Keywords
Continuing Medical Education (CME) is widespread in many countries, including the United States (US). CME “consists of educational activities which serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession”.
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The rapid advancement of research and technology in today's world that influences clinical practice increases the need for effective CME programmes.CME Content: Definition and Examples | ACCME. Accessed January 4, 2023. https://www.accme.org/accreditation-rules/policies/cme-content-definition-and-examples
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This commentary will consider the effectiveness of CME, focusing on their structure and funding sources.Is CME Effective – Structure of Programme
The format of CME has shown to influence its effectiveness in delivering content to physicians. CME can take multiple forms: from the conventional, passive lecture format to more interactive sessions. A study involving a survey of academic CME leaders in the US and Canada reported that lectures were still the most widely adopted platform for delivering content in CME programmes. However, didactic CME interventions have not shown success in impacting physician behaviour or patient outcomes though they can influence knowledge, skills and attitudes.
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These ineffective CME structures continue to be adopted potentially due to the barriers to adopt active learning techniques that are more likely to be effective. These include the increased effort in preparing and organising interactive sessions compared to didactic lectures.4
In addition, physicians themselves prefer to engage in traditional lecture CME sessions than more interactive ones. One proposed reason for this misalignment in the popularity and the effectiveness of the course structure is that interactive sessions can make physicians feel more uncomfortable with greater opportunities to “stand out”.5
The effectiveness of interactive CME is difficult to conclusively determine. Though the evidence on increased support for interactive over traditional CME is clear from multiple systematic reviews and evidence on active learning strategies, the effectiveness of interactive CME on the more salient endpoints of physician behaviour and patient outcomes especially is unclear.
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,6
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Systematic reviews present differing conclusions on the impact of interactive CME due to differences in their definition of CME interventions.- Cervero RM
- Gaines JK.
The Impact of CME on Physician Performance and Patient Health Outcomes: An Updated Synthesis of Systematic Reviews.
Journal of Continuing Education in the Health Professions. 2015; 35: 131-138https://doi.org/10.1002/chp.21290
7
For instance, a Cochrane systematic review had a restrictive definition of CME that only included courses, conferences, lectures, workshops, seminars and symposia while another review included educational outreach, auditing, group discussions and online platforms.- Cervero RM
- Gaines JK.
The Impact of CME on Physician Performance and Patient Health Outcomes: An Updated Synthesis of Systematic Reviews.
Journal of Continuing Education in the Health Professions. 2015; 35: 131-138https://doi.org/10.1002/chp.21290
8
,- Forsetlund L
- O'Brien MA
- Forsén L
- et al.
Continuing education meetings and workshops: effects on professional practice and healthcare outcomes.
Cochrane Database of Systematic Reviews. 2021; https://doi.org/10.1002/14651858.CD003030.pub3
9
In the Cochrane analysis, among 215 studies examined, 6 sought to ascertain if CME activities were associated with differences in provider behavior, prescribing or demeanor.
8
- Forsetlund L
- O'Brien MA
- Forsén L
- et al.
Continuing education meetings and workshops: effects on professional practice and healthcare outcomes.
Cochrane Database of Systematic Reviews. 2021; https://doi.org/10.1002/14651858.CD003030.pub3
Is CME effective - Marketing and Bias
The industry-derived funding sources of CME question their validity and objectivity. According to ACCME's 2020 report, 10% of CME courses are currently funded by drug and device manufacturers, which have the incentive to promote products and practices that increase their company's profits than those that are the best for patients.
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Annual Data Reports | ACCME. Accessed January 6, 2023. https://www.accme.org/data-reports
Firstly, the involvement of industries can cause market creation. In Medicine, this is termed as “condition branding”.
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With intensive marketing strategies, companies can frame conditions as diseases. For instance, CME (with the financial support from companies) has been used as a tool to frame ageing as a disease to increase the need for hormone formulations.12
Excessive marketing becomes more problematic where it can promote products that are yet to be approved by regulators. Examples include gabapentin, an anti-epilepsy drug that was promoted to be repurposed for migraines, and other disorders.- Fugh-Berman AJ.
