learning will be another satisfier because of the immediate results and the CME credits will be gathered electronically. Facilitating access to e learning platforms internet literature search es, access to evidencebased data bases and external CME opportunities goes a long way in ensuring continued participation in ongoing CME programming. Collaborat ion is an important strateg y to implement for a successful CME program. T he quality management, technology services, medical staff services and other department s in the institution can provide expertise, data, and services in the de sign delivery and evaluation of CME Collaborat ion with other local institutions to produce CME activities pertinent to community physicians as mentioned above, would be a major influence on the ability of providers to effect a change in physician behavior. Finally, c ollaborat ion with experts reduces the burden on the individual provider to be an expert in every as pect of CME. For example, there are companies whose products have been designed to assist in identifying needs and knowledge or practice gaps educational design, and outcomes measurement specifically for CME. Although the initial cost may

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213 be significant theses products and services will offer a large return on investment in a fairly short period of time. They make for a well designed activity based on the gaps and evidence and will have a greater impact on changing physician behavior and measuring that change over time. The other advantage is the adherence to accreditation guidelines and ability to meet and exceed accreditation standards. Continuing Professional Development When it is established, resources and data from the Continuing Professional D evelopment Institute (per the IOM Committee on Redesigning Continuing Education for Health Professionals ) should be utilized. T he pro posed institute is charged with researching the evaluation and assessment of CPD at various levels. In addition, it is t o relate quality improvement data to CPD and describe the linkages between educational intervention, the resulting skill acquisition and the i r relationship to improved patient care. The result may be new methods and techniques for CPD with a focus of rese arch and outcomes CME leaders may also want to ta ke the initiative to re create their CME department personnel structure to reflect the higher educational levels and experience suggested by the Redesigning Continuing Education Committe e. This should be inclusive of the pursu it of higher education preferably advanced degrees Staff members should be expected to qualify and obtain certification from the NC CME These restructuring efforts can be bolstered by taking advantage of resources available from the professional associations such as ACME, SACME, AAMC, AMA as well as adult education associations Professionals need to subscribe to their respective journals or publications and be active participants in those same organizations. Finally, CME profe ssionals should be expected to c onduct research and publish their

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214 findings Often times this can be based on CME programs that have been creative, innovative and have found ways to impact physician behavior and patient outcomes. How the Redesigning Continuing Education in the Health Professions recommendations are implemented and what changes in practice result will directly impact practi tioners. I anticipate that the required skill set of the provider will be quite different than they are today and that the CME provider will be more innovative and progressive. I expect more emphasis on interdisciplinary education that utilizes a process improvement model and less emphasis on securing funding to bring in a national expert for a didactic presentation. Adul t Education A s discussed in Chapter Two, continuing professional development and education in any profession are rooted in the principles of adult education. As a result, providers in CME need to be well versed in these principles. Conversely, continuing education professional s in other disciplines and those involved in traditional adult education can consider some of the innovative educational interventions that are becoming more common in CME such as the performance improvement model This could be im plemented in any adult education discipl ine that collects data on process, outcomes, satisfaction, enrollment, retention, etc. For example, the Department of Surgery at Montefiore Medical Center in Bronx, NY was searching for S urgical Educators to devel op curriculum and implement, analyze and report learner assessment and program evaluation proce sses for our residency programs (Personal Communication June 18, 2010) Certainly they would utilize performance improvement data to he lp assess the impact o f educational intervention s on the learners as an outcome measure. Based on the results, they can modify the curriculum to reach the outcomes

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215 they expect In the same setting, the satisfaction of the resident will be important for recruitment and retentio n Partner ing with other CME providers and with other related business es as suggested above has been well demonstrated in the unique partnerships forged by St. Petersburg College (SPC ) In 1927 it was known as St. Petersburg Junior College and transitioned to a four year institution in 2001 ( S aint Petersburg College, 2010 a ) A complete history of SPC can be found online at http://www.spcollege.edu/webcentral/catalog/Current/tradition.htm Other adult education programs could benefit from considering these types of agreements which c ertainly exhibit entrepreneurism, resource sharing, and excellence in education. For example, SPC has partnered with 16 esteemed educational i nstitutions to offer bachelor's and master's degrees in disciplines including business, computer science, hospitality, pharmacy, and physician assistant. This is the first partnership center of its kind in Florida and only one of a handful nationwide ( Sai nt Petersburg College, 2010 c). In addition, SPC offers customized corporate training and offers a wide variety of individual and business related courses. Positioned as a strategic partner for both large and small corporations this versatile department h as four main areas of focus, Technology, Professional Development, Licensed Professions, and Business Solutions ( Saint Petersburg College, 2010b) No t only do these programs enhance the local workforce but they could potentially attract corporate employ ees who may not have previously considered seeking other educational avenues including college and advanced degrees

