Research Article
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Published Online: 11 March 2020

Keeping Integrative Medicine Continuing Medical Education on the Cutting Edge—and Compliant

Publication: The Journal of Alternative and Complementary Medicine
Volume 26, Issue Number 3
Editor's Note: This is the seventh commentary through the JACM column partnership with the Osher Collaborative for Integrative Medicine. The goal of these commentaries is to stimulate critical conversations in the field through perspectives from the leaders of the Collaborative's seven prominent academically-based integrative centers. This commentary examines a powerful issue that can significantly impact the uptake of integrative practices by medical doctors and the access to such services in their patients. Issues surrounding continuing medical education (CME) - accreditation by the Accreditation Council on Continuing Medical Education (ACCME) on the one hand, and self-regulation by integrative CME providers on the other, have quietly boiled among integrative medicine conference planners for the last two years. At least four major CME providers have pulled CME recognition of integrative conferences under ACCME pressure. This timely column explores ACCME'S history, and the challenges. The authors are from three Osher Centers: Melinda Ring, MD, FACP, ABOIM, Northwestern University; Darshan Mehta, MD, MPH, Harvard Medical School and Brigham and Women's Hospital; and Iman Majd, MD, MS, LAc, EAMP, University of Washington. – Editor-in-Chief, John Weeks (johnweeks-integrator.com)
Melinda Ring, MD, FACP, ABOIM
Iman Majd, MD, MS, LAc, EAMP
Darshan H. Mehta, MD, MPH

Introduction

A physician's educational journey is maintained as a lifelong learning process; updating one's knowledge and skills is essential to improve patient care.1 This ongoing learning process has been operationalized for medical doctors through continuing medical education (CME). The Accreditation Council for Continuing Medical Education (ACCME), the agency that oversees this process in the United States, is giving increased attention to ensure that content is valid, evidence based, and not influenced by commercial interests.2 In this column, we explore the present tensions and opportunities as the field of integrative medicine (IM) has witnessed growing scrutiny by the ACCME in recent years. In addition, we review the governance of CME in the United States and how proposed ACCME policies impact IM CME offerings. Finally, we conclude with recommendations for IM educators to consider to ensure that physicians attending these programs receive the credits needed to maintain licensure while also improving clinical practice. While this commentary focuses on U.S. based policies for physician CME, we believe that some lessons apply to all health care providers as it relates to their continuing professional education in integrative products, practices, and practitioners.
IM often lives at an exploratory edge of practice. With the significant prevalence of use among the public, tallied at one-third of United States adults, and one in eight children, physicians are naturally asked about IM modalities by the patients.3,4 The movement first coined “alternative medicine” in the 1980s has become increasingly mainstreamed by the multitude of health system based innovations, ranging from integrative oncology to nonpharmacologic advances in pain management. These dynamics create areas that require necessary clarity on the education and reeducation of medical doctors.
More than half of all U.S. physicians have recommended at least one IM modality to their patients, including massage therapy, chiropractic care, herbal/dietary supplements, mind–body therapies, and acupuncture.5 Some physicians who pursue IM education are driven by a desire to be responsive to patients and recommend best practices.6 For example, medical doctors who have traditionally relied on analgesics and opioids for pain conditions are now interested in integrative pain practices.7 Oncologists hope to deliver care that has the potential to improve the standard treatment response, such as acupuncture to reduce symptoms of therapy-induced xerostomia and neuropathy.8,9 Physicians who seek training in IM may additionally aspire to a more preventive, whole-person, and health-oriented focus for their practice.10 Beyond the inclusion of broader therapeutic options, IM physicians work from a salutogenic model focused on health promotion, as endorsed by a consortium of academic medical centers and health systems.11
Targeted IM CME activities are needed to bridge the knowledge gap in service of both these populations: patients who want appropriate integrative options and medical doctors who seek to enhance their practices. To respond to these intertwined movements for change in medical practice, the CME must reflect the state of the science, support physicians in facilitating informed dialogues with patients, and enhance service delivery. Furthermore, CME activities are needed to allow medical doctors to become and stay competent in integrative approaches that support safe and evidence-based care.