The Haunting of Medical Journals: How Ghostwriting Sold “HRT.
PLOS Medicine. 2010; 7e1000335https://doi.org/10.1371/journal.pmed.1000335
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Marketing strategies can also include more subtle methods of funding influencers. Though influencers may not publicly advertise a product, they can contribute to “condition branding”.14
Secondly, the involvement of profit-driven companies can cause the downplaying or complete neglect of harms of products. This is best seen in the case of opioids. Opioid manufacturers have used CME as a tool in promoting use of fentanyl products for conditions such as migraines, and injuries.
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Individuals exposed to content from industry-funding CME materials were shown to neglect the possibility of addiction or other side effects of opioid use, which was recognised by those exposed to non-industry funded CME materials.15
Other examples where industry-funded CME have falsely minimised the harms and focused on the benefits include binge-eating disorder, menopausal hormone therapy, and testosterone therapy.16
Despite the active role of ACCME in regulating the role of industry in CME courses, some experts argue that these regulators aid in the masking of industry involvement in CME.
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Though the ACCME reports that industry-backed CME make a small proportion of the total today, this could be an underreporting with ACCME's move to stop counting “equipment, supplies, and facilities” among other resources as commercial support. Despite the seeming decrease in industry-funded CME programmes over the years, their subtle involvement is only anticipated to increase in the future with medical centres and hospitals aiming to stop funding CME for surgeons in 2022. This is reinforced with the preference of surgical residents for free CME opportunities that are more likely with commercial company backed opportunities.17
Conclusion
The effectiveness of CME depends on its structure. While the evidence that CME impacts short term knowledge assessments is strong; the evidence it changes provider behaviour, specifically with the goal of improving patient safety and outcomes is weak. With the increased importance of CME, it is essential to explore strategies to organise effective programmes that have reduced or no bias from industries.
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In organising effective CME programmes, the role of online platforms should be considered, which have grown in popularity since the COVID-19 pandemic. In achieving reduced or no bias from companies, it can be important to develop methods to identify subtle biases with the existence of three instruments to evaluate explicit bias in CME programmes.- Schulte TL
- Gröning T
- Ramsauer B
- et al.
Impact of COVID-19 on Continuing Medical Education—Results of an Online Survey Among Users of a Non-profit Multi-Specialty Live Online Education Platform.
Front Med (Lausanne). 2021; 8773806https://doi.org/10.3389/fmed.2021.773806
19
, - Takhar J
- Dixon D
- Donahue J
- et al.
Developing an instrument to measure bias in CME.
Journal of Continuing Education in the Health Professions. 2007; 27: 118https://doi.org/10.1002/chp.110
20
, - Barnes BE
- Cole JG
- King CT
- et al.
A risk stratification tool to assess commercial influences on continuing medical education.
Journal of Continuing Education in the Health Professions. 2007; 27: 234https://doi.org/10.1002/chp.143
21
- Price D
- Havens C
- Bellman P.
Audience assessment of bias in continuing medical education programs.
Journal of Continuing Education in the Health Professions. 2009; 29: 76https://doi.org/10.1002/chp.20011
References
CME Content: Definition and Examples | ACCME. Accessed January 4, 2023. https://www.accme.org/accreditation-rules/policies/cme-content-definition-and-examples
- Continuing Education in the Health Professions: Improving Healthcare Through Lifelong Learning.J Contin Educ Nurs. 2008; 39: 112-118https://doi.org/10.3928/00220124-20080301-09
- Impact of Formal Continuing Medical EducationDo Conferences, Workshops, Rounds, and Other Traditional Continuing Education Activities Change Physician Behavior or Health Care Outcomes?.JAMA. 1999; 282: 867-874https://doi.org/10.1001/jama.282.9.867
- Making it stick: use of active learning strategies in continuing medical education.BMC Medical Education. 2021; 21: 44https://doi.org/10.1186/s12909-020-02447-0
Stephens MB, McKenna M, Carrington K. Adult Learning Models for Large-group Continuing Medical Education Activities. FAMILY MEDICINE.