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216 Recommendations for Future Research This study was limited as a result of the number and types of experts that were interviewed and, as a result, the conclusions may be limited. However, the findings from the review documents and the expected implementation of the two IOM Committee recommendations help to reinforce my findings and conclusions. There are a several recommendations for future research based on the limitations as well as the anticipated changes in continuing medical education and its financial future. Interviewing experts in similar work environments may provide more focused findings that would assist that particular segme nt of the profession and their respective institutions. These groups are naturally found via the Alliance for Continuing Medical Education member sections including Federal Health Care Educators, Health Care Education Associations, Hospitals He alth Systems, Medical Education/Communication Company Alliance (MECCA), Medical Schools, Medical Specialty Societies, Pharmaceutical Alliance for Continuing Medical Education (PACME) and State Medical Societies Results may identify specific issues for those provider types that were not identified in the current study. For example, funding from this researchers perspective in a Hospital Health Systems setting is problematic at this time due to a continual budget reduction at the department level over the past four to five years reduced opportunities and more stringent rules for requesting and receiving educational grants from commercial supporters etc. However, we do have the option of applying for block grants due to membership in the Florida Medical Association and the Association for Hospital Medical Education. Other providers such as Medical Education/Communication Companies would not have that advantage.

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217 A comparison of local (accredited by state medical associations) and national providers (accredited by ACCME) may shed light on how similar or disparate they are in the design, delivery, evaluation and funding of CME Do national providers have more resources? Do they have a greater chance for partnerships with other types of companies based on their national accreditation? Since they can provide for national audiences, are the types of interventions different than t hose offered by local providers? A prospective longitudinal study looking at the implementation and outcomes of the IOM initiatives for conflict of interest in medicine, the IOM initiative for the redesign of continuing education in the health professions or interdisciplinary lifelong learning as proposed by the AAMC and AACN would be an excellent mechanism to record the history of these initiatives. In addition, the outcomes after about five years could be compared to the original intended outcomes. Were they modified over time ? Did the implementation go as planned? What barriers were encountered? What i s the future based on the initiatives that were implemented ? Assuming the Continuing Professional Development Institute as recommended by the IOMs Redesigning Continuing Education in the Health Professions Committee, comes to fruition; it could be investigated in five to seven years to determine if it achieved the desired design and function. One of the primary functions outlined by the committee is to significantly enhance the research agend a for continuing educat io n in the health professions Was th at accomplished? Was the resulting research translated into practice? Did the research reveal new techniques or methods not previously used in this f ield? Did it support continuing education as a means to improve the competence and performance of practitioners?

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218 Repeating this study with experts from the same categories in about ten years should reveal significant changes in continuing medical education as compare d to the findings in the current study. The role of accreditation, funding, CME provider credentials technology, performance improvement CME, access to data, partnerships, and collaboration may all have changed or perhaps some will be differ ent or some issues may have disappeared. Based on this researchers experience in the past ten years, the field of CME may transform dramatically in the next ten. The Dissertation Committee for the current study wondered, W hat will it take to get to the top of the pyramid? referring to the pyramid presented in Chapter Five as Figure 5 and entitled Performance Improvement CME Today, providers are working toward moving into the performance improvement levels of that pyramid inclusive of levels four thr ough seven. One of the exp erts in the current study recommend staying focused on competence and performance as measuring change in patient health and community health is very difficult, expensive labor intensive and time consuming. Most providers would not have the resources to successfully measure and demonstrate outcomes in these levels. However, it would be useful to know in about five years how providers are meeting this challenge. Based on the quantity of data collected, i s there a difference bet ween a large health system and a rural hospital in their ability to measure outcomes ? Can providers demonstrating improvements in patient or community health prove that the PI CME they implemented had an impact on the ability to facilitate these improveme nts ? George Miller, MD, whose original pyramid appears in Chapter One as Figure 1, was convinced that educational interventions based on categorical content failed to substantially change physician behavior. Miller called for an evidence based student

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219 centered model called the Process Model inclusive of delineating the health needs of the populations served and then studying hospital data in order to improve patient health (see Chapter Two) Acceptance and full implementation of this model has taken ab out 40 years Has th e process model, more commonly known as PI CME in this instance, been able to achieve the results that Miller expected ? Do hospital based CME and Quality Improvement departments communicate and work together to reach a common goal s vi a educational interventions and process improvement strategies ? Are content based interventions worthwhile in the quest to improve patient health? Technology was one of the themes in the current study specific to R esearch Q uestion Four What is the Futur e of CME? and a list of possible uses in CME was put forward in Chapter Five The questions surrounding the future use of technology in CME could represent a robust research study. How can it be utilized? What benefits could e learning have in medicin e ? What impact could consistent point of care learning (tracked as CME) have on the improved patient health ? What other types of technology would be useful in supporting the measurement aspect s of activity evaluation, program evaluation, and PI CME? Can simulations be advanced to better replicate real life scenarios with immediate feedback to the learner? Will the successful completion of simulations or virtual office visits be the preferred measurement for demonstrating improved competence, performance, or even measures for maintenance of certification? How does use of technology in CME compare to its use in other professions engaged in continuing education?

