Trends And Developments In Continuing

Otolaryngol Clin N Am 40 (2007) 1331–1345

Trends and Developments in Continuing Medical Education Phillip Kokemueller, MS, CAEa, J. David Osguthorpe, MDb,* a

Education Business Unit, American Academy of Otolaryngology, One Prince Street, Alexandria, VA 22314-3357, USA b American Academy of Otolaryngology–Head and Neck Surgery, Department of Otolaryngology–Head & Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, P.O. Box 250550, Charleston, SC 29425, USA

Medical education in North America changed dramatically with the publication of The Flexner Report on Medical Education in the United States and Canada 1910. Funded by the Carnegie Foundation for the Advancement of Teaching and authored by Abraham Flexner, the study reported that there had been an ‘‘enormous over-production of un-educated and ill-trained medical practitioners’’ owing to a very large number of for-profit schools that offered mainly didactic instruction, without laboratory or practical experiences. This overproduction of so-called physicians had been defended by the argument of affording access to the profession ‘‘in the interest of the poor boy,’’ but was ‘‘in reality an argument in behalf of the poor medical school.’’ The conclusion of the report, as summarized by Henry S. Pritchett, then President of the Carnegie Foundation, was that a hospital with wards open for teaching and under the educational control of a medical school was as necessary as a laboratory of chemistry or pathology, and that this model should serve as ‘‘a starting-point . in a new national effort to strengthen the medical profession and rightly to relate medical education to the general system of schools of our nation’’ [1]. In the report’s chapter on ‘‘The Postgraduate School,’’ Flexner raised the issue of continuing competence, advocating that a medical school should offer not only a rigorous course of undergraduate instruction, but also postgraduate education of ‘‘special courses adapted to the needs of those inclined to devote themselves . exclusively to some particular line of

* Corresponding author. E-mail address: [email protected] (J.D. Osguthorpe). 0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otc.2007.08.003

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work (ie, specialization), and to become centers to which at intervals men practicing in isolated places may return for brief periods to catch up with the times’’ [1]. The report successfully precipitated a revolution, principally in undergraduate medical education, in the United States and Canada, and laid the foundation for a series of improvements in the lifelong education of physicians that continue up to the present. Another wave of educational improvements hit in the late 1950s and early 1960s, and mainly involved the largely unregulated area of postgraduate education, termed ‘‘continuing medical education’’ (CME). The American Medical Association (AMA) took a leadership position in CME by appointing, in 1957, an Ad Hoc Advisory Committee on Postgraduate Medical Education, which developed an agenda adopted by the AMA’s Council on Medical Education. The initial goalsdto ascertain the ideal objectives of postgraduate medical education programs and to devise criteria or standards compatible with suchdwere published in 1957 in A Guide Regarding Objectives and Basic Principles of Postgraduate Medical Education Program [2]. The council was requested to (1) publish a guide or guides setting forth and explaining the objectives and criteria of acceptable programs, and to distribute such to relevant institutions and organizations; (2) devise methods for evaluating courses and other programs, and then implement an appraisal program nationally; and (3) publish in The Journal of the American Medical Association only courses and programs meeting the criteria as determined above. This approach was embraced by the association of medical schools and major specialty groups; in fact, postgraduate courses were already being presented by medical schools and by specialty societies, including the Academy of Ophthalmology and Otolaryngology (1921; the precursor to the American Academy of Otolaryngology–Head and Neck Surgery), the American College of Surgeons (1928), and the American Academy of Orthopedic Surgeons (1933) [3]. It is indeed interesting that the three early leaders in CME of specialists in the United States and Canada were all surgical specialties. In 1961 the AMA advanced the CME initiative with the appointment of a Joint Study Committee to ‘‘spell out the dimensions of a program of continuing medical education [4].’’ This committee comprised the key players in both undergraduate and postgraduate medical education, as well as teaching hospitals and specialty organizations such as the AMA, the Association of American Medical Colleges, the American Hospital Association, the American College of Physicians, the American Academy of Pediatrics, the American Psychiatric Association, the American College of Obstetricians and Gynecologists, and the American Academy of General Practice. This group joined together to address three mutually agreed-upon topics: (1) CME was one of the most important problems facing medical education, (2) there was a serious gap between available knowledge and application in medical practice, and (3) a nationwide plan was the best solution [4].

