The Evolution of Continuing Medical Education in the United States

Abstract

For centuries, medical education was obtained by serving an apprenticeship with established physicians or obtaining a degree from an established University. Incorporating new knowledge and skills into one’s practice requires a commitment to lifetime learning. Traditional Continuing Medical Education (CME) had no formal requirements for many centuries, although there is ample documentation of efforts to make certain that lifetime learning was being followed, dating back to at least the fourteenth century. Although CME was recognized as one of the silos of medical education for many years, the current system for accreditation of CME in the United States only dates back to 1968. The establishment of and current operation of this system will be presented in this manuscript.

1. Introduction

Continuing Medical Education (CME) has a long, uneven history. For centuries, physicians began their careers in medicine by serving as apprentices to established practitioners or by obtaining a degree from an established university. After starting practice and meeting new and more complex problems, physicians soon realized that graduation from a formal process of training marked not just the beginning of healthcare delivery but the need for another phase of the educational process: the need to incorporate new skills and knowledge into their lives continually and thus to make a commitment to CME [1].

Records dating back to the fourteenth century show that the City of Venice, Italy, required physicians and surgeons to maintain their competence by attending lectures, doing dissections, and presenting case studies, a mandate that lasted until 1802. Practitioners were required to swear an oath before the judicial authority that outlined the standards of practice to be followed and to promise to refrain from certain unethical or unseemly practices [2]. Whether or not these laws were followed is unclear, but they existed for five centuries. Other CME opportunities did exist from the sixteenth to the eighteenth centuries in European cities that contained medical schools where physicians had opportunities to attend lectures and dissections in order to improve their knowledge and skills [1]. Such opportunities did not exist for many practitioners in more rural areas of Europe and colonial America, where the first medical school did not open until 1782 in Massachusetts after the Revolutionary War. Sporadic CME presentations that followed are documented but were few and far between [3, 4, 5].

2. CME in the United States

Despite the subsequent growth of medical schools in the United States, they and national medical organizations were slow to mobilize to address the need for CME. Throughout the late eighteenth and nineteenth centuries, CME was offered predominantly by local county and state medical societies. At the beginning of the twentieth century, Sir William Osler and the 1907 McCormack report to the American Medical Association (AMA) independently emphasized the necessity for more attention to CME [6].

However, neither of these had much immediate impact on medical schools and national organizations, although several demonstration projects were briefly undertaken. Even in the early twentieth century, when advances were being made in undergraduate and graduate medical education, CME lagged behind and for the most part, continued to be the province of local, county, and state societies [7, 8, 9, 10, 11, 12, 13].

To address the challenges of educating physicians far from urban areas or near the 81 medical schools in the United States, a significant innovation in CME began in the early part of the second half of the twentieth century. A pilot program was initiated at the Albany NY Medical College in 1955 via its powerful FM radio station atop Mt. Greylock, the highest mountain in nearby Massachusetts, using amateur radio operators. It reached participating hospitals in New York, New Jersey, Massachusetts, Vermont, and Connecticut. Faculty were recruited from 23 medical schools across the United States and Canada [14, 15, 16, 17].

Although the Albany program ceased operating in 1981, it was followed by a host of interactive teaching modalities that have expanded even more since the COVID-19 pandemic.

Organized medicine finally began to accredit CME in a more formal manner in 1968. The AMA’s Council on Medical Education first assumed this role and then was succeeded by a Liaison Committee for Continuing Medical Education (LCCME) in 1976. LCCME was not successful in its operations because other organizations involved in medical education felt that they should have significant roles to play in CME accreditation and were not represented.