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220 Summary This chapter reviewed the purpose of the study, offered a brief discussion of how rev iew documents were incorporated in the data collection and reflected on the theoretical framework guid ing the current study T he research findings were summarized and discussed followed by the conclusions Implications for practice, including those applicable to adult education, were presented and recommendations for future research submitted The remainder of the manuscript contains the Appendices and References Cited

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221 Appendi c es

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222 Appendix A : Sample Letter of Invitation via e mail May 13, 2009 Via email to participant Dear participant: I am a doctoral candidate in the College of Education at the University of South Florida in Tampa, FL majoring in Educational Program Development with an emphasis in Adult Education. My Dissertation Proposal is ent itled Perspectives From the Lived Experience of Continuing Medical Education Experts: A Descriptive Study and the purpose of this study is to describe and explain selected participants perspectives on continuing medical education. I am recruiting voluntee rs to be interviewed for two one hour sessions in order to collect data for this qualitative study. I know you have worked in different CME settings and have been very involved at a national level. Your perspectives, especially from your current role, would lend themselves beautifully to this study. Interviews will be conducted at an agreed upon time and place that is convenient for you. I noticed that the [Meeting] is scheduled for [date] in Boston and that you and other prospective participants are s cheduled to present at this meeting. If that time frame would be convenient, I am happy to meet you there. Otherwise, another time and location can be arranged. Please contact me at 727 4030938 to let me know of your decision and, if appropriate, we w ill proceed with making arrangements for the first interview. Please know that all information obtained will be kept confidential. I have included my approved informed consent form for your review and signature should you decide to participate. Thank you very much for considering my invitation. Sincerely, Martha C. Baker, EdD Candidate, CCMEP Enclosure

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223 Appendix B : Informed Consent Form Informed Consent to Participate in Research I __________________________________agree to voluntarily participate in a study entitled A Descriptive Study of The View From the Top: Perspectives of Experts in Continuing Medical Education with Martha C. Baker as the Principle Investigator. I have the alternative to choose not to participant in this research study. This is Ms. Bakers Dissertation Study and I realize this information will be used for educational purposes. The potential benefit is being part of an educational study for the field. I understand the purpose of the study which to describe and explain t he lived experience of Continuing Medical Education (CME) experts. I will be asked to complete two (2) one (1) hour audio taped interviews on CME, at the site to be determined by agreement between us. The Principle Investigator, the Chair of Ms. Bakers Dissertation Committee, the transcriptionist and I have access to the audio tapes and transcripts both of which will be used and stored for two (2) years. They will be kept confidential and stored in a secure location in the Principle Investigators home. All participant names will be changed for confidentiality. This research is considered to be minimal risk which means that the risks associated with this study are the same as ordinary living as defined by federal standards. I understand that I may w ithdraw at any time. I you have any questions, concerns, or complaints about this study, call Martha Baker at 7274030938. If you have questions about your rights as a participant in this study, general questions, or have complaints, concerns or issues you want to discuss with someone outside the research, call the Division of Research Integrity and Compliance of the University of South Florida at 813974 9343. I freely give my consent to take part in this study. I understand that by signing this form I a m agreeing to take part in research. I have received a copy of this form. __________________________________ Signature of Person Taking Part in the Study __________________________________ Printed Name of Person Taking Part in Study __________________________________ Date

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224 Appendix C : Peer Reviewer Form I, _____________________________, have served as a peer reviewer for A Descriptive Study of t he View f rom the Top: Perspectives of Experts in Continuing Medical Education by Martha C, Baker. I n this role, I have worked with the researcher throughout the study in capacities such as reviewing drafts, and assisting in emerging issues. Signed: __________________________________________ Date:____________________________________________ Please see next pages for completed Peer Reviewer Forms

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225 Appendix D : Sample Confirmation Letter sent via e mail June 21, 2009 Via e mail to participant Dear participant: I hope this finds you well and enjoying the summer. This is to confirm our appointment on J une 30, 2009 at 7:00am in [Room] for the purpose of an interview. Since our time together will be fairly brief, I am sending the standard questions in advance so that you will have a little time to consider your responses. 1. Please describe your current role in CME. 2. From your perspective, what are the major elements that define CME? 3. Based on your experience, what factors influence CME? 4. Please describe the issues in CME that are most relevant for the advancement of the field. 5. What, from your perspective, i s the future of CME? 6. Is there anything else you would like to add at this time? So that I will be more familiar with you and your journey I would appreciate receiving your resume in advance of our meeting. Please forward via email to me at marthabaker@tampabay.rr.com or via FAX to 7278936819. Thank you very much for participating in my research study. I look forward to meeting you! Sincerely, Martha C. Baker, EdD Candidate, CCMEP