History of Self-Regulation of CME in the United States

In the 1950s, the American Medical Association (AMA) Council on Medical Education carried out a survey resulting in publication of a critical report regarding the highly variable quality of existing CME programs.12 In 1970, the AMA House of Delegates adopted guidelines, which served as the basis for accreditation by state medical associations and national providers of CME.
In 1977, the Liaison Committee on Continuing Medical Education (LCCME) was created. Representatives from seven founding organizations formed the key membership: AMA; American Board of Medical Specialties (ABMS); American Hospital Association; Association of American Medical Colleges; Association for Hospital Medical Education; Council of Medical Specialty Societies; and Federation of State Medical Boards of the United States. In 1981, the organizations founded the new ACCME.13
The ACCME was not immune to challenges of its own. In 2007, members of the United States Congress Senate Finance Committee challenged the ACCME on discovering that the pharmaceutical industry spent more than one billion dollars per year to fund CME programs accredited by the ACCME.14 To address these concerns the ACCME implemented a revised “Standards for Commercial Support” to ensure that education programs maintained independence from pharmaceutical influence. Presently, the ACCME is a nonprofit entity “responsible for setting standards to ensure that CME is effective, relevant, responsive to the changing healthcare environment, independent, free from commercial bias, and designed to promote healthcare improvement.… [its] goal is to leverage the power of education to improve clinician performance and patient care.”15 It defines CME as “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.”16 Concerns for conflicts of interest remain a priority for ACCME.

Regulation and Role of CME

In the United States, CME credits are not bestowed directly by the ACCME; rather, the ACCME and state medical societies certify which organizations can provide CME for medical doctors. Eligible organizations may be medical schools, local, state, and national medical societies, and other institutions, some of which may be for profit. These CME providers are responsible for the oversight of individual educational activities.
Governance of the ACCME is through the seven founding organizations, which continue to serve as its only member organizations. Each of these founding members elects several delegates to serve on ACCME's board. Notable is the lack of representation by the American Board of Physician Specialties (ABPS), a multispecialty certifying body that offers board certification for both allopathic and osteopathic physicians. Among the 20 specialty organizations recognized by the ABPS—which includes Emergency Medicine, Dermatology, Anesthesiology, and others—is the American Board of Integrative Medicine (ABOIM). The structure is thus one of legislation and rule without representation, as IM has neither direct nor indirect (through ABPS) representation on ACCME.
Accrual of CME serves several other purposes beyond lifelong learning for physicians. The first role is maintenance of medical licensure. Unlike many countries with centralized oversight, the United States uses a state-based approach to medical regulation, governed by state-legislated Medical Practice Acts.17 State medical boards are given the public health responsibility for regulation and discipline of physicians, “protecting [the public] from incompetent, unprofessional, and improperly trained physicians.”18 As part of this charge, state boards play a key role in physician continuing education. They establish and monitor minimum CME requirements to maintain licensure. At present, these requirements for CME credits vary significantly by state and specialty, typically inside the broad range of 15–50 hours per annum.19
A second important role for CME is for maintenance of certification (MOC). For example, the ABMS MOC requires physicians to demonstrate that they have been engaged in relevant practice-based activities that have resulted in improvement in patient care/outcomes in their practices.20 The ABMS specialty boards have collaborated with the ACCME so that approved CME activities count toward both MOC and state licensure requirements. In 2017, the AMA and the ACCME also aligned their expectations for approved CME activities certified for AMA Physician's Recognition Award (PRA) credit.21
These agreements between the ACCME, AMA, ABMS, and State Boards make clear—particularly with the noninclusion of ABPS in governance—that for IM to flourish within conventional medicine, two key steps are required. First, entities that provide CME must understand evolving requirements and establish processes to meet or exceed them. Second, leaders in the field must find ways to interface and educate credentialing organizations about IM. Optimally, they will engage with the ACCME.

