Re: JCEHP, Volume 29, Issue 2

July 17, 2009

Dear Dr. Mazmanian

Thank you for your thought provoking editorial in the Spring 2009 JCEHP "Commercial Support of Continuing Medical Education in the United States: The Politics of Doubt, the Value of Studies".

We concur with your conclusions that studies of the effectiveness of methodologies are needed. As owners in a medical education consulting firm - we are continually seeking new and better ways to assess outcomes of educational activities, within the budget constraints that we all face. We would like to offer a few observations from the field:

Effectiveness is being studied every day via outcomes assessments. Along with our educational partners - we are seeking and seeing level 4 performance changes every day in a variety of formats. What is needed are ways to tie these disparate studies together with standard measures, such as are under development by the Medbiquitous consortium.

Learning activities often have greater value than what is measurable by outcomes at any level. The best models of learning and change are still 2-dimensional and stepwise. Yet through several thousand interviews with physicians we know that change is an uneven and occasionally haphazard process. The factor that finally convinces or enables a physician to make a change in practice may be a simple journal article or an intensive workshop. But many other factors may play a role in making that change, including lectures, on-line activities, conversations with peers, or a feedback report from a managed care organization. So even when measures are very precise - they may not be very accurate in terms of the actual role of an educational activity in improving clinical practices.

There is much concern over bias in CME. Grantors are bending over backwards to avoid appearance and reality of bias. The vast majority of participants report that they perceive no bias in the activities in which they participate. Who is to be the judge of bias? Although bias can be managed, it cannot be eliminated as many times it is in the eye of the beholder. We believe that physicians are intelligent adults and can ascertain bias. When they see it – they seek other sources of education. Although providers should be required to manage conflict of interest, we believe that disclosure is the best means for avoiding bias and allowing physicians to make their own decisions about what is and is not quality medical education.

Respectfully,
Tom McKeithen
Chris Larrison
Healthcare Performance Consulting, Inc.
www.changingpeformance.com


July 9, 2009

Dear Paul Mazmanian, PhD,

In your recent editorial, Commercial Support of Continuing Medical Education in the United States: The Politics of Doubt, the Value of Studies, you note examples of CME activities at annual meetings and seminars, described as ineffective at changing physician behavior. I would like to add that the Internet is an ever increasing source of CME for clinicians where commercial support and faculty disclosures are fully transparent to the user. Internet CME has demonstrated effectiveness at the levels of physician knowledge, practice, and in some studies clinical outcomes.

As very recent examples of effective CME, impact on clinical outcomes was shown by analysis of data from 37 studies from The Johns Hopkins University Evidence-Based Practice Center, for the Agency for HealthCare Research and Quality (AHRQ) published in 2009.¹ In addition, a 2009 review of 15 randomized controlled trials demonstrated multi-component Internet CE improved knowledge and clinical performance.² Internet-based learning was associated with large positive effects on knowledge, skills and practice behaviors according to an analysis of 201 studies by Cook et al. published in JAMA, 2008.³ Further, a controlled trial of Internet CME demonstrated increased likelihood of physicians choosing evidence-based care for standardized patients.⁴ These data point to the value of the Internet in education that is both effective, and transparent.

Sincerely,
Jennifer Brown, PhD
Scientific Director
MedscapeCME^sm
jjbrown@medscape.net