Graham T. McMahon, MD, MMSc Accreditation Council for Continuing Medical Education, Chicago, Illinois.

Corresponding Author: Graham T. McMahon, MD, MMSc, Accreditation Council for Continuing Medical Education, 515 N State St, Ste 1801, Chicago, IL 60654 (gmcmahon @accme.org). jama.com

Advancing Continuing Medical Education Physicians are facing enormous pressure in a rapidly changing health care environment and look to the education community to help them stay current with advances in medicine and provide optimal care. Most clinicians feel increasing time constraints as they seek to balance professional and family responsibilities and seek efficiency in their learning. Clinicians expect highquality, relevant, and effective education that is independent of commercial bias and expect that when possible their participation meets the variety of expectations of the state licensing boards, specialty certification, hospital credentialing, and other regulatory requirements. Accredited continuing medical education (CME) has a key role in supporting physicians’ continuing professional development. CME can meaningfully change attitude, knowledge, skills, and performance; the effects of education on patient outcomes has been more difficult to demonstrate because of the complexity of the intervening variables.1 The Accreditation Council for Continuing Medical Education(ACCME),itsaccreditationcriteria,andtheCME delivered by accredited organizations have evolved substantially over the last 15 years. Although educational planners now base their activity construction and pedagogy on assessment of needs that underlie problems in practice and are required to measure outcomes of their educational interventions, much of the evolution may not be visible to the learner. Often, CME has been considered to encompass only lectures and knowledge but now increasingly is designed to improve skills and performance, and many activities aim to specifically affect patient outcomes. Of the more than 140 000 learning activities offered by accredited organizations each year, approximately 60% are designed to achieve improvements in physician performance, with 40% measured for those changes. Thirty percent are designed to improve patient outcomes; 13% measure those changes.2 Despite these improvements, many clinicians express frustration at the pace of change in CME. Accredited CME could be more flexible and innovative in meeting both practice-based needs and public health imperatives. CME can and should offer a rapid response to close competency gaps for practicing physicians and can provide valuable opportunities for quality improvement in clinics and hospitals.3 CME educators should embrace the advances in educational technology to maximize retention using adaptation, repetition, and personalization.

Learner-Centered Activities With more than 1 million hours of instruction annually in the United States, CME delivered by accredited organizations offers a wide choice of approaches and content areas to meet the needs of physicians where they live, work, and learn. Some learning is best achieved through

problem-solving, case studies, and small group discussionsaspartofliveactivitiesinwhichphysicianslearnfrom each other. Some learning goals are best achieved through online delivery, through self-assessment activities, or the facilitation of discussion through webinars and other formats. Most learners need a combination of educational opportunities to stay current with best practices. With so many options, clinicians need to take responsibility for choosing educational activities that meet their educational needs, rather than choosing activities that are merely convenient. Clinicians should participate actively and complete the assessments. Accredited organizations that provide CME rely on clinicians to report their participation accurately.

Maintain Independence and Stewardship of Resources The resources used to support CME—including commercial support—deserve scrutiny and stewardship so the independence of content from any external support is protected. The most recent data from 2014 (self-reported by accreditedorganizationsandreviewedbytheACCME)shows that only 11% of CME activities received commercial support, representing 18% of all interactions. About 25% of totalCMErevenueisderivedfromcommercialsupport;registration fees, government grants, and institutional allocations make up the majority of the revenue.2 Data from a 2010 report suggest that physicians perceive low rates of commercialbiasinCMEandthatthereisnoassociationbetweentheextentofcommercialsupportandthedegreeof perceivedbiasinCMEactivities.4 Theimportanceofensuring that CME activities are free of commercial bias is a critical priority for ACCME and is under continual review. The Standards for Commercial Support: Standards to Ensure Independence in CME Activities include requirements for content and faculty selection, disclosure, identification and resolution of conflicts of interest, and management of commercial support; the ACCME provides ongoing guidance and educational resources to support compliance with these requirements. In addition to the oversight provided by the ACCME through regular, recurring accreditation reviews, which include 3 sources of data—randomly selected activity files, interviews conducted by trained surveyors, and self-study reports—as well as a complaints process, the entire medical community needs to take responsibility for preventing, detecting, reporting, and remediating commercial bias. It is also imperative that regulation does not impede the rapid dissemination of discovery and research—including advances that involve industry—into clinical practice.

