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Dr. Torres explores continuing medical education programs and whether they're successful in helping physicians obtain new knowledge.
To err is human,” says Abel Torres, M.D., J.D., M.B.A., professor and chairman of the department of dermatology, University of Florida, Gainesville, Fla., and past president of the American Academy of Dermatology, reminding an audience at the 24th World Congress of Dermatology in Milan of a 1999 Institute of Medicine report.1
Assessing patient safety is in the eye of the beholder, he says. Patients interpret safety as how they can prevent being harmed; the government, regulators and insurers look at how to prevent cost of that harm; and physicians consider how to improve outcomes of care for patients to prevent harm.
Since most data looks at outcomes, Dr. Torres says he uses outcomes as a proxy for discussing safety, and he raises logical questions about the impact of continuing medical education (CME) programs and certification programs on the improvement of patient safety.
Multiple studies have shown that voluntary board certification is associated with higher quality care in numerous specialties. Dr. Torres cites a meta-analysis prior to July 1999 with 16 findings showing a positive association between board certification and quality of patient care,2 and two surgery studies also linking initial board certification with better outcomes.3,4
However, Father Time takes its toll on everyone. One review of 62 studies showed that physician knowledge, skills and compliance with evidence-based care and outcomes tends to decline as a function of time.5 Also critical, multiple studies have shown that physicians often can’t accurately identify this decline and accurately address it.6,7 This correlates with other studies showing that the incidence of adverse licensure actions increases as a function of time and the harm leads to malpractice claims.8
MOC AND CME CONUNDRUMS
Dr. Torres explores the conundrums in the context of four parts of the United States maintenance of certification (MOC) format that address the following:
Research underscores the relationship between communication skills and physician patient outcomes. However, research on improving physician interpersonal and communication skills also has yielded mixed results, casting doubt on how well this problem can be fixed or measured.9
#2 CONCERNS ABOUT CME ACTIVITIES
Past studies showed a small-to-moderate association between CME formats and improvement in patient health outcomes. The Institute of Medicine (IOM) reported in 2010 that “there are major flaws in the way continuing education...is conducted, financed, regulated, and evaluated.”10 Furthermore, externally guided self-assessment is important given what’s known about inaccurate physician self-assessment. Yet there is substantial and more recent positive data celebrating CME effectiveness, including a Cochrane review that revealed a positive correlation in patient outcomes11 and an AHRQ review showing that CME impacts knowledge retention, professional skills, practice behaviors and patient outcomes.12
#3 COGNITIVE EXPERTISE
A substantial body of research supports the validity of initial certification examinations and the impact on patient outcomes. Yet, the data to support the value of recertification exams is weak at best, with most studies having focused on initial certification testing.
#4 PRACTICE IMPROVEMENT ACTIVITIES
Randomized comparative trials found practice improvement modules can help facilitate improvements in care.13 But a primary limitation of these activities is the time, effort and cost required relative to the improvement.
VERDICT FOR CME AND MOC
Data on whether MOC helps is weak, and most shows mild-to-moderate improvement, at best, in terms of patient outcomes. Just as important, a number of more recent studies could not show that MOC participation was associated with a difference in quality of care or patient outcomes. Recently a large study looking at national Medicare claims complications for eight elective procedures showed that board-certified surgeons were less likely to be outliers, but completion of MOC was not associated with differences in complication rates.14 Dr. Torres says this speaks to both CME and MOC because MOC actually incorporates CME.
A NEW ‘VISION’ FOR MOC
On Feb. 12, 2019 the 27-member Continuing Board Certification: Vision for the Future Commission, representing the American Board of Medical Specialties (ABMS) - among many other constituents and including a survey of 34,000+ physicians - recommended that the term “maintenance of certification” be abandoned in favor of a new term, but still invoked the importance of lifelong learning.15
According to Dr. Torres, key takeaway points from the report were:
There are gaps in research evidence that conclusively demonstrate that MOC results in better patient outcomes, so do more research.
Better data sharing between the ABMS with societies, CME and licensing bodies can better help identify gaps and reduce burdens.
