At a Board of Directors’ Workshop, participants assessed current and future efforts

There’s no denying that the continuing medical education (CME) programs sponsored by the American Academy of Orthopaedic Surgeons (AAOS) are among the best available in the United States. Not only do they earn high marks from members, they serve as the backbone of the Academy’s programs and are models for other organizations. Most members, in fact, when surveyed rank education as the primary function of the Academy.

But changing circumstances—ranging from the new Maintenance of Certification (MOC) requirements from the American Board of Orthopaedic Surgery to increasing opportunities from specialty societies, industry, and academia—are posing challenges to the Academy’s position as a leader in orthopaedic education. At a planning workshop held in conjunction with the December 2006 Board of Directors meeting, Academy members, staff, and invited guests examined current trends in CME in American medicine, evaluated our own CME program, and laid the groundwork for future changes.

It’s a jungle out there
In any given year, more than 300 orthopaedic education programs are available to Academy members. Some are free programs sponsored by industry to instruct physicians in the use of a particular device. Others are offered by orthopaedic specialty societies, universities, and private institutions and individuals. And the proliferating surgical skills laboratories present competitive courses to the Academy’s offerings in the Orthopaedic Learning Center, a joint venture with the Arthroscopy Association of North America (AANA).

“We are competing against ourselves,” said Board of Councilors Chair Matthew Shapiro, MD. “The conveners and faculty for many of these programs are Academy members. The bottom line is that the Academy faces formidable competition in CME from a number of sources.”

Where are we now?
According to Edward Akelman, MD, chair of the CME Courses Committee, the Academy is facing the following significant challenges:

• Increased competition, particularly from free and low-cost industry-sponsored courses
• Increased demand for shorter courses at regional locations, to reduce the time spent away from the office
• Developing courses that meet the participants’ needs as well as their “wants”

In response to these challenges, the Academy has introduced several innovative programs. “We recently began using pre- and post-testing,” said Dr. Akelman. “This helps members identify the knowledge gained and helps faculty understand the impact of their efforts. The Audience Response System is being used with increasing frequency to make programs more interactive. A new feature in surgical skills education is the use of performance checklists, which let members self-rate their skill on the individual portions of a procedure both before and after a lab session.” He noted the work of one of his committee members, Matt Putnam, MD, in fashioning a performance checklist that breaks a procedure down into its component parts, so each can be studied, performed, and mastered. The checklist includes knowledge required and failure points, creating a teaching and learning tool.

Annual Meeting Committee Chair Colin Moseley, MD, noted that the meeting is the Academy’s “crown jewel.” For that reason, the committee considers the impact on both the meeting’s educational reputation and its finances when evaluating potential changes to format or coverage. Current efforts are focused on finding ways to make the meeting more relevant to a larger portion of the membership and to enable learners to get more value for the time they spend at the meeting. He said the Academy meeting must appeal to the specialist and generalist alike and that his committee constantly tweaks the meeting to make this happen.

J. Lawrence Marsh, MD, incoming chair of the Evaluation Committee, noted that members frequently use the Academy’s self-assessment programs as educational tools, but that “just 40 percent of those who purchase special-interest examinations actually seek CME credit for them.” The new MOC requirements and the increasing need to incorporate evidence-based medicine into the examination process present challenges and opportunities in this area. MOC requires “scored and recorded” self-assessment activities as part of one’s evidence of a commitment to lifelong learning.

The number and type of CME activities by the AAOS has grown and changed during the past four years.

Other trends
Over the past two years, the Academy’s efforts to strengthen ties with specialty societies have created positive results—particularly in the area of CME. The AAOS jointly sponsors more than 30 courses and annual meetings with specialty societies and state orthopaedic societies and has engaged in cooperative program planning with AANA, the American Orthopaedic Society for Sports Medicine, and other societies.

In addition, increasing support from industry has been a key factor in the Academy’s ability to conduct surgical skills courses, in terms of educational grants that help keep registration fees manageable and in terms of equipment and supplies that are used in hands-on skills training.