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The Joint Study Committee subsequently proposed creation of a nationwide ‘‘University without Walls’’ for CME, tailored to the realities of community, professional, and personal demands. All physicians were to have an equal opportunity to continue their medical education at a time, place, and pace convenient to the demands of their ongoing clinical and personal obligations. The curriculum was to be organized around a continuously, or at least frequently available, sequential, and comprehensive program of instruction, with the participant able to choose any or all of the curriculum. The physician–learner was expected to actively participate in the program, and be afforded an evaluation of her or his performance, including a variety of voluntary examinations, and the opportunity to likewise evaluate the program. The curriculum was initially to be designed and produced by a national ‘‘faculty,’’ and then regularly modified according to feedback from participants. Although nationally organized and developed, the program was to gradually become available on a regional and local selective basis, for the convenience of participants. Administrative requirements for the aforementioned plan were substantial, entailing development of not only ‘‘core curricula,’’ but also a nationwide distribution system. The venues for presentation were to be specialty organizations, medical centers or other groups with the ability to deliver direct bedside teaching, and local or regional discussion groups. Teaching materials for the local programs would be furnished by the national agency, and each regional or local distribution center could decide to receive and distribute all or any part, with each physician being able to elect to participate in any part of the program, or to take the entire program. A series of self-appraisal examinations was integral to the process [4]. This initiative, published as a guide in 1962, was never fully realized, but started the CME community down the road to accreditation and the establishment of guidelines for consistency in CME courses and programs. Shortly after the recommendations outlined above, the AMA council disbanded the Ad Hoc Committee and replaced it with a permanent structure, the Advisory Committee on Continuing Medical Education, whose first action was to recommend establishment of an accreditation program. Surveys were conducted to help establish procedures and mechanisms for accreditation, and included on-site visits to gather information and observe the organizations that were conducting postgraduate courses. On the basis of the results IBID of those surveys, in 1964 the Advisory Committee recommended to the council, and the Council forwarded to the AMA House of Delegates, consideration of approval of ‘‘formal appraisal procedures’’ [2] for accreditation. Guidelines for conducting CME, and the accreditation of valid programs, were half of the equation, and in 1968 the AMA added the other halfd namely, a ‘‘Physician’s Recognition Award’’ (PRA)dto denote practitioners who demonstrated a satisfactory level of participation in the CME process. The related AMA CME credit system codified two types of education attainment, Category 1 and Category 2. The former initially entailed the traditional methods of learning such as formal interaction between

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faculty and physician audience in a certified activity or review of enduring materials, such as monographs, followed by a self-assessment exam. Category 1 was gradually expanded during the subsequent 30 years to allow audio, video, online/electronic delivery of learning materials; participation in focus groups (such as a ‘‘journal club’’); writing or reviewing articles for peer-reviewed journals; and for faculty time preparing lectures and writing test items. Credit for active participation in a performance review and improvement processdpursuits that have recently been mandated by some of the Boards of the American Board of Medical Specialties (ABMS)d has been the most recent addition to Category 1. Category 2 credits are more loosely defined, being self-reported rather than tallied by accredited CME providers, and not subject to documentation requirements by the participating physician. Examples include preceptorships, research activities, consultation with peers or experts, teaching medical residents or students, and reading journals. The AMA views both categories of CME as integral to a continuing educational framework, and offers 1-, 2-, and 3-year PRA certificates based on a mix of such. For instance, the 3-year PRA entails a minimum of 60 hours of Category 1 and 90 hours of Category 2 CME. Resident training is assumed to entail all aspects of Category 1 and 2 activities, and so 3 years in an accredited (by the American Council on Graduate Medical Education [ACGME]) training program automatically meets the criteria for a 3-year PRA certificate. Recently, physician attainment of a Maintenance of Certification certificate from an ABMS Board has been added as sufficient validation of current medical knowledge to warrant a 3-year PRA, without the need for other documentation. Accreditation of CME for physicians was initially performed, beginning in 1968, by the AMA’s Council on Medical Education, but by 1976, the volume of courses had increased over 10 fold. Accreditation was becoming a sufficiently complex undertaking to warrant formation of a dedicated subsidiary organization, the Liaison Committee for Continuing Medical Education, which morphed into the current Accreditation Council for Continuing Medical Education (ACCME) in 1981, and under whom the more recent guidelines for Categories 1 and 2 as outlined above were promulgated. During this evolution, the AMA broadened input into the CME process and accreditation thereof, and ACCME constituents were expanded to include the ABMS, the American Hospital Association, the Association of American Medical Colleges, the Association for Hospital Medical Education, the Council of Medical Specialty Societies, and the Federation of State Medical Boards [5].

