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March 04, 2011

ABMS MOC CME White Paper: SACME and CMSS Responses

Response 
In response to the American Board of Medical Specialties (ABMS) White paper on CME for Maintenance of Certification (MOC), the Society for Academic Continuing Medical Education (SACME) and the Council of Medical Specialty Societies recently made comments to the Joint Working Group on MOC and CME.

SACME

SACME, raised several concerns in their comments regarding content of the draft white paper. One concern they raised is that the document states that diplomates involved in relevant educational activities must be able to demonstrate learning or improved outcomes. SACME is concerned that in practice this will have an unintended consequence and translate into a requirement for improved outcomes only, and this  could  undermine learning. SACME believes the next version of this proposed white  paper needs to clarify the meaning of  "learning  and/or  improvement  outcomes" to  avoid this  problem.

SACME also raised serious concerns about the funding framework described in the document. SACME asserted that the ABMS artificially made the present state of funding one end of the spectrum and thus forces the focus and discussion towards the opposite end, which as described in the document is a state of no acceptable funding. However, SACME recognized that “the current valid framework should be one in which one end of the commercial support spectrum is full funding without any controls and the far end is no commercial funding.”

Under such a valid framework, SACME noted that “the present system is seen as an attempt to find an appropriate mid-point. The validity of such a framework has been supported in studies on bias and support. This is simply lost in the framework described in the document.” Furthermore, SACME recognized that “choosing to utilize such a framework might unfortunately give the impression to some that the ABMS might be biased on this important topic, an impression that SACME suggests ABMS avoid by shifting to the suggested framework.” Ultimately, SACME asserted that the consequences of such a position would be to significantly, and unnecessarily hamper the conduct of high quality CME.

Although SACME wholeheartedly agreed that public trust in the health care system and their provider is an important issue, “focusing on any possibility of an event is a false idol.” They asserted that “science and healthcare can and must focus on probabilities not possibilities as anything and everything is possible.” Accordingly, SACME noted that “defining public trust in such a manner appears to be an extremist position and sets the bar at a height where any and all systems must fall.” In addition, “it is contrary to the very evidence that exists which shows patients, at a reasonable percentage, just want to be aware of who has paid their physician, how much and for what purpose. Patients are not interested in physicians not being paid for what they do, they are interested in enhanced transparency without stifling innovation.”

SACME also pointed out that “even the courts established a little over a year ago that the standard for a judge is the probability of bias not the possibility of bias, in part for the very reason that one can only address probabilities.”

Lastly, SACME noted that the white paper does not define team-based education, and recommended the document elaborate on the benefits of multidisciplinary and inter-professional approaches to education. SACME also recommended that a firewall be re-erected and that the ABMS, and its component boards, return to a state in which their role is to create standards but not barriers to high-quality, evidence-based cost-effective education.

CMSS

CMSS raised concerns about the ABMS white paper as well. They noted that the document blurred the boundaries between the “separate roles for entities assessing physicians (certifying boards) and educating physicians (specialty societies and others),” which risks placing certifying boards in positions of conflict of interest that the US system has avoided since the inception of certifying boards (Ophthalmology in 1916 and Otolaryngology in 1924) and ABMS (in 1933).

As such, CMSS does not support language in the document that does not clearly separate the roles of certifying boards as standard setters and assessors of physician knowledge and practice, with the roles of specialty societies and others as educators and facilitators of practice improvement among physicians.

Instead, CMSS recommended clarifying the language so that the language clearly states what is meant for the reader to understand. CMSS further recommends that this finding clearly articulate the separate roles for certifying boards as standard setters and assessors of physician knowledge and performance, and for specialty societies and others as educators and facilitators of physician performance improvement in practice.

With respect to funding, CMSS asserted that “the overwhelming evidence from articles published in the peer reviewed literature calls attention to the documented influence on prescribing practices and practice behaviors of direct financial relationships between industry and physicians.”

However, CMSS recognized that the same influence “is not documented in the peer reviewed literature for commercial support of CME in the 20 years since the adoption and implementation, and 7 years since the revision of the ACCME Standards for Commercial Support: Standards to Ensure the Independence of CME (ACCME SCS).”

Accordingly, CMSS recognized that “public perception is shaped more by public media than by peer reviewed literature and that the media have been unclear as to the differences between direct financial relationships of industry with physicians, compared with industry support of CME providers under the ACCME SCS.” As a result, they note that the profession must clear up the understanding and communication of these relationships.