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226 Appendix E : Sampl e Member Check Form Date Participant Address Dear___________: Thank you very much for volunteering to participate in my dissertation research study. As part of the qualitative research process, I am offering you the option to check the accuracy of our in itial interview. I have attached a draft copy of the verbatim transcript. Please take some time to review the transcript for accuracy of responses and reporting of information. Please contact me with any corrections or questions. My contact informatio n is listed below. If you do not wish to review it, just let me know. I will be in touch regarding any follow up questions and a second interview. Thank you again. Sincerely, Martha C. Baker, EdD Candidate marthabaker@tampabay.rr.com 1500 13th Street North St. Petersburg, FL 33704 Mobile 7274030938 FAX 727 893 6819

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227 Appendix F : Interview Questions Interview Questions 1. Please describe your current role in CME. 2. From your perspect ive, what are the major elements that define CME? 3. Based on your experience, what factors influence CME? 4. Please describe the issues in CME that are most relevant for the advancement of the field. 5. What, from your perspective, is the future of CME? 6. Is there a nything else you would like to add at this time?

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228 Appendix G : Sample Interview Transcripts with E mbedded C odes Excerpts from Ms. Browns Interview Ms. Brown: As elements do you mean in terms of differentI guess that the way, and you can direct me if Im not answering the question, I guess the way I view CME and its very much based on and the education that I received from our CME committee. I was mentored right from the very beginning when I got here, and CME is education is planned by physicians for phy sicians. [e physician involvement] M: Correct. Ms. Brown: Sometimes I wonder if there arent other organizations, other people who have a different opinion of that but from my standpoint it is for physicians, planned by physicians, so physicians have the instrumental role in defining gaps, planning, setting the objectives, choosing the speaker, setting the content. I think to me that is a sacred role. Physicians have to remain at the center of the system. [e physician involvement] If they dont, then it s just professional education for anybody, for everybody. But I also think that its definitely based on principles of adult education. [e adult education] I recognize that, so I think that it is extremely important to recognize how adults learn. Physicia ns are no exception to that. For sure adult education, but again the role of physician to me, I cant overstate it is that too many times we try to take them out of the equation and thats wrong. And I also see the CME system that facilitates learning, rat her than a system that just produces curriculum. What I mean by that is that as a CME provider, Im not really teaching physicians as much as Im helping physicians to learn to teach themselves what they need to know. Thats how I view CME. So those are th e elements to me. Youve got the physician role, the adult education, and then a system of not teaching but facilitating learning on the part of physicians, so they can change themselves. M: Oh, cool. And then what factors do you see influence CME at this point? Ms. Brown: Definitely their preferences and desires as physicians, their willingness to participate in the system, the availability of funding is pretty crucial right now. I think that also the commitment of organizations to remain accredited, I s ee that as huge. That really worries me because I think that organizations are washing their hands, this is too much. I see accreditation to provide CME as an organizational designation. Youve got to have commitment from the top, down. It cant be from the bottom, up. Thats kind of where weve been and are. With funding being so tight right now, those are two major factors that are really influencing CME. I think the other thing that influences CME is the way that physicians practice medicine, the heal thcare delivery system. [I physician involvement] [different] systems I think thats why as providers were struggling a little bit. It used to be that physicians would go to a meeting and they would make time for a weekly meeting, or a monthly meeting and it wasnt a big deal. Now thats not really what physicians are looking for, or are able to do right now. I think that it has everything to do with the way that the healthcare delivery system has changed. [I funding] It used

