CME: How do you get yours?

Requirements are multiplying, but so are opportunities to meet them.

By Dorothy L. Pennachio
Senior Editor

Getting those mandated CME hours can be not only expensive, but time consuming—six states require 150 hours of CME over a three-year period for relicensure. Another 30 demand between 24 and 50 hours over two years.

And requirements can be quite specific: Kentucky wants doctors to keep up with developments in HIV/AIDS; West Virginia demands classes in pain management; Florida wants a course in domestic violence; and Nevada doctors have to brush up on ethical issues.

You can't pick up credits just anywhere, either: Of the states that require CME, all but four require that at least a significant percentage of your credits be Physician's Recognition Award (PRA) Category 1, as defined by the AMA: The event or activity must provide material pertinent to a physician's needs and be presented by an organization accredited by the Accreditation Council for Continuing Medical Education (ACCME), such as the AAFP or a state medical society.

But if more is expected of doctors in the CME area, there are also more ways to fulfill the requirements. For instance, three years ago, the AMA began awarding Category 1 credit for publishing articles and for presenting posters and teaching at accredited medical meetings. There are also an increasing number of online CME options that require no travel at all, and, often, cost you nothing.

The problems with traditional CME programs

More and more doctors are looking for new options because they've become dissatisfied with traditional CME conferences. William T. Sheahan, an FP in Winter Park, FL, says he now favors self-study courses offered by universities. "Conferences tend to be short on useful information and long on snooze time. Pearls—if there are any—tend to be dispensed in the last five minutes."

Steven Gitler, an FP in Cherry Hill, NJ, shares that view. "I can't tell you how many expensive but worthless CME programs I've attended over the years," he says. "When I take time to attend a course, I expect to learn how to make the best choices for my patients. I don't want to be told which drug molecule binds to which receptor. I just want to learn how to prevent my diabetic patients from going blind or losing a limb. I want to see real-life scenarios and compare treatment options.

"Case presentations are best—how to approach patients, what tests and products are appropriate to order." He describes one of the most helpful programs he's attended: "When we got there, there were only a handful of us, so the speaker said, 'I have a slide show and formal presentation planned, but let's talk about your patients instead. How do you decide when to order a CT scan?' Everyone brought up cases that were problematic or clinically unusual, and we learned from each other."

Learning from colleagues also works for John R. Dykers Jr., an FP in Siler City, NC. Dykers has chaired his hospital's CME group, the Thursday Morning Intellectual Society, for 30 years.

"We meet every other week, and the North Carolina Academy of Family Physicians accepts those CME hours." Topics have included timely issues like bioterrorism, antibiotic resistance, and whether to be vaccinated against smallpox.

Dykers also attends CME sessions sponsored by pharmaceutical companies or at the university—but doesn't go on trips. "I've figured it costs about $100 per credit hour after paying registration fees, travel, and housing," he says, "and I don't consider it a vacation."

Getting your CME without leaving home

The audiotape option for CME has been around for at least a decade or two, but probably the biggest change in CME has come via the Internet. There are now upwards of 11,000 CME activities available online, according to Bernard Sklar, a Berkeley, CA, FP-turned-informatics guru who monitors online CME offerings at www.cmelist.com. Many courses are free, others cost $15 or less per credit hour. Your only problem is choosing what best serves your needs.

The most straightforward courses are text-only offerings where you read articles about a particular topic and answer questions. A bit more familiarity with the Internet is required to view and hear slide-video lectures. Your computer probably already has speakers and the software programs necessary to do that. You can also get a more interactive learning experience. Some sites offer case-based activities where a clinical scenario is presented and you're asked to choose modes of action—diagnosis, testing, and therapy.

Although online CME accounted for only 8 percent of all offerings in 2002, according to the ACCME, Murray Kopelow, ACCME's executive director, says the Web has tremendous potential for user-friendly live video and audio streaming—materials constructed for participation, as opposed to just observing.