“There is no easy solution to a situation in which a company provides substantial financial and equipment support to the Academy while simultaneously competing in the education arena,” noted AAOS President James H. Beaty, MD. “The primary concern is maintaining the Academy’s credibility for providing fair and balanced education. We need to maintain relationships with industry that are ethical, appropriate, and necessary.” He also noted that the Academy needs to help its members with the new requirements of pay-for-performance and assessing their practice performance.

Where are we going?
Interactive education, just-in-time learning, and increased opportunities for self-directed learning are among the future trends in CME, according to Patrick Alguire, MD, director of the American College of Physicians department of education and career development. External influences, such as MOC and pay-for-performance, will promote increased use of demonstrably effective CME and the availability of benchmarks and guidelines.

The American College of Surgeons (ACS) is evolving its educational efforts from CME to continuing professional development, reported Ajit Sachdeva, MD, director of the ACS division of education. To change the paradigm from apprenticeship training to proficiency-based training, innovative modules using simulators (such as the virtual reality simulator for knee arthroscopy the Academy is working on) are needed to acquire skills in new procedures and using new technology.

New accreditation requirements for CME providers, such as the AAOS, emphasize documenting outcomes of educational activities, paralleling the increased emphasis on evidence-based medicine, reported Mark W. Wieting, the Academy’s chief education officer. “Learning and change will be the goals for both the learners and the providers like AAOS,” he said. “The new accreditation criteria for CME providers are the impetus for the AAOS to invest time and attention on new methods of teaching, learning, and evaluating programs.”

Council on Education Chair Alan M. Levine, MD, pointed to the increased funding needed to meet the demands of the “new CME.” It’s no longer sufficient, he said, to mount a CME course based on what the faculty and course director feel are the right topics to teach. The new CME will be based on more stringent and creative modes of self-assessment to identify learning needs at the individual learner level, and the outcomes of the courses will need to be measured, analyzed, and communicated. He said the council has been working for more than a year on new modes of needs assessment, program and product evaluation, and creative teaching methods, all with an eye toward staying ahead of the curve.

Breaking out the issues
In three separate break-out discussion groups, participants addressed the impact of MOC on the Academy’s CME program, the growth of practice-based learning, and the need for education on new technology. Although the Academy is currently tailoring its examination programs to meet MOC requirements, participants recommended providing smaller, shorter courses on a regional basis. In addition, practice audit tools to help physicians measure their practice performance should be included in various CME offerings. Finally, although the Academy should not be involved in deciding who is competent to use new technology, participants thought that the Academy should set minimum educational standards for using new technologies.

“We have set the bar high,” said Dr. Beaty, “but that is the challenge we face in the competitive marketplace. We will have to reshape current working relationships with specialty societies, the American Board of Orthopaedic Surgery, and industry to address MOC and accreditation criteria.”

What do you think?

Here are some of the workshop participants’ audience responses from the workshop. Do you agree or disagree with these statements? Weigh in with your answers and comments...send them to aaoscomm@aaos.org

63% do not think that the industry presence at the Annual Meeting is excessive

90% think that industry participation (donations of equipment and provision of representatives for information) is appropriate for OLC courses

74% believe that the Academy isn’t doing enough with the specialty societies regarding education

95% think it would be totally unacceptable for the Academy to stop providing CME courses

91% think it would be acceptable for the Academy to decrease course fees and subsidize the CME program to compete with industry

Workshop recommendations
The following recommendations are among those developed by workshop participants:

The Academy should develop new CME program evaluation tools consistent with the new ACCME accreditation requirements.

The Academy should develop a set of tools members can use to audit their practice as part of a practice-based learning and improvement program; this analysis sets the baseline for the physician to create a learning program on an individualized and focused basis.

The Academy should establish a practice-based learning and improvement program that provides CME credits for participation and create an audit and feedback mechanism as part of this program.

The Council on Education should work with the Council on Research, Quality Assessment and Technology to develop methods to implement technology assessment evidence into Academy CME programs.