CMSS noted that unfortunately, “the current draft of the MOC CME White Paper fails to draw the appropriate distinctions between the consequences, in perception and in reality, of direct financial relationships of industry with physicians, and of industry support of CME providers under the ACCME‐SCS.” In so doing, CMSS asserts that the “draft does a disservice to the profession, and to the public whose trust the profession seeks to serve.”

Accordingly, CMSS recommended that the draft read:

“The profession of medicine, stewarded by ABMS, by specialty societies and by others, is continually challenged to serve responsibly in the public’s interest and trust. As such, it is important for ABMS through setting standards for MOC CME to reflect both the reality and perception of the consequences of relationships between industry and physicians, as well as between industry and CME providers. Both sets of relationships have come under public scrutiny, and both deserve consideration.

 Articles published in the peer reviewed literature reveal that direct financial relationships between physicians and industry influence physician prescribing practices and practice behaviors. In contrast, strict adherence to the ACCME Standards for Commercial Support: Standards to Ensure the Independence of CME results in continuing education for physicians which is independent and unbiased, regardless of the source of financial support.

It is therefore incumbent on the profession, through certifying boards setting standards for MOC CME, and through specialty societies and others providing independent and unbiased programming and activities for physicians participating in MOC CME, to incorporate these realities into the design MOC CME.”

In addition, CMSS also took issue with the language used in the white paper that the ABMS and the MOC Committee should “assist” the Member Boards. They noted that it is unclear what is meant by “developing approaches” and it is unclear what is intended in the recommendation to “assist member boards.” If “developing approaches” means setting standards, then CMSS would support this concept, as standard setting is an appropriate professional role for both ABMS and for its certifying boards. If this is the case, CMSS recommended clarifying this language to state its intent.

If “assist member boards” means that ABMS will develop programs, activities, registries for physician data or other elements of implementing knowledge or performance assessment coupled as part of a performance improvement cycle with educational intervention and/or practice improvement, then CMSS has significant concerns.

CMSS acknowledged that “these roles are separate from and beyond standard setting or assessment, which are the purview of ABMS and its certifying boards, and fall within the purview of specialty societies and others. Again, they recommended clarification of this language to reflect the separate roles of certifying boards and specialty societies would be key to our support of this document.

Accordingly, CMSS asserted that “ABMS should limit its activities to standard setting and assessment of physician knowledge and performance, and should not enter into activities which develop programming, including registries, for intervening in the education of physicians or facilitating the improvement of the performance of physicians in practice, which are the roles of specialty societies and others.”

CMSS recommended that the document read, “ABMS should assist member boards in setting standards for and assessing physician knowledge and performance that incorporate the following characteristics:”

Lastly, CMSS recognized that the document is unclear as to what is meant by establishing a “general framework” to reduce or eliminate the influence of commercial entities, and asked for clarification. In “eliminating or reducing, to the extent possible, influence exerted by commercial entities,”CMSS assumed that this refers to managing in some way relationships between physicians and industry. Consequently, they said “it is not clear how certifying boards would accomplish that task, nor is it clear that it is the purview of certifying boards to do so.”

However, CMSS asserted that should “this phrase be directed toward commercial support of CME used for MOC, then it ignores the current function of the ACCME‐SCS, which serve to eliminate influence exerted by commercial entities.” Since strict adherence to the ACCME‐SCS eliminates influence,  CMSS asserted that “there is no further need to recommend that it be reduced to the extent possible.” As a result, they recommended the document to say:

“ABMS should support the profession’s self regulation of direct financial relationships with industry and commercial support of CME rather than proposing to establish separate policy and procedure in these areas. ABMS should express its support of the strong language and strict requirements of the professional self‐regulatory bodies and codes that govern relationships between industry, physicians and physician organizations.

Should ABMS wish to express concerns or recommendations for modifications to professional self‐regulation of relationships between physicians and industry, such communications should be directed to the entities whose Codes govern such relationships, such as the AMA CEJA Ethical Opinions on Gifts to Physicians from Industry, the CMSS Code for Interactions with Companies, and the ACCME Standards for Commercial Support: Standards to Ensure the Independence of CME.”

Summary

So far the responses have been by and large harmonious with two simple messages:

A)    Engage the ACCME in developing standards for CME for MOC

B)    For commercial support for the ABMS to focus on quality and see that providers strictly follow ACCME Standards of Commercial Support.

All the ABMS member board requirements need to weigh the demand for greater access to health care under the Affordable Care Act which more of physician’s services are performed by less regulated allied health professionals with increasing standards.  At the specialty boards standards are winning but at the state boards access is holding the day.

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