Another recent study conducted by The Boston Consulting Group reveals that a growing number of physicians are completing CME courses online: 58 percent of respondents had completed CME course work online last year, an increase of 29 percent over 2001. Nine of 10 physicians in the study who completed course work online said they found the virtual CME useful.

But Charles Davant, an FP in Blowing Rock, NC, isn't one of them. He notes that not all doctors are technologically equal. "I've tried using the Internet for CME, but find it time-consuming. Some online sources offer one-hour credits, but it takes me more than an hour because I don't have a high-speed connection."

The latest in CME: doing the right thing

There's no high-speed connection to worry about in the latest CME wrinkle. Indeed, there's no need to do anything beyond practice good medicine. On January 1, the AMA and AAFP partnered with CMS in a one-year pilot project to evaluate a new approach for granting CME credits: awarding hours for the good care physicians give their patients.

"By and large, doctors want to do the right thing," says Charles Willis, Director of the AMA's Department of Physician Recognition Awards Standards and Policy Liaison Activities. "This pilot is designed to give them the tools to accomplish that." The idea is to encourage physicians to use interventions that have been established as effective according to evidence-based standards. And for doing that, they're awarded AMA PRA Category 1 CME credits.

To earn credits, you have to show that you're implementing certain quality improvement measures in at least one of three areas: diabetes, adult immunization, and breast cancer screening. Track your outcomes: If your interventions are not successful, adjust them until they are. Medicare Quality Improvement Organizations in each state provide support for the program.

"Each of the three topic areas has specific quality indicators identified by CMS to be effective," says Mike Speight, the director of partnership development with the Iowa Foundation for Medical Care, the QIO in Iowa.

"For example, there are well-established, evidence-based performance measures for the management of diabetes patients, such as annual retinal checks, lipid profiles, and HbA_1c level checks. The evidence indicates you should be doing those things for all your diabetic patients."

At the end of the pilot period, the AMA and AAFP will decide if the CME program is valuable.

To get involved, contact your state Quality Improvement Organization office (go to cms.hhs. gov/contacts, select your state, and select "QIO" from the dropdown list under "Type of organization"). The QIO will work with you to ensure that all the requirements are met and documented. You can earn up to 10 credits per year per topic. Typically, doctors work on one topic area, according to Speight.

A few places to find online CME

How objective is your CME?

Arnold Relman, professor emeritus of medicine at the Harvard Medical School and former editor-in-chief of the New England Journal of Medicine, has written extensively about CME and its relation to the pharmaceutical industry.*

"Let's tell the truth," he says. "What we have is drug marketing camouflaged as education when drug companies organize the content and select speakers. If the industry wants to support CME, it should abide by the meaning of 'unrestricted support.'

"The industry can't be objective when it's committed to improving its sales performance. The medical profession loses integrity when it joins with industry. Doctors must stay independent evaluators of therapies, and drug companies must stay out of the education business."

Relman criticizes the Accreditation Council for Continuing Medical Education for not insisting that pharmaceutical companies stay on their side of the divide between industry and the profession.

"We agree with Dr. Relman, to the extent that CME must stay independent, and doctors must be the evaluators of therapies," says Murray Kopelow, executive director of the ACCME. In 2002, he says, the ACCME adopted a policy that stipulates that "all the recommendations involving clinical medicine in a CME activity must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients."

In the view of John Kelly, senior vice president for scientific and regulatory affairs at the Pharmaceutical Research and Manufacturers of America (PhRMA), "When pharmaceutical companies underwrite a medical conference not their own, the responsibility for and control over the selection of content, faculty, educational methods, materials, and location belong to the organizers of the conference in accordance with their guidelines."

*For more information, see Dr. Relman's latest article, "Defending Professional Independence: ACCME's Proposed New Guidelines for Commercial Support of CME," JAMA 2003 289:2418-2420.

Dorothy Pennachio. CME: How do you get yours?

Medical Economics

Aug. 22, 2003;80:21.