A paradigm shift in continuing medical education coincident with the transition between the twentieth and the twenty-first centuries The ACCME guidelines had completed the initial phase of growth by 1984, and periodically received modest updates when technology warranted,

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as when the Internet became a viable vehicle for learning. However, in 1998 a substantially different system was introduced, centered on three essentials and a set of required elements for each: (1) purpose and mission, (2) educational planning and evaluation, and (3) administration. The ACCME also put in place guidelines for commercial support of CME, which have become progressively more explicit over the years. Initiatives outside the ACCME and the constituents of its board impacted the way organized medicine, state licensing boards, and other governmental entities viewed postgraduate physician competencies, and are today reflected to some degree in the CME landscape. In 1999 the Institute of Medicine (IOM) published To Err is Human: Building a Safer Health System [6], which emphasized reduction in errors in patient care by specific physician education, and integration of continuous practice evaluation and improvement by both the individual physician and by health care organizations (eg, hospitals). In 2001 the IOM issued Crossing the Quality Chasm [7], which re-emphasized process improvement and accountability, and in 2003 Health Professional Education: A Bridge to Quality [8], with specific suggestions regarding the organization and evaluation of CME, and reflecting some of the ACGME’s recommendations from 2001. These IOM recommendations encompassed five competencies (instead of six proposed by the ACGME in 2001, Box 1), as follows: providing patient-centered care, working in interdisciplinary teams, employing evidence-based practice, applying quality, and using informatics. In a parallel timeframe, with emphasis on continuing physician competence, the Council of Medical Specialty Societies (CMSS) released in 2002 Repositioning for the Future of Continuing Medical Education [9]. In 2005, in conjunction with a large group of organizations (eg, ACCME, ACGME, ABMS, Federation of State Medical Boards, American Hospital Association, AMA), the CMSS published Reforming and Repositioning Continuing Medical Education (Box 2), a process that remains ongoing and from which further position papers are expected; drafts of such are open for public comment on the CMSS Web site (www.cmss.org) [10]. The ACCME’s ‘‘sister’’ organizations, by virtue of broad participation from organized medicine, recognition by governmental entities, and many shared board constituents, are the ABMS and the ACGME. These organizations have all recently initiated changes that depart significantly from prior practices. The ABMS, after much internal discussion, mandated a transition from ‘‘lifelong’’ certification after residency training and a single board examination to a term-limited certification of no more than 10 years [11]. By 2002 all certificates issued by ABMS constituent boards were time limited. Integral to eligibility for the periodic board re-examination is a documented level of CME during the intervening period between exams. This approach of mandatory CME, the effectiveness of which is periodically verified by formal examination, has been termed ‘‘maintenance of certification.’’

