CME: Is Honesty the Best Policy?

Sean Tunis was a man to be trusted. The 47-year-old emergency room physician held a number of distinguished posts: Director of the Health Program at the Congressional Office of Technology...

Sean Tunis was a man to be trusted. The 47-year-old emergency room physician held a number of distinguished posts: Director of the Health Program at the Congressional Office of Technology Assessment, Health Policy Advisor to the US Senate Committee on Labor and Human Resources, and Director of the Centers for Medicare and Medicaid Services (CMS) Coverage and Analysis Group. All the while, Dr. Tunis had continued to serve with distinction as an ER practitioner at Mercy Medical Center in Baltimore, MD. In April 2003, he was named Chief Medical Officer of CMS; announcing the appointment, CMS administrator Tom Scully noted, “[Tunis] not only brings a vast amount of scientific understanding to CMS... but he is a very good guy with excellent judgment.”

But behind the scenes, certain parties were beginning to call that judgment into question. Sometime in 2002, the Maryland Board of Physicians had received an anonymous letter suggesting that Dr. Tunis had been falsifying the continuing medical education (CME) credits he reported to Mercy. The Maryland Board alleged that Dr. Tunis had fabricated CME certificates representing nearly 60 hours of credit—using government supplies—and sent them to his employer when applying for reappointment.

While he admitted falsifying the certificates, Dr. Tunis denied intentional wrongdoing; in a letter to the Maryland Board, he wrote, “I was fully confident that I was reconstructing records [for credits] I had legitimately obtained.” In June of this year, Tunis agreed to a one-year suspension from the practice of medicine; he was also fined $20,000 and will be required to complete 35 hours of CME, including an ethics course. He also resigned from Mercy; his future with CMS is uncertain.

This high-profile case has sparked considerable discussion among critics and defenders of the existing CME system. Some observers are even calling for a complete overhaul of that system, complete with vigilant monitoring of the credits reported by physicians and more muscular enforcement of CME rules and regulations. Said Arthur Caplan, PhD, Chair of the Department of Ethics, University of Pennsylvania: “The requirements are too flimsy. In this day and age when doctors are asking for malpractice relief, they need to do what they can to beef up the expertise of the profession. When the [CMO] of Medicare fudges on his CME, it doesn’t do much for public confidence.”

Big Brother is Emphatically Not Watching You (Or Anyone)

At present, all but 11 US states require some amount of CME as a condition of relicensure . Opportunities to “game” the system, to claim credits not earned in keeping with the letter and/or spirit of the regulations, abound; to understand why and where, it will be helpful to briefly review the way the CME requirement is monitored and enforced. This we will do in the following paragraph.

It’s not.

Notional efforts at enforcement are in place, of course, but they generally pose no real barrier to the physician who, for whatever reason, wishes to claim unearned credit. The North Dakota State Board of Medical Examiners (NDSBME; www.ndbomex. com) has a relatively typical monitoring procedure. Applicants for relicensure are sent a CME card on which they check whether they: (1) are in compliance with North Dakota CME regulations; (2) are not in compliance; or (3) are exempt from the requirement for some reason (just getting out of residency, for example). No documentation of any kind is required from most physicians. Periodically, however, the Board engages in a random audit, contacting physicians and asking to see documentation of reported CME—usually certificates from the accred-ited provider. However, the Board has no reliable method of checking that the certificates provided are not falsified.

The Massachusetts Board of Registration in Medicine also simply asks physicians to state whether they have met the CME requirement. Unlike North Dakota, however, Massachusetts has no auditing mechanism at all. Russell Aims, a Board representative, told MD Net Guide that “we rely on the physicians to be honest; the application for relicensure is signed under penalties of perjury.”

Enforcement is generally lax among providers, as well; very few providers make more than a token effort to verify that the individuals who complete their programs are who they say they are—or even that they are physicians at all. In fact, an MD Net Guide report-er was able to earn dozens of hours of CME credit online under a host of assumed names in no time at all—often by skipping the activity altogether, jumping directly to the post-test, and selecting answers at random until he received a passing grade.

While spectacular abuses are gen-erally regarded as ethically unsavory and are relatively rare, there are other ways to duck and dodge the spirit, if not the letter, of CME requirements; these include falling asleep during CME lectures, signing in to a CME presentation and leaving after 10 minutes to go windsurfing, skipping directly to the post-test without actually learning anything from the activity (as our reporter did), or claiming the maximum number of credit hours available for a program even if it takes less time. In short, the entire system depends on the ethics of the individual physician.

So, What’s the Problem?