AMA transiently resumed its supervisory by forming a standing Advisory Committee on Continuing Medical Education and, in 1968, developed the AMA Physician’s Recognition Award and Credit System. It defined CME as nonpromotional learning activities certified for credit prior to the activity by an organization authorized by the credit system owner or nonpromotional learning activities for which the credit system owner directly awards credit. It also defined activities that are ineligible for AMA PRA credit. These include:

1. Clinical experience

2. Charity or mission work

3. Mentoring

4. Surveying

5. Serving on a committee, council, task force, board, house of delegates, or other professional workgroup

6. Passing examinations that are not integrated with a certified activity.

It developed categories of AMA PRA Credit, Eligibility for Credit, AMA monitoring, and withdrawal of privilege to designate credit. It developed core requirements for certifying activities and format—specific ones: these are:

1. Live activities

2. Enduring materials

3. Journal-based CME

4. Test-item writing

5. Manuscript review

6. Performance improvement CME

7. Internet point of care learning

8. Other.

And listed activities that could receive credit directly:

1. Teaching at a live activity

2. Publishing articles

3. Poster presentations

4. Medically related advanced degree

5. American Board of Medical Specialists (ABMS) member board certification and Maintenance of Certification (MOC)

6. ACGME accredited education

7. AMA international conference recognition

8. AMA PRA credit system international agreements.

Finally, in 1981, medical educators cooperatively formed the Accreditation Council for Continuing Medical Education. Those seven member organizations are:

1. The American Board of Medical Specialists (ABMS)

2. The American Hospital Association (AHA)

3. The American Medical Association (AMA)

4. The Association of American Medical Colleges (AAMC)

5. The Association for Hospital Medical Education (AHME)

6. The Council of Medical Specialty Societies (CMSS, now CMS)

7. The Federation of State Medical Boards (FSMB) [18].

Whereas its predecessors were unsuccessful in accomplishing a role that was acceptable to all involved in the credit process for CME, ACCME has done so for over 40 years. Jointly with the AMA, ACCME promulgated its definition of CME.

“Continuing Medical Education (CME) consists of educational activities that serve to maintain, develop or increase the knowledge, skills and professional performance and relationships that a physician uses to provide services for patients, the public or the profession. The content of CME is that body of knowledge and skills generally recognized and accepted by the profession as within the basic medical sciences, the discipline of clinical medicine, and the provision of health care to the public.”

This definition is widely accepted by the profession.

In 2022, the most recent Data Report by ACCME reported 1620 accredited providers who offered approximately 230,000 accredited educational activities. Although over the past few years, the number of providers has fallen because of hospital closures, provider mergers, and economic issues, the number of AMA Category 1 Credits offered, Physician Interactions, and Other Learner Interactions continue to increase.

Although the Albany Medical College Program had been discontinued, it had been succeeded by numerous telelectures, one-way and two-way television programs, and the like. The pandemic introduced numerous presentations available to learners, primarily via ZOOM. Such media has increased attendee numbers and remains widely used despite the end of pandemic restrictions.

There are multitudes of reasons for this success. Among them is the growth of Hospitalists, which causes many physicians to have less presence in hospital settings and the convenience of attending learning opportunities from their offices or even off-hours from their homes. Remote faculty become available from many sources. A further innovation has been the development of a “hybrid” format where some learners attend in person and others remotely. Detractors of remote learning decry the lack of opportunity for in-person attendees to chat or discuss presentations with peers and faculty.

The US CME enterprise is financially very successful: In 2022, the Grand total income was $3387, 101, 116, reflecting Registration Fees, Commercial Support, Advertising and exhibit income, Government grants, and Private donations [18].

3. The survey process

Organizations that provide either state or national CME accreditation undergo a three-part process: they submit a Self-Study document along with a number of their activities labeled “Performance-in Practice” (also known as Activity files) for review by a team of two Surveyors. The Surveyors then interview the Provider, increasingly by ZOOM, thereby obviating a need for travel.