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229 Appendix G (Continued) to be fee for service, physicians were practicing very independently, they were in their own office, and they didnt have to answer to any higher authorities. I think even the society role; we might have had one member of the family working. So basically I think that a lot of that has changed now. Just the preferences of physicians, I dont think theyre joiners. It used to be you just joined your professional associations; you just participated in organized medicine because thats what we did. Thats not what physicians do anymore. So its really tied to how physicians practice medicine, how theyre reimbursed, and the way theyre employed now. I think theyre more employees rather than owners in a lot of ways. I think that has really influenced the way CME i s being delivered, and why a lot of us are really struggling with attendance. M: In looking at what we learned at our provider meeting about the quality piece, do you think that based on physicians practice now that would be an easier avenue for us to do provide the learning youre talking about? Or to facilitate that learning? Ms. Brown: Youre talking about the quality performance improvement. I think that logically it should because you feel like, and I feel strongly that physicians want to do a good job. They want to take care of their patients. It goes without saying that these are people who are highly intelligent, highly competitive and wouldnt be in this profession if they didnt want to do a good job, care for patients, and be recognized for that ability so I know its not a question of that. But I think theres a real difficulty in getting physicians to accept CME for that and I dont know why that is. And Im not basing that so much on personal experience, as to when I talk to providers who ar e trying to do PI CME [I PICME] or CME that is more based on quality measures that are identified within the hospital setting particularly. It doesnt seem like it hasnt taken off like I thought it would. I dont know why and Im a little surprised. I dont know what that has to do with. Another thing about physicians is that its a traditional kind of profession. Clearly you have your older physicians for the most part still are the anchor of the profession, doing the lions share, fifty and above are doing the lions share of care for the patients. Then you have your residents, your fellows, and your younger physicians [I age] who are obviously contributing to the profession as well, but I dont know if theres such a schism there that youre trying to serve two masters as a sense. You have your younger doctors who I would think that would be the way we would be going. And then we have these other physicians who want to sit in the back of the room, and Im the guy with PowerPoint slides, and then I don t want to participate in any learning activities ok, because this is the way weve done this and we dont see why we need to change it now. Im really surprised that the performance improvement hasnt taken off. It seems like the providers have really str uggled with setting it up, and having physicians participate in the process. And maybe the message there is that its smaller I think were used to wanting to see one hundred people sitting in the seats and then thats a success. Maybe we have to change t he way we view success. It may be that it comes in smaller doses, and that we will only have five or six physicians who do this, and five or six that do this, and one or two that do this. We may have to as providers change our idea of what success is. But I think its a disruptive technology, something we have to pay attention to be and be ready

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230 Appendix G (Continued) for so that when our target audience is ready for it we can jump right on it. So I think its good what were doing. Its like dabbling, g etting used to it. I wonder if the other thing with performance improvement CME, [I PICME] maybe the physicians dont feel like theyve participated [I physician involvement] enough in the identification of the gap, or the data that indicates that well th eres a problem here. Do physicians necessarily agree with what that measure is? I dont know a lot about performance improvement, in terms of what groups are measuring these things but I know that I hear a lot of our members talk about pay for performa nce, bad. The hospital, bad. Physicians want to be independent, they want to be autonomous, they have their realm, and they really dont appreciate the government or any other organizations like HMOs, and PPOs infiltrating this realm. I wonder if there is concern that thats whats happening. Theyre telling me I have to do this, and I dont agree with that. I think theres some of that too, some reluctance. Which is again why physicians really need to be inserted into the process because we need physi cian buy in. [I physician involvement] And I dont hear a lot of people talking about that. The ACCME doesnt seem to be talking about that at all, and that I dont understand. Theres a lot of talk about what the public is saying about care and what the I OM is saying about care, but what about what practicing physicians say? And theres a lot of blame to be shared, and one of my frustrations has been you do have to accept the fact that care isnt perfect. Lets not worry about is it 100,000 deaths per yea r by medical errors or whatever that number is. It doesnt really matter, because we know its too much. So lets just forget that and focus on preventing medical errors. So doctors do need to be encouraged to take control and actually suggest proactive w ays to prevent medical errors, improve care. [I physician involvement] I think that physicians are feeling very burdened right now and I think the CME system is reflecting that. I think that morale is low. I think that physicians dont think they have cont rol of the practice of medicine, they dont have control over what they love. They want to care for patients. Thats what they want to do, so CME should be a natural extension of that. I think that CME is getting lost in this shuffle in trying to figure ou t who is going to be in control of medicine. I think its too bad actually, because I think that physicians should play a really instrumental role in defining their own gaps and setting goals for how to address those gaps and it seems like were relying m ore on gaps that are being thrust upon. That may be why physicians are resisting that PI CME. Excerpts from Mr. Blues Interview M: Right. So what do you think will impact or whats relevant for the advancement of what were doing? We spoke about that f or a few minutes outside, but is it going to be more interdisciplinary, is it going to look totally different, what do you think its going to push to change? Mr. Blue: I think thats a very interesting question Martha. Youll hear a lot about age [I age ] today because my back is sore and I feel like Im one hundred years old! I think the change...youve probably seen this in hospital management, its much more program