Collaboration Across and Within Communities Almost two-thirds of ACCME-accredited entities participate within an institutional or system framework for qual(Reprinted) JAMA Published online July 20, 2015

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Opinion Viewpoint

ity improvement. Yet quality improvement and education offices are frequently separate and misaligned. State licensing boards, specialty certifying boards, hospital senior executives, and public health leadership should recognize accredited CME as a partner in quality improvement and use education as a strategic resource to drive change—and organizations that provide CME need to be ready to assume that responsibility. Learning exists on a continuum, and the CME community should carry forward the information from undergraduate and graduate education to most effectively engage with individual learners for the rest of their careers. Accredited CME can offer rapid process improvement initiatives to address the needs identified through assessment of the milestones—competency-based developmental outcomes demonstrated progressively by residents and fellows.5 To advance the learning agenda and reduce burdens on physicians, accrediting, licensing, and certifying bodies need to collaborate to align their requirements and create educational homes where physicians can meet multiple requirements while participating in effective continuing professional development. Private/public partnerships provide a vehicle for responding to emerging health issues and accelerating the translation of research intopractice.Forexample,theUSFoodandDrugAdministration(FDA) leveraged the accredited continuing education community to deliver prescriber education for extended-release and long-acting opioids and is now considering other opportunities for collaboration. Rather than duplicate the development of multiple activities with similar learning objectives, accredited organizations that provide CME could divide responsibility for creating education solutions that meet a common need and that can be shared and distributed. The CME system has a responsibility to highlight “educational deserts” in which important public health issues are receiving inadequate attention. In turn, the organizations that provide CME need to share experiences about how to create optimal activities that clinicians value. Leading health care education organizations should continue to facilitate this collaboration.

Continuing Education by the Team, for the Team Health care is delivered by teams, and those teams need to learn together. In their governance role, the organizations that accredit the provision of CME have the opportunity to facilitate team-based learning. Barriers between accreditation systems and professions must

Accreditor Role Continuingeducationaccreditorsareserviceorganizationswhosemission is to reflect and meet the needs of the public as well as to maintaintheintegrityofthesystemforeducationalprovidersandtheirlearners. In their governance function, these accreditors are positioned to promote a culture of engagement among stakeholders so that the community can evolve together to provide relevant, participatory, and independent education in a system that is straightforward and transparent. Accreditors also have a role in setting goals for the community: ACCME’s proposed menu of Accreditation With Commendation Criteria—which have been developed collaboratively—are designed to respond to emerging issues and award commendation status to CME programs that address the integration of health data, interprofessional collaborative practice, individualized learning activities, CME research, and higher levels of outcomes measurement.8 Among the challenges in advancing CME that improves health outcomes are the numerous intervening variables between education, physician change, and patient care, such as health system and institutional barriers, access to care, and team performance, to name only a few. CME is part of the health care community and the community at large. To meaningfully improve health, educators, health system leaders, and engaged learners will all need to share responsibility for meeting health care challenges. Effective CME programs have the capacity to help physicians and health care teams learn how to improve practice and patient care; how to intervene in health behaviors, social and economic factors, and the public’s physical environment; and how to improve the health of the nation.

/publications/annual-report-data/accme-annual -report-2014. July 7, 2015. Accessed July 8, 2015.

ARTICLE INFORMATION Published Online: July 20, 2015. doi:10.1001/jama.2015.7094. Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. Cervero RM, Gaines J. The impact of CME on physician performance and patient health outcomes. J Contin Educ Health Prof. 2015;35(2): 131-137. 2. Accreditation Council for Continuing Medical Education (ACCME). 2014 ACCME Annual Report. http://www.accme.org/news-publications


be overcome to achieve this shared mission. The continuing education accrediting organizations in medicine (the ACCME), pharmacy (the Accreditation Council for Pharmacy Education), and nursing (the American Nurses Credentialing Center) have collaborated to develop the first joint accreditation system to facilitate interprofessional continuing education, a process that can improve alignment between education and health systems; expansion of the programs to other professions would be welcome.6,7 Patients need to be recognized and respected as part of the health care team. They need to be included in CME activities, not only as participants when they can, for example, present at grand rounds to share their experiences with the health care system, but also as planners and teachers so they can guide educators and clinicians in meeting their needs and priorities.

3. Combes JR, Arespacochaga E. Continuing Medical Education as a Strategic Resource. http://www.ahaphysicianforum.org/resources /leadership-development/CME/index.shtml. September 2014. Accessed June 8, 2015. 4. Steinman MA, Boscardin CK, Aguayo L, Baron RB. Commercial influence and learner-perceived bias in continuing medical education. Acad Med. 2010;85(1):74-79. 5. Accreditation Council for Graduate Medical Education (ACGME). Milestones. http://www .acgme.org/acgmeweb/tabid/430 /ProgramandInstitutionalAccreditation /NextAccreditationSystem/Milestones.aspx. Accessed May 30, 2015.

6. Joint Accreditation for Interprofessional Continuing Education website. http://www .jointaccreditation.org/. Accessed May 30, 2015. 7. Institute of Medicine (IOM). Measuring the Impact of Interprofessional Education and Collaborative Practice and Patient Outcomes. https://www.iom.edu/Reports/2015/Impact-of-IPE .aspx. April 22, 2015. Accessed June 8, 2015. 8. Accreditation Council for Continuing Medical Education (ACCME). Proposal for New Criteria for Accreditation With Commendation. http://www .accme.org/requirements/accreditation -requirements-cme-providers/proposal-new -criteria-accreditation-commendation. Accessed May 30, 2015.

JAMA Published online July 20, 2015 (Reprinted)

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Advancing Continuing Medical Education.

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