We’ve established that, in essence, no one—not CME providers, nor the AMA, nor the state medical boards—is watching. The million-dollar question: should someone be? Anecdotal evidence suggests that at least some physicians earn some credits in ways inconsistent with some regulations. According to Lynette McDonald of the NDSBME, between one and three providers are caught with each random audit, “not necessarily fudging or fabricating; they just don’t have the CME as they indicated on their card.” Further, an MD Net Guide poll conducted in early June, 2005, revealed that 18 of 746 respondents (about 2%) have claimed credit for an activity they did not complete. If this proportion were to hold true for the estimated 850,000+ physicians currently licensed in the United States it would mean that up to 17,000 doctors have fabricated CME credits (it is important to note that the small sample size used in this study limits its predictive value).

Still, exhaustive efforts at monitoring and enforcement would come at substantial financial cost and impose a burden on physicians; such an endeavor would be worth it only if demonstrable harm accrues from whatever “fudging” does occur. At first glance, the harm appears to be obvious; CME is required for a reason, after all. Massachusetts’ Aims ex-plains thusly: “Physicians should be engaged in continuous training throughout their careers to learn about new modalities, research, trends, etc.”

Other physician readers argued that a doctor’s willingness to adhere to the rules reflects his or her professionalism to some degree. “The idea of CME is to keep one’s knowledge up to date, is it not? I’m disgusted that anyone with an MD after his/her name would even consider cheating,” wrote one. Our survey respondents generally agreed that outright cheating is a problem; 93% feel it is a “serious ethical violation to claim credit for a CME activity actually completed by another person,” for example. However, only 66% feel it is “a serious ethical violation to complete a post-test without having actually viewed the activity,” and 37% disagreed that accepting the maximum number of credits available for a program even if it took less time to complete constituted a serious ethical violation. “The concept of time for CME makes no sense,” said one respondent. “It seems that spending two hours for a CME is the goal in and of itself. Shouldn’t the knowledge gained from the activity be the goal?”

Moreover, many professionals persuasively argue that adherence (or nonadherence) to an arbitrary CME standard is irrelevant, as long as the practitioner in question remains educated in one way or another. As one of our survey respondents averred, “There is no objective correlation between CME and patient care.” In an ideal world, as long as the latter is excellent, the former ought to be a non-issue.

Beyond the CME Police

One option for improving the current CME system is to institute more thorough requirements and standards. For example, Dr. Caplan suggests adding “a simple set of questions, a small exam at the end of live lectures; they can be simple questions, just design-ed to ensure that the participant has been there and breathing,” he recommends. For online CME, he suggests that participants be required to stop, read all the material and view accompanying multimedia components before accessing the post-test. A small but significant proportion of our survey respondents agreed, with about 25% feeling that post-tests should generally be more difficult and 33% agreeing that online activities should not allow users to skip directly to the post-test.

There are drawbacks to each of these proposed reforms, of course. Aggressively monitoring attendance could lead to problems with excessive stringency; says Robert Addle-ton, EdD, Medical Education Director for the Medical Association of Georgia, “Do we need to ring the bell, lock the door, and take roll call? I don’t want to put CME staff members in the place of telling doctors, ‘No, you can’t have a certificate because you came five minutes late.’” Altering post-tests to make them more difficult or resistant to “gaming” is also problematic. “If one CME course gets a reputation for more difficult post-tests, physicians [may] avoid that course even though it may offer [higher] quality learning,” says one survey respondent.

Nearly half of our survey respondents would like to see some mechanism in place to audit and verify CME credits; while it might theoretically be possible to audit everyone, this would be prohibitively expensive, and offensive to many physicians. “I do what I do well, and I resent government interference with my profession under the guise of protection of the public,” says one reader.

Perhaps the most important way to improve the system is to call for CME that is effective, innovative, interesting, and that makes physicians want to learn and allows them to feel that they haven’t wasted their time. “There’s no systematic evaluation or upgrading of CME programs,” notes Dr. Caplan. “CME hasn’t im-proved or changed a lot over the years. It’s not a hotbed of educational innovation.” He suggests that the major professional organizations take a hand in evaluating programs, trying to find “innovative ways to teach, so it’s not just PowerPoint again and again. Perhaps the organizations could give awards for outstanding CME courses, and otherwise try to encourage excellence.” Hopefully, making CME seem more valuable and less busywork to the physician will help accomplish the real goal: the promotion of education and the improvement of patient care.

You Talk Back: Selected Results From the MD Net Guide Survey

Total Respondents: 759 (not all respondents answered all questions)

Specialty Breakdown

Primary Care - 41%

Pediatrics - 17%

Psychiatry - 14%

Oncology - 8%

Other - 20%0

Does your state have a CME requirement for license reregistration?

Yes - 89%

No - 11%

How useful to you in your daily practice is the information gained from CME?

Extremely useful - 21%

Useful - 48%

Somewhat useful - 29%

Not at all useful - 2%

Have you ever claimed credit for a CME activity you did not complete?

Yes - 2%

No - 98%

Have you ever completed a post-test for a CME program without having completed the activity itself?

Yes - 17%

No - 83%