ACCME Content Validity and IM

IM is sometimes wholesale and inappropriately targeted by mainstream academics as “alternative,” “quackery,” and subject to dismissal due to a perceived lack of evidence. Several calls by eminent scientists urged the dismantling of the very entity at the National Institutes of Health that has been tasked to fund high quality research in IM.22 ACCME leadership has verbalized during meetings and conversations that diagnostic and therapeutic strategies common in IM (e.g., natural products, manual medicine, and acupuncture) fall in the category the ACCME designates “controversial topics,” which they define as “…topics in the field of medicine that remain experimental, unproven, and/or unconventional”23 [personal communications]. Yet this polarization reflects a diminishing part of the story of IM's relationship with dominant medical practice. Important physician organizations such as the American College of Physicians (ACP), federal agencies, and the National Academy of Medicine have included IM in their clinical practice guidelines.24,25 The American Society of Clinical Oncology (ASCO) endorsed evidence-based guideline on use of integrative therapies during and after breast cancer treatment formulated by the Society for Integrative Oncology (SIO).26 The Massachusetts Board of Registration in Medicine has approved new policy to risk management CMEs to include wellness and burnout prevention topics, an area of overlap with many modalities in IM.27 Most recently, the Centers for Medicare and Medicare Services (CMS) has approved acupuncture as a treatment option for low back pain for Medicare beneficiaries.28 CME programs in these areas should reflect these important updates.
A challenge in implementation of these new clinical recommendations relates to an emerging barrier to training medical professionals in IM CME content. The second goal in the ACCME Strategic Plan 2018–2021: Transforming Education to Improve Health—to assure accreditation quality and equivalency—emphasizes ACCME's responsibility to “monitor accredited CME providers to assure they are compliant with ACCME requirements regarding education quality, independence, and content validity.”29 One critique that IM CME programs have faced in recent years is that IM-focused educational conferences and topics fail to meet ACCME standards of scientific validity [personal communications]. In multiple cases, these complaints impacted the ability of academic health centers, independently accredited organizations, and joint providers who partner with nonaccredited organizations to host CME content and grant AMA PRA Category 1 CME credits to attendees.
A key issue for IM CME providers is whether the content is contextual information about a given therapy or, on the other hand, is directed at providing information that may lead to practice change. The ACCME suggests that authors of such content refer to their webpage, “Strategies that can be utilized to facilitate discussion about controversial topics without promoting unscientific care recommendations in accredited CME activities.”23 This discourse states, “…CME providers need to develop activities that encourage free and rigorous scientific discourse—while ensuring that faculty do not advocate or promote unscientific treatments and that clinical care recommendations are based on established scientific consensus. When a CME activity includes information about an approach to diagnosis or treatment that is not generally accepted, it is allowable to facilitate debate and discussion about the approach, but it is not allowable to advocate for the test or treatment or teach clinicians how or when to use it.”23
Underscoring the tight network of medical agencies that constitute the ACCME is that this ACCME stance is consistent with AMA written policy which states: “CME activities may describe or explain complementary and alternative health care practices. As with any CME activity, these need to include discussion of the existing level of scientific evidence that supports the practices. However, education that advocates specific alternative therapies or teaches how to perform associated procedures, without scientific evidence or general acceptance among the profession that supports their efficacy and safety, cannot be certified for AMA PRA Category 1 Credit.”21
Further guidance is provided in the ACCME policy entitled CME Clinical Content Validation30:
“Accredited providers are responsible for validating the clinical content of CME activities that they provide. Specifically,
1.
All the recommendations involving clinical medicine in a CME activity must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients.
2.
All scientific research referred to, reported, or used in CME in support or justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection, and analysis.
3.
Providers are not eligible for ACCME accreditation or reaccreditation if they present activities that promote recommendations, treatment, or manners of practicing medicine that are not within the definition of CME or known to have risks or dangers that outweigh the benefits or known to be ineffective in the treatment of patients. An organization whose program of CME is devoted to advocacy of unscientific modalities of diagnosis or therapy is not eligible to apply for ACCME accreditation.”

Core Issues

The ACCME and AMA policies highlight two factors, which have the potential to discriminate against IM: the definitions of scientific evidence and generally accepted standards of care. This presents a dilemma for educators trying to provide high quality IM education that serves patients, while conforming to ACCME guidelines. Several questions emerge:
What constitutes acceptable scientific research?
How should evidence be discussed?
How do CME providers learn to communicate to physician learners around topics not usually taught in undergraduate or graduate medical education?
Many topics that are covered in IM CME programming lack large-scale double-blinded randomized-controlled trials, which are considered the gold standard for evidence in medicine. Even more lack well-powered systematic reviews. Historically, physicians avoid making statements when the evidence is meager; however, in clinical practice physicians cannot avoid making decisions and recommendations, regardless of how much or little evidence there is. In addition, these topics often reflect content that have not been covered in conventional undergraduate and graduate medical education and are thus not a core aspect of the practices of the majority of physicians. In actual clinical practice, even guideline recommendations (low back pain, notwithstanding) using the GRADE system do not directly relate to clinical practice. In addition, they may not always be based upon randomized controlled studies.31,32 Literature describing and quantifying time lags in the health research translation processes have estimated the lag being 17 years, hence even with the increase in funded research IM content is at present minimally represented.33 Finally, a key question is how IM topics are determined as standard of care—are they evaluated by IM-trained colleagues or the general population of organized medicine (that may or may not have IM knowledge)?

Recommendations for IM CME Providers

Herein are recommendations of how providers of IM CME can adhere to new policies under public review at the time of this submission and allow for ongoing provision of accredited CME.

Recommendation #1: Focus on professional practice gaps

In designing IM CME programs, address professional practice gaps. These are defined as the difference between what clinicians are currently doing and what they should or could be doing. These may result in improvements in population health. The CME Outcomes Pyramid provides a rubric for consideration (Fig. 1).34 Most traditional CME programs focus on learning and competence. However, through this rubric, IM CME programs must begin to demonstrate change not only at an individual learner level but also at a population health level. For example, participation in IM CME might result in decreasing professional practice gaps, especially as it relates to physician performance (or burnout), patient health (e.g., mind/body practices and depression management), and population health (e.g., nonpharmacologic approaches to address opioid epidemic). Very few CME programs do this. In this regard, IM can be a trailblazer by ensuring that well-educated physicians can guide patients in evidence-based IM care.
FIG. 1. “CME Outcomes Pyramid. Reprinted from “Ascent to the Summit of the CME Pyramid,” by Stevenson R and Moore DE. JAMA. 2018;319(6):543-544. Reprinted with permission.”

