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Ann Thorac Surg 2005;80:1985-1987
© 2005 The Society of Thoracic Surgeons
Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
* Address correspondence to Dr Edmunds, The Annals of Thoracic Surgery, 3440 Market Street, Suite 306, Philadelphia, PA 19149 (Email: hank.edmunds{at}uphs.upenn.edu).
With this issue, The Annals introduces journal-based Continuing Medical Education (CME) for its 10,000 worldwide subscribers. Simultaneously our sister journals will do the same to bring "home schooling" to all members of our profession. For elementary and high school children home schooling by parents or relatives is controversial, but there are few drawbacks to home schooling for cardiac and general thoracic surgeons. Journal-based CME fills a need: 39 states of the United States now require CME credits for renewal of medical licenses and the American Board of Thoracic Surgery has increased the number of CME credits required for renewal of certification. Canada, Japan and soon other countries will require verification of ongoing professional learning. For many practitioners the opportunity to earn CME credits in the domain of their interests and expertise is limited by time, expense, availability and relevance. Specialty journal-based CME overcomes these deficiencies and adds other advantages such as a motivated learner, subject matter directly relevant to practice, exposure to additional articles of interest and "exercise of the brain," which is prescribed for keeping it in working order [1].
Postgraduate continuing medical education may have had European origins in the middle ages, but in the new world the Association of Medical Colleges first suggested mandatory CME in 1932 and formally proposed the requirement in 1940 [2]. In 1947 the American Academy of General Practice mandated that its members acquire 150 hours of CME every three years as a condition for membership. The American Medical Association (AMA) used the same criteria to establish the "Physician's Recognition Award" in 1969. New Mexico was the first state to require CME for renewal of medical licenses in 1971.
These early beginnings stimulated development of a potpourri of CME "activities," which not infrequently featured suspect education at plush spas and resorts. By 1977 the AMA recognized the need for an accrediting body and in 1981 seven organizations each appointed one representative to create the Accreditation Council for Continuing Medical Education (ACCME). The member organizations of ACCME are: the AMA, the American Board of Medical Specialties, the American Hospital Association, the Association for Hospital Medical Education, the Association of American Medical Colleges, the Council of Medical Specialty Societies and the Federation of State Medical Boards [3]. The primary responsibilities of the ACCME are to establish and administer standards and policies for CME activities and to accredit organizations that provide CME activity to individuals [3]. The ACCME also establishes the "Standards for Commercial Support" [4].
In 1992 Congress passed the Prescription Drug User Fee Act (Public law 102-571), which was intended to hasten processing of new drug applications. Worried about potential conflicts from industry-supported, physician educational programs, the Federal Food and Drug Administration (FDA) published a draft policy statement in 1992, which was amended and codified in 1997 [5]. This statement interpreted the 1992 law as subjecting programs and materials provided and disseminated by industry to the labeling and advertising provisions of the Federal Food, Drug and Cosmetic Act. Subsequently the Center for Drug Evaluation and Research (CDER), a unit of the FDA, published a Manual of Policies and Procedures relating to education and training [6] and endorsed the standards and criteria for quality established by the ACCME and the American Council on Pharmaceutical Education (ACPE). Within its broad mission CDER reviews new drug applications, supervises post marketing surveillance, enforces compliance with drug regulatory law, but also provides education and training for doctors, pharmacists and scientists as an accredited provider of both ACCME and ACPE.
These intertwined relationships are briefly summarized as follows. The ACCME establishes the requirements of CME credits, certifies providers and defines standards for commercial support of CME activities. CME providers (eg. The Society of Thoracic Surgeons) award Category 1 credit for each hour of ACCME certified CME activity. These Category 1 credits are accepted by state license boards for renewal of medical licenses and also by the AMA for "Physician Recognition Awards." CDER is both an ACCME and ACPE accredited provider of education and training and a regulator of the drug industry.