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Box 1. Six ‘‘core competencies’’ of physician training, as specified by the American Council on Graduate Medical Education (2001) Medical knowledge  Acquisition  Analysis  Application Patient care  Gathering information  Synthesis  Partnering with patients/families Practice-based learning and improvement  Lifelong learning  Evidence-based medicine  Quality improvement  Teaching skills Systems-based practice  Health care delivery system  Cost-effective practice  Patient safety and advocacy/systems causes of error Professionalism  Professional behavior  Ethical principles  Cultural competence Interpersonal and communication skills  Communicating with patients and families  Communicating with team members  Scholarly communication

The ACGME in 2001 [12] gave notice of arguably the largest change in the required elements of resident physician education since the Flexner Report, and mandated compliance by all training programs by July 2003 (see elsewhere in this issue.) This approach has now been integrated into the ABMS approach to candidate examination (both initial and maintenance of certification), and has been the impetus for development of CME offerings in topics previously given scant attention. Comprehensive physician education after medical school has been broken down into six essential areasdtermed ‘‘competencies,’’ as outlined in Box 1dand each must be formally taught to trainees, with evaluation of not only each trainee but also the overall effectiveness of the program at imparting the competencies.

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Box 2. Conjoint committee on continuing medical education (CCCME) recommendations, as presented by the Council of Medical Specialty Societies (2005, and ongoing) 1. Medical education continuumdCCCME serves as forum for communication and coordination, builds relationships, and ensures visibility and accountability among all stakeholders. 2. Self-assessment and lifelong learningdPhysician learners, CME professionals, and physician educators should engage in self-assessment of competencies and lifelong learning to maintain competency. 3. Core curricula and competenciesdspecialty-specific core curricula should be developed to improve physician competencies. The core competencies described by ABMS/ ACCME and ACGME/American Osteopathic Association. 4. Valid content: Evidence-Based MedicinedAssure that all recommendations for patient care presented in CME are based on current best evidence, physician expertise, and patient values. 5. Performance and continuous improvementdFacilitate continuously improved approaches to evaluate CME’s effectiveness. 6. Metrics to measure and recognize physician learning and behavioral changedCurrent CME credit system should evolve and the CME system should facilitate evaluating CME’s effectiveness in forms and technologically advanced tools that are user-friendly. 7. Resources and supportd‘‘Blue-Ribbon’’ panel, medical, entrepreneurial, foundation, and governmental, and other organizational leaders should be established to offer advice, guidance, and support to focus CME as the practice and scope of medicine evolve [10].

A 7-year phase-in period was allowed for teaching hospitals, training programs, and accredited CME organizations to develop and integrate the four competencies not previously specified by the ACGMEdnamely, all but medical knowledge and patient care. So over the last decade, the ABMS and the ACGME have changed the metrics and standards of physician training and competence. The ACCME soon followed suit in 2006, with substantially updated accreditation criteria that aim to enhance performance in practice and improve patient outcomes [13]. Twenty-two criteria for accreditation of CME were codified, as outlined in Box 3, that included detailed

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Box 3. Accreditation Council for Continuing Medical Education criteria for credentialing organizations to award continuing medical education (2006) [13,14] 1. The provider has a CME mission statement that includes all of the basic components (CME purpose, content areas, target audiences, type of activities, expected results), with expected results articulated in terms of changes in competence, performance, or patient outcomes that will be the result of the program. 2. The provider incorporates into CME activities the educational needs (knowledge, competence, or performance) that underlie the professional practice gaps of their own learners. 3. The provider generates activities/educational interventions that are designed to change competence, performance, or patient outcomes as described in its mission statement. 4. The provider generates activities/educational interventions that matches the learners’ current or potential scope of professional activities. 5. The provider chooses educational formats for activities/ interventions that are appropriate for the setting, objectives, and desired results of the activity. 6. The provider develops activities/educational interventions in the context of desirable attributes (eg, IOM competencies, ACGME competencies). 7. The provider develops activities/educational interventions independent of commercial interests (standards for commercial support [SCS] 1, 2, and 6). 8. The provider appropriately manages commercial support (if applicable, SCS 3). 9. The provider maintains a separation of promotion from education (SCS 4). 10. The provider actively promotes improvements in health care and not proprietary interests of a commercial interest (SCS 5). 11. The provider analyzes changes in learners (competence, performance, or patient outcomes) achieved as a result of the overall program’s activities/educational interventions. 12. The provider gathers data or information and conducts a program-based analysis of the degree to which the CME mission of the provider has been met through the conduct of CME activities/educational interventions.