- Best evidence continuous medical education.Arch Gynecol Obstet. 2009; 280: 683-687https://doi.org/10.1007/s00404-009-1128-7
- The Impact of CME on Physician Performance and Patient Health Outcomes: An Updated Synthesis of Systematic Reviews.Journal of Continuing Education in the Health Professions. 2015; 35: 131-138https://doi.org/10.1002/chp.21290
- Continuing education meetings and workshops: effects on professional practice and healthcare outcomes.Cochrane Database of Systematic Reviews. 2021; https://doi.org/10.1002/14651858.CD003030.pub3
Marinopoulos SS, Dorman T, Ratanawongsa N, et al. Effectiveness of Continuing Medical Education. Agency for Healthcare Research and Quality (US); 2007.
Annual Data Reports | ACCME. Accessed January 6, 2023. https://www.accme.org/data-reports
- Hypoactive sexual desire disorder: inventing a disease to sell low libido.Journal of Medical Ethics. 2015; 41: 859-862https://doi.org/10.1136/medethics-2014-102596
- The Haunting of Medical Journals: How Ghostwriting Sold “HRT.PLOS Medicine. 2010; 7e1000335https://doi.org/10.1371/journal.pmed.1000335
- Narrative Review: The Promotion of Gabapentin: An Analysis of Internal Industry Documents.Ann Intern Med. 2006; 145: 284-293https://doi.org/10.7326/0003-4819-145-4-200608150-00008
- Industry-funded medical education is always promotion—an essay by Adriane Fugh-Berman.BMJ. 2021; 373: n1273https://doi.org/10.1136/bmj.n1273
- Continuing Medical Education and the Marketing of Fentanyl for Breakthrough Pain: Marketing Messages in an Industry-Funded CME Module on Breakthrough Pain.World Medical & Health Policy. 2019; 11: 43-58https://doi.org/10.1002/wmh3.290
- Marketing Messages in Continuing Medical Education (CME) Modules on Binge-Eating Disorder (BED).J Am Board Fam Med. 2020; 33: 240-251https://doi.org/10.3122/jabfm.2020.02.190129
- An e-Delphi study generates expert consensus on the trends in future continuing medical education engagement by resident, practicing, and expert surgeons.Medical Teacher. 2020; 42: 444-450https://doi.org/10.1080/0142159X.2019.1704708
- Impact of COVID-19 on Continuing Medical Education—Results of an Online Survey Among Users of a Non-profit Multi-Specialty Live Online Education Platform.Front Med (Lausanne). 2021; 8773806https://doi.org/10.3389/fmed.2021.773806
- Developing an instrument to measure bias in CME.Journal of Continuing Education in the Health Professions. 2007; 27: 118https://doi.org/10.1002/chp.110
- A risk stratification tool to assess commercial influences on continuing medical education.Journal of Continuing Education in the Health Professions. 2007; 27: 234https://doi.org/10.1002/chp.143
- Audience assessment of bias in continuing medical education programs.Journal of Continuing Education in the Health Professions. 2009; 29: 76https://doi.org/10.1002/chp.20011
Article info
Publication history
Accepted:
February 8,
2023
Received:
February 7,
2023
Publication stage
In Press Journal Pre-ProofFootnotes
Funding and Conflict of Interest: VP has received research funding from Arnold Ventures and royalties from Johns Hopkins Press, Medscape, and MedPage. He actively participates in lectures at universities, medical centers, non-profits, and professional societies. He also engages in consulting with UnitedHealthcare and OptumRX, hosts a podcast, writes on Substack and is active on YouTube.
Contributors: Both authors contributed to the manuscript.
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© 2023 Elsevier Inc. All rights reserved.