Does CME produce better-informed doctors and improve practice? Multiple studies have addressed these questions. The ACCME allows CME providers to use an almost infinite variety of learning venues, but requires written, subject specific, learning objectives and evidence of engagement and information uptake for credit awards. For many years educators have worked hard to assess the impact of various CME exercises on "progression of learning" and "change in practice." Traditionally, medical journals have been the bulwark of postgraduate physician learning. Medical journal reading and patient management are the most frequent stimuli for initiating physician learning [7]. Although journal-based CME was not assessed, a comprehensive review concluded that didactic CME activities (lectures, presentations) does not lead to a change in practice as compared to interactive learning to enhance physician participation (discussion groups, hands-on training, case solving) [8]. Few studies have documented the impact of journal reading [9]. In a careful study of journal-based CME for family practitioners Cole and Glass found that 77% of responders (81.2% response rate) progressed in learning and that 27% committed to change practice [10]. New offerings of interactive CME exercises utilizing the tremendous potential of modern electronics, imaging and the internet are clearly in the future, but meanwhile there is also a need for many more, cost-effective, journal-based CME exercises. In 2004 the ACCME reported that only 0.57% of all CME activity hours (1,271,249) were journal-based [11].
The Annals, Journal of Thoracic and Cardiovascular Surgery and European Journal of Cardiothoracic Surgery use the same CME activity software, which was written by Stanford University's HighWire Press and is made available through CTSNet's journal collection. Subscribers to The Annals can link to CME activities on the journal home page at http://ats.ctsnetjournals.org. The collective CME journal web address is http://cme.ctsnetjournals.org. Participation in the CME exercises of each journal requires that the learner subscribe to that specific journal; a subscriber of one journal may not engage the CME exercise of another.
Each CME exercise consists of the CME article and the CME activity. The term, CME activity, refers to the interactive portion of the CME exercise. Current articles are chosen for CME. Editors, representing, the STS, AATS or EACTS choose the article from recently accepted articles and oversee creation of the learning objectives, questions and multiple choice answers. Articles are selected from each of the three major subspecialties: general thoracic and adult and pediatric cardiac surgery. The print journal carries a banner to alert readers; the CME activity is tied to the electronic article, which is published within the monthly issue of the journal on CTSNet.
A link from the electronic CME article takes the learner to the interactive portion of the CME exercise. The CME activity is interactive and enables the learner to answer questions and to access links to the correct answers, which are located within the text of the CME article.
The learner answers the entire list of questions before submitting his or her answers. Wrongly answered questions are identified and the learner tries again. Links from the correct answers to highlighted, relevant sections of text are opened when all questions are answered correctly.
When all questions are answered, the learner answers a questionnaire that evaluates the entire CME activity . This evaluation is required by the ACCME. After the evaluation questionnaire is completed, the citation of the article and date are recorded as one hour of CME practice or credit in the "My Journal CME" section of CTSNet. If taken for credit, this information is also sent to the sponsoring medical specialty society (STS or AATS). Learners who want credit are instructed to print out a certificate awarding the learner one hour of CME credit. The certificate designates the CME article and the date of completion of the activity.
Journal CME activities are subject to the Standards for Commercial Support, which were revised by the ACCME in September 2004 [4], but compliance is perhaps easier for journals than for other CME options. Authors will be required to disclose the "nature of the relationships" with commercial interests, not just the fact that a financial relationship exists. Commercial interests may not have any input into CME activities and CME editors may not have any financial relationship with commercial interests identified in the article. Advertisements for industry products are allowed, but journal editors must not place advertisements next to CME articles in which their products are named. Needless to say The Annals will comply with these standards.
The three societies have made a large investment in creating journal-based CME and are making this learning tool available without cost to subscribers. This investment has considerable risk, but the societies and journal editors speculate that journal-based CME will prove less costly, more convenient and more informative for busy practitioners, who are required to earn CME credits, than alternatives. Annual and regional meetings provide CME credits and practitioners also may earn up to 12 CME credits per year by attending and participating in morbidity and mortality conferences. Local meetings are available within large medical institutions and occasionally through local medical societies, but attendance is often difficult for outside practitioners. Specialty specific, journal-based CME allows the practitioner to choose the time and place for learning and has the advantage of exposing learners to other articles specific to their interests, expertise and practice.
The experiment is designed and funded; the methods are in place; the hypothesis is that journal-based CME meets a need of our subscribers. Is this true or false?
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