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13. The provider identifies, plans, and implements the needed or desired changes in the overall program (eg, planners, teachers, infrastructure, methods, resources, facilities, interventions) that are required to improve on ability to meet the CME mission. 14. The provider demonstrates that identified program changes or improvements that are required to improve the provider’s ability to meet the CME mission are underway or completed. 15. The provider demonstrates that the impacts of program improvements that are required to improve on the provider’s ability to meet the CME mission are measured. 16. The provider operates in a manner that integrates CME into the process for improving professional practice. 17. The provider uses non-education strategies to enhance change as an adjunct to its activities/educational interventions (eg, reminders, patient feedback). 18. The provider identifies factors outside the provider’s control that impact on patient outcomes. 19. The provider implements educational strategies to remove, overcome, or address barriers to physician change. 20. The provider builds bridges with other stakeholders through collaboration and cooperation. 21. The provider participates within an institutional or system framework for quality improvement. 22. The provider is positioned to influence the scope and content of activities/educational interventions.

integration of essential elements of a 2004 document, Standards for Commercial Support [14]. The latter enumerated specific regulations restricting commercial influence from entities that might sponsor CME such as the pharmaceutical or medical equipment/supply industries. These regulations had been forged after considerable discussion at government, third-party payer, and medical organization forums about the potential for undue influence on physician prescribing and other practices. The regulations commenced with the charge to a CME provider to make decisions ‘‘free of the control of a commercial interest,’’ and then defined the types of conflicts of interest to be considered; how agreements with commercial supporters would be written; and what was acceptable for social events, meals, travel reimbursements, honoraria, and the like. Disclosures of potential conflicts of interest and of commercial support were mandated, and product promotion prohibited. Another section of substantial change involves measuring outcomes. The provision in question is ‘‘C 11,’’ which states, ‘‘The provider analyzes changes

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in learners (competence, performance or patient outcomes) achieved as a result of the overall program’s activities/educational interventions.’’ Although ‘‘closed-panel’’ entities such as the United States military hospitals, Veterans Administration hospitals, the Kaiser Foundation hospitals, and the like have complete records of medical staff practice outcomes and prescription patterns, the vast preponderance of organizations currently offering CME do not have access to those kinds of data. The prior practice of a postcourse test, and a course evaluation form, no longer suffices. For such reason, most medical organizations can achieve only certification cycles of no longer than 4 years from the ACCME. Many, such as the American Academy of Otolaryngology-Head and Neck Surgery, are experimenting with the most practical way to assess the physician-learner 6 or more months after a CME event, such as with a Web- or letter-based questionnaire. This is a work in progress, and it is a concern of the authors that the increased paperwork and the follow-up mandates being required by the ACCME will substantially diminish the number of organizations choosing to continue CME offeringsdlocal medical societies, hospitals, state specialty societies, and the like come to mind. This could make the 1957 goal of the Ad Hoc Advisory Committee on Postgraduate Medical Education (ie, CME available to physicians locally as well as nationally) difficult to maintain. Response to these new developmentsdtrends in continuing medical education An important educational concept driving contemporary CME is selfdirected learning. Malcolm S. Knowles, in his groundbreaking 1970 book, The Modern Practice of Adult Education [15], described the difference between androgogy and pedagogy: The technology of ‘‘pedagogy’’da term derived from the Greek stem paid(meaning ‘‘child’’) and agogos (meaning ‘‘leading’’). So ‘‘pedagogy’’ means, specifically, the art and science of teaching children. . To distinguish it from pedagogy, this new technology is being given a new name: ‘‘andragogy,’’ which is based on the Greek word aner (with the stem andr-), meaning ‘‘man.’’ Andragogy is, therefore, the art and science of helping adults learn.