Practice improvement activities are onerous or difficult to implement for some diplomats.
Highs stakes exams should be revisited.
Overall, Dr. Torres offers these insights on the current landscape:
The modern world of the internet and the rapid pace of new information demand a new paradigm.
Research shows physician deficits are critical factors in medical errors and poor quality healthcare, and a recent study by the American Board of Internal Medicine suggests that declining knowledge is more reflective of a failure to acquire new knowledge. Thus, once a basic minimum fund of knowledge is established by initial certification, this may, in fact, be sufficient for a physician to access new knowledge.
In light of the mixed results regarding CME and MOC, it may be best to not concentrate on a physician’s ability to “cram” more knowledge that will quickly be outdated.
Instead, measure a physician’s skills at rapidly accessing and utilizing new knowledge and using modern tools such as computers, cell phones, tablets and the internet.
Consider research on how this type of approach improves patient outcomes and safety.
1. To Err is Human. Institute of Medicine. National Academies of Sciences Engineering Medicine website: http://www.nationalacademies.org/hmd/~/media/ Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%20 1999%20%20report%20brief.pdf. Published November 1999. Accessed August 2019.
2. Sharp LK, Bashook PG, Lipsky MS, Horowitz SD, Miller SH. Specialty board certification and clinical outcomes: the missing link. Academic Medicine. Published June 2002; 77(6): 534–542. Accessed August 2019.
3. Kelly JV, Hellinger FJ. Physician and hospital factors associated with mortality of surgical patients. Med Care. 1986;24(9):785-800.
4. Prystowsky JB, Bordage G, Feinglass JM. Patient outcomes for segmental colon resection according to surgeon’s training, certification, and experience. Surgery. 2002;132(4):663-70.
5. National Healthcare Quality Report 2012. AHRQ Publication No. 3- 0002. U.S. Department of Health and Human Services. https://archive.ahrq.gov/research/ findings/nhqrdr/nhqr12/index.html. Published May 2013.
6. EvaKW,RegehrG.“I’llneverplayprofessionalfootball”andotherfallaciesof self-assessment. J Contin Educ Health Prof. 2008;28(1):14-9.
7. Davis DA, Mazmanian PE, Fordis M, Van harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA. 2006;296(9):1094-102.
8. Khaliq AA, Dimassi H, Huang CY, Narine L, Smego RA. Disciplinary action against physicians: who is likely to get disciplined?. Am J Med. 2005;118(7):773-7.
9. RoterDL,HallJA,KernDE,BarkerLR,ColeKA,RocaRP.Improvingphysicians’ interviewing skills and reducing patients’ emotional distress. A randomized clinical trial. Arch Intern Med. 1995;155(17):1877-84.
10. InstituteofMedicine,CommitteeonPlanningaContinuingHealthProfessional Institute. Redesigning Continuing Education in the Health Professions. https://www.nap.edu/catalog/12704/redesigning-continuing-education-in-the-health-professions. Washington, DC: National Academies Press; 2010.
11. Forsetlund L, BjÃ¸rndal A, Rashidian A, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2009;(2):CD003030.
12. MarinopoulosSS,DormanT,RatanawongsaN,etal.Effectivenessofcontinuing medical education. Evidence Reports/ Technology Assessments. https://www.ncbi.nlm.nih.gov/books/NBK38259/. Published 2007(149):1–69. Accessed August 2019.
13. Simpkins J, Divine G, Wang M, Holmboe E, Pladevall M, Williams LK. Improving asthma care through recertification: a cluster randomized trial. Arch Intern Med. 2007;167(20):2240-8.
14. XuT,MehtaA,ParkA,MakaryMA,PriceDW.AssociationBetweenBoardCertifi- cation, Maintenance of Certification, and Surgical Complications in the United States. Am J Med Qual. 2019;:1062860618822752.
15. Continuing Board Certification: Vision for the Future Commission. Continuing Board Certification website: https://visioninitiative.org/wp-content/ uploads/2019/02/Commission_Final_Report_20190212.pdf. Published February 12, 2019.