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231 Appendix G (Continued) management, so twenty years ago it was division of cardiology Now its the program in cardiovascular health, has surgeons, internists, dieticiansI think that will drive it more. I think the more programmatic initiative; the disease classification from the hospital environment will drive it. We have better data n ow than we did five years ago, even one year ago. Were getting better data, [I data] we can pinpoint it, and we make people accountable a little more. So I think those two things well be able to say, Hmmm, you know what? Our congestive heart failure pat ients do bounce back to the emergency department with a higher rate than they should state wide, and I think we should do something about it. Were looking bad in the hospital state report cards, the state legislature is pointing at us. Several of our wel l to do Alliance patients are coming back and are complaining. Thats not good for us. Maybe its good for the bottom line in some ways, but you know what? Were more than just the bottom line? So I think thats gonna drive us. That might say Where is the ???? so we know we should be getting these three drugs when you leave the hospital. Patients arent either being told that they need it theyre not getting their prescriptions, or the doctors dont know to order it, theyre residents and dont know to order it. Or they go home on a Saturday and there is a failure in the system; so figuring out where that failure is and then fixing it. So if its educational, it means presenting grand rounds on the topic for example, or sort of a clinic day Better Cong estive Heart Failure Management, or the CME office getting hold of the feed back data, the global data and feeding that back to the group and say Lets build something around this, whether more teamwork would do it. All those things I think are in the purview, what isnt in the purview are the quality measures, determination, and payment systems. But much of this is in the purview of the CME providerthis new smart, renaissance, the Martha Bakers of the world who understand it, who understand what it is and then can intervene, might intervene in a traditional way, ok well accredit rounds or medicine. Three times this year I can just about fit in. Well present the data globally on those three occasions and look for trends, and look for the barriers, a nd post a focus group; the hospital will pay us for that because our measures will improve. Thats the goal. It may be a bit idealized. M: As opposed to in six months were going to talk about MRSA. Well in six months the information we might need to talk about something else, or how do you know what you need to talk about in a years time? Mr. Blue: Thats right. So we need to have more accurate and up to date data. [I data] I think thats a part of it. I think with an issue like MRSA, its a much more sort of onsite training. Handwashing is a small example. And there the SWAT team that the CME provider would develop is a little bit different than if its an issue like congestive heart failure where its a lack of prescriptions, or a lack of understandi ng, or maybe we need a patient educator. Maybe its a nursewe did this in Toronto. We had a nurse patient educator and she was the discharge coordinator, so it was a little bit extra work for her. Twenty minutes to a half hour with every discharge on the cardiac ward. But she was the knowledge broker, going through the file, determining what had happened to the patient, asking the patient what they understood, making sure all the guidelines were

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232 Appendix G (Continued) being met. So its a congestive he art failure patient. Here are the three things you need to go home. You have that prescription? Do you understand why you need to take it? Will you see your primary care provider within a week or two weeks? Would you like us here to make an appointment for you in order to do that? Sometimes we can get through on a backline with the primary care provider where you cant. What about salt? How about making sure that its not just the medication, but you understand not to have a lot of salt like potato chip s and what not. M: Do you think that the joint commission or other sort of overshadowing entities like you will help people like me to make that change in culture? And how to go we go about it? Mr. Blue: Actually the Joint Commission to its credit has already changed some of its provisions so its looking less at just Does the doc have continuing education credentials, like is he building all his credits and looking more at interprofessional education and team based training and that sort of thing. A nd the joint AAMC nursing conference that we just held this year, one of the recommendations is to the joint commission to be much more thoughtful about workplace learning. So the hospital system must encourage workplace learning based the best data. And so were hopeful that the joint commission will pick that up. The process is pretty slow, I mean it might be a year before the Joint Commission [ I JCAHO] picks that up, but thats kind of whats in our mind and hopefully will be in their minds as well. M: I had to have my standard questions but that all sort of leads into what is the future and what does it look like and I think you hit that one right on the head. As you have said before, theres a place for an update but theres also probably more of a place for hands on work group type of stuff that can really make a difference and then blend that with the learners that we have now who will be more comfortable going online just in time to find out what they need to know. And based on the self reflective stuff, there are lots of possibilities of how it could be done. I think it just depends on how creative people want to be in, and how much support they have. Mr. Blue: Thats right. I think we used to think of a hundred people in an audience, all at the same level. Im going to teach them. But some of the guys and gals have already done what Ive suggested they do. Some wouldnt consider it in 100 years. And some are doing their Blackberry, or reading the morning paper, or not paying any attention. I thi nk one of the big breakthroughs for us in CME is that by changing the culture of CME also change the audience. So if the question is, theres a brand new discovery or theyve never heard of thisa new form of anti depressant for example, or a new screening test then maybe the lecture or online learning, or disseminating by means of newsletter to all your 500 to 600 docsmaybe thats good enough. If they know about it but they dont agree with it because there are guidelines created for cardiologists, and I m a family doctor or general internist, then there are other things we can do. Maybe thats peer groups, maybe thats grand rounds, and maybe thats workshops. If the issue is that Im aware of it, (this

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233 Appendix G (Continued) isnt my model by the way ) its somebody named Pathman. Do you know the Pathman model 96, medical care 96? He talked about how people adhere to guidelines 100% of the time. He had a four phase model. One was awareness of it. One was agreement with it. One was adoption of it. So not all the time, but enough that I felt pretty comfortable, to adherence which meant everyone did it. And so the issue is agreement. Were talking about small groups, peer pressure, maybe an opinion leader, in the ward or in a community setting. If the question is adoption, that is Alright I should be using insulin more. Im so used to prescribing something thats been many years that Ive prescribed intramuscular subcutaneous insulin. I think I should go to a workshop so I can learn how to do it better. Thats the adoption question. The adherence is Should I do it every time its needed? And the interventions are different. On the front end its more like the lecture, the newsletter, the online thing. On the back end, its more like reminders at the point of care [f point of care] so it pops out. Sixty five year old lady diabetic needs flu shot. Have you given her the flu shot? Yes, no. If no, click here and the nurse will bring it in. So I mean that much more point of care learning will happen. I think just understanding it that way is the way we need to proceed. And theres a big question there about where we do all of that. You were talking about the extent to which your hospital would be able to support you. [f funding] Thats a question isnt it? I ts not just you convincing the C.E.O. that you need the monies. Its looking at the data to say Look weve got a problem here. Weve got a gap [f gap] in the perception of our patients, or a gap in care.