Alan B. Knox, in a 1977 book, Adult Development and Learning [16], wrote: Many adults reach a point in their life when they conclude that they would like to become more self-directed in their priority setting and decision making. . Effective decision making is the result of many factors, including clear specification of the issue to be decided, accurate diagnosis of major facilitators and barriers in the situation, fit between personal values and those of others affected by the decision, the extent to which the decision maker is self-directed, and the effectiveness of the process used for priority setting and decision making.

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This explanation is an apt description of the physician as both a medical professional and a self-directed learner, and this framework of the physician as self-directed adult learner has been adopted by both the ACCME and the ABMS. Being a self-directed learner necessitates a frank needs assessment and then stepwise assembly of a deliberate learning plan. A valid learning plan for CME should contain all of the following elements: 1. Self-assessmentda process of assessing the current state of knowledge, competence, and performance of the individual physician. This is not only a ‘‘personal’’ evaluation, but also is validated by a comparison with external benchmarks through use of practice guidelines, performance measures, or other points of reference. 2. Didactic activitiesda gap between the individual physician’s knowledge, competence, and/or performance and the group norm. If such a gap is identified learning interventions can be employed to close and/or eliminate this gap. 3. Reflectiondan internal process that the physician engages in before she or he acts. This allows the physician-learner to analyze, synthesize, and form her or his judgment on the information gained during the learning phase. This period introduces the affective values of the physician into the learning process. Ethics, morality, and professionalism are included in the judgment decision. 4. Competencedthe ability to act. This component pulls together the original question, the results of the self-assessment, the learning interventions, and the reflective judgment. The physician sets the strategy that she or he will employ to answer the question in practice. 5. Performancedaction. Here is where the ‘‘rubber meets the road,’’ with the goals of a learning plan/improvement in the physician’s performance in practice and improved patient health outcomes. 6. Evaluationdat the outset, a question in practice was described. The question can serve as the goal of a learning plan. Was the goal attained? Did it answer the question in practice? ‘‘A pre-test is often given to determine the students’ entry knowledge or ability and special needs. During the course of instruction, increased knowledge and ability are monitored, continuously or periodically, to determine what changes in either learning procedures or goals should be made; this is called ‘formative evaluation.’ At the conclusion, the final accomplishment by the learners is assessed; this is called ‘summative evaluation’’’ [17].

Continuing medical education in otolaryngology In amount offered and in physician participation, the AAO–HNS is the foremost source of specialty-specific CME for otolaryngology. Unlike some surgical specialties, clinical practice of otolaryngology is equal parts

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surgical and medical care (ie, office based), and comprehensive presentation of CME must encompass both. Currently, and reflecting the mandates of the ACCME and the ACGME, within organized otolaryngology there are five avenues for CME. The first, and the traditional form of postgraduate education within the profession since the 1940s, is the ‘‘face-to-face’’ teaching at meetings such as the AAO–HNS Annual Meeting and the Combined Otolaryngological Spring Meetings; other examples include state and local society meetings. Face-to-face teaching is principally via lecture, where the learner is usually a ‘‘passive’’ participant. For the most part, the theme and topics are determined by a planning group without the opportunity of the individual physician learner to provide direct input, so the learner needs to examine the offerings and determine which fit her or his learning plan. Second is ‘‘self-study,’’ and examples include the AAO–HNS Home Study Course, Self-Instructional Packages, and Patient of the Month programs. Delivery can be either print or electronic, and self-assessment examinations are provided for the learner. The learner is therefore an active participant, selecting the materials to study based on her or his personal assessment of needs, and to be taken at the time and place of the learner’s choosing. Third is a ‘‘hands-on’’ approach to acquisition of a ‘‘skill’’ or ‘‘technique,’’ most suited to procedural issues for which conveying knowledge alone is insufficient. Hands-on activities usually involve the use of equipment, patients, and/or tissue specimens. Examples include the instruction courses on how to use software such as PowerPoint conducted in computer-equipped classrooms, or the proctored neck ultrasound courses on paid volunteers. They demand special settingsdnot always convenient to the learnerdand extra time is frequently involved to allow for conveying both the basic knowledge and the procedural skill. The delivery method is both lecture and demonstration, and the learner-to-teacher interface is open and active. Fourth is ‘‘electronically based education,’’ and audio and video teleconferencing, videotape, audiocassette, CD-ROM, DVD, and satellite (cable) television fall into this delivery method. Here again, the learner is mainly passive, but some technologies allow for interactivity with programmed questions/ answers or other tools, and the learner can frequently pick a convenient time/place to acquire the knowledge offered. Finally, ‘‘Internet-based learning’’ is the most recent avenue for CME activities, and many specialty societies have already initiated some Internet-based learning activities. Using a learning content management system, activities are developed that are accessed by the physician via a computer and Internet connection. This delivery method ranges from simply placing static text on a Web page, to animated, interactive courses and simulations that mimic the ‘‘real’’ world. Internetbased CME is available almost anytime and anyplace as long as the learner is able to connect, and is becoming the principle mechanism of outreach to physicians in third-world countries that have little access to the first four methods of CME acquisition outlined above. Further discussion of Internet-based learning applications can be found elsewhere in this issue.