Recommendation #2: Conduct and document needs assessments

In IM CME education, there are very little data on what health care providers desire to learn. This type of data is fundamental in understanding clinical challenges, patient inquiries, and practice patterns.35 In addition, there needs to be a greater understanding of learner needs. This can explore both the desire for information “about” integrative content and expressed need for practical guidelines in implementation in patient care.

Recommendation #3: Accurately reflect the evidence

When reviewing an IM CME program, encourage and educate content experts and presenters to use specific language around the type of evidence, as well as how it reflects CME objectives. In addition, there can be creativity on how these topics are discussed, which can include debate and dialogue around a range of opinions and perspectives.
One proposed rubric for lower-level evidence consists of the following categories: nonrandomized comparisons, extrapolation using indirect evidence, rationale, and clinical experience (i.e., an accumulated general impression).36 Another example is the Hierarchies of Evidence Applied to Lifestyle Medicine (HEALM) tool from the American College of Lifestyle Medicine that illustrates how to evaluate the specific contributions of diverse research methods to understanding lifetime effects of health behaviors.37

Recommendation #4: Use methods that better target learners

Greater improvements post-training are noted when learning activities are more interactive, use more methods, and involve multiple exposures.38 CME activities are encouraged to shift from an hourly-reported activity based upon self-study and lectures to a more engaged interactive activity, such as direct experience, case-based work, audience-response systems, and gamification.39–41 Creating space for learners to share challenges and specific questions faced in patient care with guidance by IM faculty with clinical and research expertise may be more relevant than didactic lectures or online readings.

Recommendation #5: Study the effects of the CME

There is a general dearth of literature around the outcomes of CME programs of all kinds. This is especially true for CME programs within IM. However, CME has been found to improve physician performance and patient health outcomes, as supported by systematic reviews.38 It is imperative that IM CME programs begin to study outcomes and publish upon this.

Recommendation #6: Be involved with and closely monitor ACCME policy making

The ACCME and its constituent members are the key players in determining policies regarding the provision of CME. Developing relationships and participating in advocacy and education may influence the perception of IM. Partnership with local accredited offices of CME can facilitate support and development of processes to ensure compliance. Finally, monitor the ACCME website to remain abreast of ACCME policies and calls for comment to stay current and have an active voice.42

Recommendation #7: Be involved in your professional or state medical society

State and professional medical societies hold tremendous sway in how CME programs, and specifically IM CME programs, are perceived and regulated. As Ceverro and Gaines state, the “effectiveness of CME must include the wider social, political, and organizational factors that impact physician performance and patient health outcomes.”38 One profound example is the inclusion of spinal manipulation in the professional clinical guidelines in the treatment of low back pain by the ACP.25 There was a time when the chiropractic care profession and the medical profession were at war with each other; and now, there is a significant body of evidence that promotes its clinical use as a standard recommendation.43 And so, it is important that leaders in IM, especially those engaged in the provision of CME programs, participate locally and nationally in these broader efforts in order that this type of knowledge is able to be properly disseminated.

Conclusion

CME can address the many dimensions of health care—both at the individual and organizational levels. While IM CME programs may be under scrutiny, this is a ripe opportunity to innovate and advocate for high quality programs. Borrowing the vision of ACCME leadership, this education needs to “promote mutual respect and reflection.… provide a safe space where all voices are heard” and “recognize the remarkable capacity of our clinician community and the role of education in supporting them.”44

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Published In

cover image The Journal of Alternative and Complementary Medicine
The Journal of Alternative and Complementary Medicine
Volume 26Issue Number 3March 2020
Pages: 166 - 171
PubMed: 32167829

History

Published online: 11 March 2020
Published in print: March 2020

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Authors

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Melinda Ring, MD, FACP, ABOIM [email protected]
Osher Center for Integrative Medicine at Northwestern University, Chicago, IL.
Iman Majd, MD, MS, LAc, EAMP
Osher Clinic for Integrative Medicine, University of Washington, Seattle, WA.
Darshan H. Mehta, MD, MPH
Osher Center for Integrative Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, MA.
Benson-Henry Institute for Mind-Body Medicine at Massachusetts General Hospital, Boston, MA.

Notes

Address correspondence to: Melinda Ring, MD, FACP, ABOIM, Osher Center for Integrative Medicine at Northwestern University, 150 East Huron Street, Suite 1100, Chicago, IL 60611 [email protected]

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