What's the point of Continuing Medical Education anyway? Looking beyond content experts.

CanMEDS Framework CPD

Much of last week was devoted to the annual and somewhat annoying task of reporting my Continuing Medical Education (CME) activity, referred to here in Canada as Continuing Professional Development (CPD). Between that and working on my year-end tax paperwork, it really has not been a fun week! Of course the purpose of this exercise is not just to file paperwork but rather to help us continue to develop as physicians. I had originally intended to write this article on how best to use technology to track these activities but this has evolved into a discussion on how to better ourselves as physicians through CPD activities.

CME implies keeping up with the latest medical literature in order to be content experts whereas as CPD deals with many more aspects of evolving as a partner in healthcare; this is what led to the change in philosophy in Canada in the past decade to develop our core competencies beyond that of being a medical expert. Beyond the need to keep current in our specialty (and sub-specialty) areas of practice, we have other roles that we need to always improve. This includes being professional in our conduct, working on communication skills with patients, staff, and colleagues, and being an advocate for our patients in navigating through the healthcare system. in Canada, we report our CPD activities to the organization that initially accredits us as 'board certified' with the designation Fellow of the Royal College of Physicians & Surgeons of Canada (FRCSC). Also, in Canada, unlike the United States, we cannot even practice medicine unless we are board certified. As part of keeping our certification, we have to maintain our core competencies but is this being tracked and encourage by our current CPD credit system?

Alas, the process of reporting our activities, seems to distract from Continuing Professional Development. So, what's the point of continuing medical education anyway? We always need to provide the best care possible for our patients. The information that we acquired during medical school, residency and sub-specialty training slowly becomes out-of-date during our years in practice. Therefore, becoming content experts requires always keeping up with new advances. As noble as this sounds, it still takes at least a decade for the results of new medical studies to spill over into medical practice. In part, the slow adoption of new information is related to how best to spread the new findings but there are many other factors as well. New findings can often later be refuted, as evidenced by the backlash against the COX-2 inhibitor anti-inflammatories as well as drug eluting coronary stents that both were presented as major game players and have now fallen into dis-favour. Score one more against keeping up with the literature!

In the complicated healthcare systems there are many barriers to patient care and this is one area in which our CPD can make a difference. As physicians, it is important to be better advocates for our patients. The CanMEDS core competencies recognizes this but there is no category as part of our score sheet to make sure we all earn credits toward being advocates. Is there some way to require this of all physicians to maintain their certification?

When reporting our CPD credits, although the Royal College stresses the importance of the CanMEDS roles in our daily practice, the 6 different sections under which we report have little relationship with these roles. We have to accumulate time under these categories:

Section 1 Group accredited learning activities

  • Rounds and Journal Clubs
  • Small Group Learning Activity
  • Accredited conference and courses
  • Web based CME

Section 2 Other (non-accredited) learning activities

Section 3 Accredited self-assessment programs

Section 4 Structured Learning Projects

  • Personal Learning Project
  • Critically appraised topics
  • Traineeships
  • Courses or fellowships

Section 5 Practice Review

Section 6 Educational Development

Within this framework, there are minimum requirements for the number of credits needed over a 5-year cycle, and emphasis is placed on identifying key points that can lead to changes in our practice patterns. This is an excellent measure of the quality of a learning activity. In other words, if we learn something that will change how we manager our patients, then it must have been useful. For this reason, some sections are more valuable than others. For example, there is a limit on how many credits can be claimed under Sections 2 and 6 as these are least likely to influence how we practice. Section 2 is a grab-bag for conferences that are not designated as accredited learning activities. An accredited learning activity, Section 1, implies that the program was designed to meet the needs of the target audience, the goals are clearly stated in advance, and at least 25% of the time is allowed for audience discussion. Section 6 is mostly for time spent teaching our trainees. Again, although very valuable to make sure we keep up to date in order to not embarrass ourselves and also to help society, it is not likely to change our practice patterns. 

RCPSC Mainport Web Log

What I fail to see in this framework for reporting our CPD activities, is the relevant relationship to the CanMEDS framework of core competencies. If these are so important, how come the way we report our CPD activities pays only lip-service to these? I say this because on the website where we log our activity, there are checkboxes for each of these competencies, an after-thought perhaps, rather than the CPD sections being defined based on them. In fact, checking off the CanMEDS competencies is not even designated as a mandatory field with a red asterisk.

We are way ahead in Canada in terms of assuring a high standard of continuing medical education thanks to the these 6 Sections that reward us for activities that require a degree of self-reflection such as auditing our charts to see how we can be doing better. The US American Medical Association is much weaker in having basically one category that would often fail to be accredited in Canada. I have been to many regular accredited conferences in the U.S. in which one expert after another parades onto the stage to state whatever they have to say as undisputed fact with no opportunity at all for any audience interaction (eg American Academy of Ophthalmology Subspecialty Days.) You might as well buy a book to read and you are more likely to stay awake and actually retain some information that way than sitting through a packed lecture hall in uncomfortable chairs. As good as our CPD framework is in terms of emphasizing customizing our learning based on our self-identified needs and mandating that all accredited conferences must include at least 25% discussion time from the audience, we can be doing an even better job by building our whole CPD credit system around these CanMEDS competencies.