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The AAO–HNS has begun integrating CME into some other areas as recently allowed by the ACCME. An example is credit for reviewers and editors of Otolaryngology–Head and Neck Surgery, who critically assess submitted manuscripts, and for test items writers of the Home Study Course and other educational materials. The ‘‘Best ENT’’ network under the research department at the AAO-HNS affords practitioners the opportunity to participate in surveys of their own practices, and from such to develop best practices and provide the basis for evidence-based medicine. Per the ACCME (2006), CME credit can now be earned for participation in such a self-evaluation and learning process, and the present authors expect it will be integrated by the AAO–HNS into the ‘‘Best ENT’’ process in the future. This development is timely because, in 2006, the federal Centers on Medicare and Medicaid Services introduced a Physician Quality Reporting Initiative [18] that ties reimbursement to physician compliance with some basic practice guidelines (eg, thromboembolism prophylaxis, perioperative antibiotics), and such could be part of future ‘‘Best ENT’’ initiatives, not only with reimbursement but CME as incentive. It is hoped that this short article has examined CME as part of the continuum of medical education. A review of the historic setting of postgraduate medical education as ‘‘brief periods to catch up with the times’’ [1] leads to a ‘‘well conceived, deliberate learning plan’’ that will position the physician as a lifelong learner ‘‘working for the best ear, nose, and throat care’’ (the AAO–HNS mission statement). CME will continue to evolve as the elements of adult learning theory are applied to CME, technology is incorporated into instruction, and outcomes measures are developed that maximize the practical benefits of continuing physician education.

Further readings Accreditation Council for Continuing Medical Education. Mission. Available at: http://www. accme.org/index.cfm/fa/about.home/About.cfm. Accessed August, 2007. Accreditation Council for Continuing Medical Education. Bylaws of ACCME. Available at: http://www.accme.org/index.cfm/fa/about.bylaws.cfm. Accessed August, 2007. Accreditation Council for Continuing Medical Education. ACCME’s essential areas, elements, and decision-making criteria. Accessed July, 2006. Accreditation Council for Continuing Medical Education. Ask ACCME updated accreditation criteria (general questions). Available at: http://www.accme.org/index.cfm/ fa/faq.detail/category_id/1296d289–7c5a-40f6-a841-b72264d9124e.cfm. Accessed August, 2007. Accreditation Council for Continuing Medical Education. Ask ACCME updated accreditation criteria (questions related to criteria). Available at: http://www.accme.org/index.cfm/fa/ faq.detail/category_id/f270fb8d–50ba-437e-926b-3dd408e2ffab.cfm. Accessed August, 2007. Accreditation Council for Continuing Medical Education. Ask ACCME updated accreditation criteria (questions related to implementation). Available at: http://www.accme.org/index. cfm/fa/faq.detail/category_id/ad75d238–28afc-4ffe-8af7-f736f78a08f6.cfm. Accessed August, 2007.

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