The specific areas covered in the updated Self Study are:

1. Mission

2. Program analysis

3. Program improvements

4. Educational needs

5. Designed to change

6. Appropriate formats

7. Competencies

8. Analyzes change

and a number of standards and policies

1. Standard 1: ensure content is valid

2. Standard 2: prevent commercial bias and marketing in accredited continuing education

3. Standard 3: identify, mitigate, and disclose relevant financial relationships

4. Standard 4: manage commercial support appropriately

5. Standard 5: manage ancillary activities

6. Accreditation statement policy

7. CME activity and attendance records retention policy

Performance-in practice submissions reflect the nature of the organization being surveyed.

Accreditation is granted to multiple learning formats derived from the AMA PRA. These include:

1. Enduring material

2. Live courses

3. Regularly scheduled series

4. Journal CME/CE

5. Other/blended learning

6. Performance/quality improvement

7. Committee learning

8. Manuscript review

9. Test-item writing

10. Internet searching and learning

11. Learning from teaching.

The findings of the Survey Team are reviewed in a tripartite process first by a member of the ACCME Accreditation Review Committee and presented to the Committee for a vote. It is further reviewed by the Accreditation Decision Committee of the Board of Directors, and the decision is conveyed to the organization.

Organizations that are newly applying for accreditation, if successful, receive a two-year level of accreditation entitled Provisional, after which they are again surveyed. Two levels of accreditation then may be achieved: a Four-Year status, which may also require Progress Notes if any of the replies are unsatisfactory, which are further reviewed, or a Six-Year level of Accreditation with Commendation that is granted after an applicant answers additional Criteria from a menu that encompasses:

1. Promotes team-based education

   Engages teams

2. Engages patients/public

3. Engages students

1. Addresses public health priorities

   Advances data use

2. Addresses population health

3. Collaborates effectively

1. Enhances skills

   Optimizes communication skills

2. Optimizes technical/procedural skills

3. Creates individual learning plans

4. Utilizes support strategies

1. Demonstrates educational leadership

   Engages in research/scholarship

2. Supports CPD for CME team-based demonstrates creativity/innovation

3. Achieves outcomes

4. Improves performance-in improves healthcare quality

5. Improves patient/community health

It is required to demonstrate compliance with any seven criteria of the organization’s choice plus one criterion from achieves outcomes. No leeway is allowed in the responses for providers seeking commendation in the form of progress notes. The vast majority of providers achieve a four-year accreditation, with less than 10% acquiring commendation.

It must be noted that in addition to the 155 medical schools in the United States and 17 in Canada that award the MD degree, there are an additional 41 accredited medical colleges that grant the degree of Doctor of Osteopathic Medicine (DO) that are accredited by the American Osteopathic Association’s (AOA) Commission on Osteopathic College Accreditation [19]. Approximately 19% of practicing physicians in the US hold that degree. There has been increasing integration of both undergraduate [20] and graduate medical education between allopathic and osteopathic training, and many osteopaths, following their graduate training, become certified by ABMS and obtain CME largely through ACCME. As of this moment, despite that there have been some attempts to do so [21], there has not yet been a successful merger in the CME functions of the AOA and AMA, and so the AOA has a parallel accreditation process to ACCME’s. An increasing number of osteopathic medical colleges have applied for ACCME certification and may award CME to allopathic attendees.

4. The role of academic medicine

Academic medicine began to play a significant role in CME with the establishment of the Society of Medical College Directors of Continuing Medical Education in 1976. It developed a publication, Mobius, in 1981, which was retitled The Journal of Continuing Education in the Health Professions in 1988 and renamed itself the Society for Academic Continuing Medical Education in 1998. Although the organization emphasized educational advances, by 1995, it received a request from the Association of American Medical Colleges (AAMC) for a statement on CME and entered into working groups with ACCME, and participated in its restructuring process in 1996; SACME now recognized for its commitment to being the leading academic society that advances the field of continuing education and professional development in the health professions in the best interests of clinicians, patients, and communities. SACME now describes its mission as:

1. Health equity

2. Practice and value of CPD/CE

3. Clinician practice and wellbeing

4. Patient care and health of the public.

SACME reaches its members in the academic medical community via its additional publications CE News and Intercom. Utilizing a grant from ACCME, SACME has developed the CE Educator’s Toolkit, an accessible resource for educators containing best practices and guidelines to deliver effective continuing education [22].

