Fresh Harvest or Stale Chaff?

Apr 25 2011 Published by under [Information&Communication]

Sorting through the literature challenges most medical professionals. My "pure science" friends usually have a set search in PubMed that updates on a regular basis so they can find relevant new findings for their research.  That strategy helps in my lab-life, but as a practicing nephrologist I often do not know what I need to know until I need to know it. [What a sentence; my apologies in advance to the grammar police.]

The AMWA Journal started a new section this issue to reprint relevant articles from other journals. The first entry in this section caught my eye:

How to search and harvest the medical literature: Let the citations come to you, and how to proceed when they do. Citrome et al. Int J Clin Pract 63:1565, 2009

The article discusses electronic table of contents (eTOCs), automated alerts, stored searches, newsletters, and other available online resources. Article evaluation is addressed in rather standard ways, via title and abstract scanning, along with endorsements by evidence-based medicine groups and other authorities. Electronic storage and indexing is discussed, and online tagging sites noted as a final step. The general approach to their literature harvesting plan is shown in the figure:

I am disappointed by this piece. The general advice is sound; I have eTOCs of major journals in my field emailed when available, as well as keyword notifications from a number of sources. If a title looks appropriate, I click through for the abstract and, often, the article itself. For papers I want ready accessible, I have a PDF library in my Dropbox. If I know I will be able to retrieve the publication online (I belong to a society that publishes the journal, for example), then I may just index it.

My index system is in flux. I bought EndNote as soon as I had a computer. Those in my age bracket who have used typewriters for preparation of grants and manuscripts immediately recognized the value of this type of software. Lately, I have also established a Mendeley Library. This web-based reference manager appears to do everything EndNote can, but with the power of the hive-mind as well. Its Web 2.0 twist involves users providing tags and other meta-data to published literature. I have only played with Mendeley for a few months, but I can see great potential for this type of information in medicine and medical science. I hoped the Citrome piece would include more on these sharing sites for primary steps in literature harvesting, but these authors saw sharing as merely an added final step.

One thought I particularly enjoyed:

A major challenge that remains is determining what is worth reading beyond the abstract and what is worth saving. On a cautionary note, restricting thechoice of journals to what you consider as most worthy works only moderately well, as gems can be found in the most unlikely of places, and publication in a first-tier journal is not always a hallmark of quality.

The article did not change my ways; it pretty much summarized what I already do. How do the rest of you go about harvesting the literature? I am especially interested in finding out how others use Mendeley and other such sites as primary literature search tools - or do you?

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Regulation of Continuing Education in Medicine

Sep 14 2010 Published by under Continuing Development, Regulation, [Education&Careers], [Medicine&Pharma]

Last week we examined the history of continuing medical education (CME) in the US, and the various levels of regulation of physician practice.  Today's post explores the regulation of CME.

Initially, no one certified CME. Courses run by medical schools and local medical societies existed for the edification of those they served. Only when the AMA/PRA Category 1 Credit(TM) became necessary for practice did CME become regulated. Today we have a confusing, circuitous system of checks and balances, primarily to keep CME from becoming merely marketing for new drugs and devices.

US CME Regulation, 2010

The trip through the illustration should begin with the American Medical Association (AMA), the group that owns the coin of the realm in CME. The AMA, along with 6 other medical organizations, elects the Board of Directors of the Accreditation Council for Continuing Medical Education (ACCME). ACCME accredits national providers, including the AMA. The AMA certifies state medical societies as providers of CME. State societies can accredit sponsors of CME that serve participants from a single state; generally, the audience must be at least 70% participants from the state or region in question. The ACCME reviews and recognizes state medical societies, but has no real regulatory power; only the AMA can revoke the ability of these organizations to grant CME credit.  At present time, the ACCME certifies 727 national providers.; there are 1560 state-level providers in the US.

Over time, the ACCME has increased its regulatory heft, requiring more justification of the content of offerings, reports of conflict of interest, and other compliance efforts. Assessments for accreditation have also increased over time, along with the paperwork. It is unclear if the time and funds invested have improved the CME process, let alone physician practice or patient outcomes.

Enter the report of the Institute of Medicine which provides five broad messages for US CME:

  1. There are major flaws in the way CE is conducted, financed, regulated, and evaluated. Among various problems, health professionals and their employers tend to focus on meeting regulatory requirements rather than identifying personal knowledge gaps and finding programs to address them. Many of the regulatory organizations that oversee CE also tend not to look beyond setting and enforcing minimal, narrowly defined competencies.
  2. The science underpinning CE for health professionals is fragmented and underdeveloped. These shortcomings have made it difficult, if not impossible,to identify effective educational methods and to integrate those methods into coordinated, broad-based programs that meet the needs of the diverse range of health professionals.
  3. Continuing education efforts should bring health professionals from various disciplines together in carefully tailored learning environments. As team-based health care delivery becomes increasingly important, such interprofessional efforts will enable participants to learn both individually and as collaborative members of a team, with a common goal of improving patient outcomes.
  4. A new, comprehensive vision of professional development is needed to replace the culture that now envelops continuing education in health care. Such a vision will be key in guiding efforts to address flaws in current CE efforts and to ensure that all health professionals engage effectively in a process of lifelong learning aimed squarely at improving patient care and population health.
  5. Establishing a national interprofessional CE institute is a promising way to foster improvements in how health professionals carry out their responsibilities. The committee proposes the creation of a public-private entity that involves the full spectrum of stakeholders in health care delivery and continuing education and that is charged with developing and overseeing comprehensive change in the way CE is conducted, financed, regulated, and evaluated.

The call had been made to fundamentally change CME in this country. These are exciting times for those of us who deliver and study continuing professional development, as the IOM report suggests we rename CME.

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Continuing Medical Education: Where Have We Been?

Sep 09 2010 Published by under Continuing Development, [Education&Careers], [Medicine&Pharma]

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

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

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

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

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

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

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

More reading:

Image adapted from PhotoXpress.

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