Continuing Education for Physicians Needs More Flexibility, More Relevance, and Fewer Headaches

Summary

To keep pace as medical knowledge advances, physicians have an opportunity—and an obligation—to rethink continuing education. We need our learning to be more continuous, more experiential, and more collaborative.

Medical knowledge is advancing fast. Consider the recent “domino” surgery in which one 11-year-old received a complete heart transplant, followed by two healthy valves of hers being donated to two other children. All three girls experienced successful outcomes, and the first-ever living mitral valve replacement surgery was a success. If we value evidence-based medicine, we’ll need nearly continuous education to keep up with the rapid pace of change.

Preventing Early Retirements Due to Maintenance of Certification in a Time of Physician Shortage

Just as physicians’ need for continuing medical education (CME) is increasing, so is their frustration with our current system for maintenance of certification (MOC). Many physicians have grown so exasperated with this process—which makes burdensome demands on time and finances and often forces physicians to study matters not relevant to their practice—that they have retired early, or at least earlier than they otherwise would have, in order to wash their hands of MOC forever. The evidence from a variety of specialties suggests that more will do the same.

This process of MOC-xit, as we might call it, will exacerbate physician shortages, affecting both patients and the medical profession. Where do we go from here?

Preserving Educational Relevance

Danielle Ofri, MD, PhD, begins her New York Times op-ed, “Board Recertification: A Waste of Time?” by measuring the height of the book stack on her nightstand. Since I also recently completed what she calls “the decennial rite of cramming a thousand pages of facts for an eight-hour-long multiple-choice test”—in my case, for the 10-year MOC American Board of Internal Medicine cardiology exam—I have some thoughts. Our shared goal as physicians is to practice as competent, well-meaning medical professionals who continue to learn. How well is our current MOC system serving this goal?

To prepare for my 10-year recertification exam, I was memorizing minutiae for subdomains of cardiology that do not relate to my practice. Even information directly applicable to my day-to-day work was losing relevance while I studied it or had lost relevance before I started studying due to the time gap between test preparation and test administration.

Sadly, my pile of medical journal subscriptions went untouched, because I was studying for a test prepared two years prior, so reading the latest research would have caused me to miss answers. We ask the public to trust that board certification indicates a higher standard of competence, yet to pass my exam, I had to temporarily suspend one of my usual methods of maintaining competence. There must be a better way.

Evolving Toward More Timely Testing

The longitudinal knowledge assessment (LKA), launched in 2022, has transformed MOC to quarterly questions on a 5-year cycle. The LKA has been popular with physicians weary of the 10-year exam’s expense, hassle, and time away from practice and family.

The LKA has brought greater flexibility and timeliness to recertification, and it’s a move in the right direction, but it does not go far enough to make our continuing education serve our continuing competence. “The system we have today was designed for a different era, and it is showing its age,” says Harlan M. Krumholz, MD, SM, Editor-in-Chief of the Journal of the American College of Cardiology (JACC).

In cardiology, we have devices, therapies, and protocols today that we did not have a couple of years ago. Changes include new post-stent protocols for antiplatelet therapy, new best practices for beta-blockers, and new research into how to use—or not use—oxygen for heart-attack patients.

No doubt physicians in other specialties can easily call up their own laundry list of changes that are turning over faster than the LKA testing cycle.

Differentiating Core Knowledge From Collaborative Practice

Dr. Krumholz of JACC affirms that “to be called a cardiologist, there should be a general core that we all agree people should know off the top of their heads.” Each specialty retains its own core of knowledge, and such information is readily testable. That said, Dr. Krumholz also describes “a fundamental misalignment between what we test and what truly matters for patient care.” Many physicians have observed how MOC testing misses communicating well with patients, combining information from multiple sources, considering risks and benefits, collaborating with colleagues, and so on.

We need to pivot in our approach to testing. We need a combination of closed-book testing for core knowledge, open-book testing for critical thinking and synthesis, simulation training for procedural skills, peer collaborations for communication skills, and mentorship, which helps us pass on existing knowledge while pushing us to keep our eye on new findings.

CME is the path by which we maintain ourselves as competent physicians who practice safe medicine because we’re up to date, but what are the steps along that path? They include:

1. Formal CME: We need a reasonable amount of formal CME, the amount of which should vary by specialty and type of practice. For instance, the National Board of Physicians and Surgeons (NBPAS), run mostly by physician volunteers, which has built an alternate path to ongoing board certification, validates that participating physicians complete CME that is both high quality and relevant to their specialty. (Small but scrappy, the NBPAS is accepted so far by more than 250 hospitals.)
2. Simulation and procedural skills updates: We should be working on scenarios with mannequins, with animals, and/or with simulation facilitators standing next to us. Personally, I have gotten the most out of simulations in which a facilitator, narrating play-by-play the immediate outcomes of each intervention, put me under pressure—followed by providing feedback.
3. Peer discussions and case reviews: We should participate in peer discussions and case reviews. We should attend morbidity and mortality conferences.
4. Teaching and mentorship: We can teach and mentor individual students, residents, and fellows. Mentoring will necessarily keep us up to date on our journal reading.
5. Peer-reviewed journals and quality medical media: We can stay abreast of top journals, top publications in our specialties, and the newsletters of our medical professional societies—and we should embrace podcasts. The American Medical Association (AMA) curates recommended podcast lists.
6. Self-assessment, reflection, and feedback from our peers: The value of feedback is recognized in medical education, so CME should include it. Where peer feedback programs don’t exist, clinicians can start them.
7. Digital media: We can avail ourselves of up-to-date, clinically relevant media materials that can help us. The AMA covers recommended apps; professional organizations may also offer direction.

We all have an obligation to continually update our skills and knowledge base. This serves the safety of our patients and improves our professional satisfaction. The origins of the present system are not a mystery: Physicians invented it. And we can revise it to better serve us—and our patients.

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