5. Discussion

ACCME is defined as accredited providers and organizations that offer CME to primarily national or international audiences.

In addition to its directly accredited providers in the United States, many of which are Medical Colleges, Academic Medical Centers, State Medical Societies, large member Specialty Societies, and corporate entities in or associated with the field of healthcare.

ACCME collaborates with 32 state and territorial medical societies, “state accredited providers,” several of which accredit CME in contiguous ones. As an example, the Commonwealth of Massachusetts also accredits neighboring Connecticut and Rhode Island. The nomenclature for such providers is accreditation by ACCME Recognized Accreditors. Some entities within those states may receive that level of accreditation instead of national accreditation.

This is accomplished by a concept of Substantial Equivalency propagated early this century that such accreditation is based on shared principles and values. State Societies review processes are similar to those outlined for national accreditation.

The results of the State Societies processes are then entered into ACCME’s Program and Activities Reporting System (PARS) for the convenience of the learners and licensing boards.

The third group of Providers are Jointly accredited ones that focus on continuing education by and for healthcare teams. These providers are accredited by Joint Accreditation for Interprofessional Continuing Education.

ACCME works in concert with the AMA to simplify and align its expectations for accredited CME activities that it certifies for AMA Category 1 Credit.

ACCME also cooperates with ABMS member boards to simplify the process of Maintenance of Certification (MOC), which is another convenience for its learner audience.

The US Food and Drug Administration collaborates with ACCME via its Opioid Quality Payment Risk Evaluation and Mitigation Strategy.

CMS, formerly CMSS (The Centers for Medicare and Medicaid Services) Quality Payment Program includes, as an improvement activity, accredited CME.

The development of Joint Accreditation for Interprofessional Continuing Education allows for the accreditation of activities specifically designed to promote collaborative interprofessional activities in healthcare delivery.

Collaborative programs with international accreditors who have shared principles allow for continuing professional development for clinicians and teams worldwide.

ACCME has increasingly taken a leadership role with CME representatives from many countries. It played a significant role in creating the International Academy for CPD Accreditation in 2013, whose goal is to facilitate peer-to-peer support for leaders of CPD/CME accreditation systems while encouraging networking, mentoring, and interactions about common issues.

Through its principle of Substantial Equivalency, six organizations outside the United States are recognized by ACCME as equals:

1. The Royal College of Physicians and Surgeons of Canada

2. The Canadian Committee on Accreditation of Continuing Medical Education

3. European Board for Accreditation of CE for Health Professionals

4. The Oman Medical Specialty Board as part of the Ministry of Health of the Sultanate

5. The Qatar Council for Health Practitioners

6. The Federation of the German Chambers of Physicians.

ACCME also directly accredits organizations outside the United States that undergo its Survey Process. These include organizations in the United Kingdom, Canada, Korea, Pakistan, Qatar, Saudi Arabia, and Chile.

6. Conclusion

In its 42 years of existence, ACCME has accomplished elevating CME to reach a level of expertise in the United States that is on a level offered in both undergraduate and graduate medical education that had not previously existed.

In the United States, CME has survived and rebounded from the negative effects of the pandemic and has developed new and exciting modes of delivery.

In addition, ACCME has taken a leadership role in international CME, which has also profited from its expertise.

CME in the United States and increasingly worldwide is thriving despite the fact that changes lagged behind those at the levels of undergraduate and graduate medical education. Its advances over the past 42 years have progressed so that CME has become equal with medical school and graduate education programs.

Changes that are continually present in healthcare will continue to present challenges in review of activities for scientific integrity. Issues surrounding commercial support will continue to challenge Surveyors and Reviewers and the emerging role of Artificial Intelligence will present new ones.

The strengthened CME community looks forward to meeting these challenges in the United States and worldwide.