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234 Appendix H : Sample Field Notes Notes to Self 6/25/09 /7am/Tampa/ Mr. Gray A2 Dictaphone Signed Consent in advance and e mailed Setting: [conference hotel] Business casual No breakfast just coffee Observed as speaker here and at another Med Assoc conference Need to read article by [JG] and Mr. G ray and Review Rand Study Names dropped: Norman Kuhn, Don Moore, Joe Green, Nancy Bennett, Marsha Jackson, Barbara Barnes, Karen Overstreet, Ron Cervero Interactions: Fun to talk with, very talkative and interested in project. Not shy to state bias. Lots of focus on PI/QI Decision Pathways to guide CME (brother is an expert in PI) Pay attention to If I were King of ACCME Said 15 providers in Missouri dropped accreditation too difficult and expensive!! Did Qualitative Dissertation should look at i f time allows/U of M Go Blue! So excited to finish first interview. I thought it sent very well! Reflections: Primary Topics Decision Pathwa y s Physicians perspective is important Mind the Gap (knowledge/performance gap) Evaluate Outcomes System Accredi tation/Stark Laws PhRMA FDA Pharmaceutical companies Independent Medical Education Departments are powerful know the rules and expectations have increased in terms of quality of grant requests Mission of CME Department need to meet it/be mission driven Physician funded education

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235 Appendix H (Continued) Notes to Self 6/25/09 /12 noon/Tampa/ Mr. Green B1 Dictaphone Signed Consent on site Setting: Setting: [conference hotel] Business casual No Lunch already ate (I ate outside afterwards) Observed as speaker here and at another conference Did Qualitative Dissertation on Self directed learning Interactions: Very easy to talk with We share a similar educational background with guidance/counseling degree and rehab counseling Said he was tired Current role 3.5 years with a 2 year startup Mentioned the 15 providers in Missouri Reflections: Primary Topics ACCME too many form and focus on the activity folders Self directed learning like external degree??? cant read writing! Key to CME C ME should become more self directedour young and new physicians are them are self directed group we have ever seen but will remain independent in their search of knowledge via technology/electronic tools o Agrees with Mr. Gray that role of PI in CME especi ally with self directed process Future of CME will have less funding and less CME with credit Just CME for CME itself Increased use of technology in future is key example was demonstration he saw of virtual patient interactions developed by gaming compa ny VALUE of CME We dont have to conduct research CME itself as it is no different from any other adult education Commitment to change; change in behavior (physician) --measureable outcome Notes to Self 6/30/09 /3pm/via telephone/ Ms. Amber B4 Dicta phone (only on B Dictaphone) Signed Consent in advance Setting: Conference Observed as speaker at state med ical association conference

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236 Appendix H (Continued) Interactions: Spoke by telephone limited interaction Expected it to be quiet but betwe en the glasses, silverware and patrons along with the A/C it was too loud and difficult to hear [Ms. Amber Her experience is very valuable because of the variety of places where she has worked the different facets. PI CME is the way of the future During lecture business attire Reflections: Primary Topics Role is in instructional design/Education Planning from basic to advanced Has worked in all segments o Hospital o Pharmaceutical o University o Government o Professional society o consulting Works on projects and grant proposals Works with professional organizations for needs analysis and strategic planning Basic elements consist of planning setting goals, minding the Gestalt and improved patient care as an outcome; accountability CME moving form seat time to certification/competency/ documentation Likes clinical trial format o Improves consistency in patient care o Impacts cost of care o Reduces medical errors Influences: o Ready access to tools o Measuring improvement in patient care o Conflict of interest/Funding o Facu lty Barriers for advancement o Lack of data o Physician time (data, differential diagnosis and history taking o Lack of funding Providers need to get help from hospital departments o Research o QI data o Patient registries o Lobby(?) faculty o Use EMR Future CME as les s of a commodity and move towards Maintenance of Certification to enable board/license continuation; point based on true need (data)

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237 Appendix I : Original Categories and Codes Elements of CME [e resource] 2 [e process] 2 [e providers] 2 [e CPD] 1 [e AC CME] 6 [e evaluation] 1 [e PICME] 1 [e CME] 1 [e strategic assest] 1 [different] 21 [e research] 1 [e credibility] 1 [e ethics] 1 [e government] 1 [e knowledge translation] 1 [e collaboration] 1 [e gaps] 1 [e physician involvement] 3 [e mission] 1 [e age] 2 [ e self directed] 2 [e acceleration] 1 [e adult education] 1 Influences [I acceleration] 1 [I ACCME] 8 [I providers] 3 [I funding] 10 [I process] 1 [I transition] 1 [I government] 5 [I innovation] 1 [I physician involvement] 11 [I mission] 0 [MARTHA ] 14 [ I JCAHO] 2 [I research] 3 [I portfolios] 1 [ I systems based practice] 1 [I value] 2 [I collaboration] 1 [I PICME] 4 [I age] 6 [I Marginalized] 2 [I data] 2 [I buy in] 1 [I Industry] 1 [I COI] 1 [I Accountability] 1 [I technology] 1 Significant I ssues/Barriers to Advancement [s ACCME] 1 [s value] 2 [s providers] 3 [s data] 2 [s research] 1 [s funding] 1 [s physician involvement] 2 [s partnership] 2 [s strategic mgt and leadership] 2 [s mission]1 Future [f strategic asset] 1 [f faculty development ] 2 [f MOC] 1 [f government]1 [f funding] 9 [f partnership] 2 [f collaboration] 1 [f one off] 2 [f providers] 5 [f data] 1 [f research/knowledge translation] 1 [f series]1 [f technology] 3 [f gap] 2 [f point of care] 1 [fPICME] 2 [f physician involvement ] 2 [f accountability] 1 What havent I asked/Anything to add? [? PICME] 8 [? VALUE] 2 [? Comp/perf/outcome]1 [? Providers] 3 [? Physician involvement] 1 [? ACCME] 3 [? Self directed] 1 [? Content] 1 [? COI] 1 [? comparative effectiveness research]1 [? Ev idence] 1 [? QI] 1 [? Detailer] 1 [? Knowledge translation]1 [? Marginalized] 12 [? Funding] 1 [? One off] 1 [? Define education] 1 [? Research to practice] 1 [? culture shift] 1 [? Strategic assent] 1

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238 Appendix J : Final Categories and Codes Element s of CME [e ACCME] 6 [e physician involvement] 3 Influences [I ACCME] 8 [I funding] 10 [I physician involvement] 11 Significant Issues/Barriers to Advancement [s providers] 3 Future [f funding] 9 [f providers] 5 [f technology] 3 What havent I as ked/Anything to add? [? PICME] 8 [? Providers] 3 [? ACCME] 3

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About the Author Martha C. Baker was born in Flint, MI, earned a Bachelor of Science in Psychobiology, an individually designed major, at Denison University, Granville, Ohio in 1980 and a Master of Arts in Counselor and Guidance Education at the University of South Florida (USF), Tampa, FL in 1983. Ms. Baker entered the EdD Educational Program Development with an emphasis in Adult Education program at USF in 2004. Since 1993, Ms. Baker has been employed in a variety of hospital leadership roles. During the past eight years she has managed the continuing medical education and continuing pharmacy education programs, the medical library, conference center, and more recently, medical staff services. She is a Certified Continuing Medical Education Professional and communit y volunteer.


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ABSTRACT: This study describes and explains the perspectives of selected experts in continuing medical education (CME) and provides a glimpse at their lived experience. The theoretical frameworks are inclusive of constructivism and social constructivism reflecting the learning that takes place in medicine and that which occurs in the interview process. The voice of the researcher is heard through her professional role as a continuing medical education provider. The major elements of CME are identified as the role of accreditation and physician involvement in the design and delivery of CME; the primary influences as funding, physician involvement and accreditation; the significant issue is the expertise of CME providers; the future of CME is to be molded by the funding of CME, its providers and technology in continuing education venues. Performance improvement continuing medical education will continue to be the gold standard of accredited organizations. Implications for practice are many as the role of the CME provider changes to meet the expectations of the Accreditation Council for Continuing Medical Education, the Institute of Medicine and organizations such as the American Association of Medical Colleges and American Association of Colleges of Nursing. Future research studies could include the following: interviewing experts in similar work environments may provide more focused findings that would assist that particular segment of the profession and their respective institutions; a comparison of local and national providers may shed light on how similar or disparate they are in the design, delivery, measurement, and funding of CME; a prospective longitudinal study looking at the implementation and outcomes of the IOM initiative for conflict of interest in medicine, the IOM initiative for the redesign of continuing education in the health professions or interdisciplinary lifelong learning in the health professions as proposed by the AAMC and AACN; investigate the proposed Continuing Professional Development Institute in five to seven years to determine if it achieved the desired design and function, and finally, repeating this study with experts from the same categories in about ten years should reveal significant changes in continuing medical education as compared to the findings presented in the current study.
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