CME: GOOD INTENTIONS GONE AWRY

Steven Reidbord, MD

American physicians attend continuing medical education (CME) courses throughout their careers. Continuing education is a hallmark of medical practice, and state licensing boards require it in order to maintain an active medical license.

However, CME is not without controversy. In addition to concerns about commercial bias 1 and what constitutes “evidencebased” teaching2, social issues and current events also influence the content of CME. State legislatures, and the medical profession itself, tailor CME to embrace topical concerns, either optionally or as educational requirements. Thus, some state licensing boards require CME hours on the opioid crisis, on end of life issues, on domestic violence, and so forth.3

Eighteen years ago, the California legislature sought to tailor CME to address social ills within medicine itself. But instead of mandating education on these topics specifically, as many states do with end of life issues or domestic violence, California required that nearly all CME, on every topic, include this teaching.

Assembly Bill 1195 (Coto, 2005) established that all CME offered by California providers “shall contain curriculum that includes cultural and linguistic competency in the practice of medicine.” The only exclusion: a CME course “dedicated solely to research or other issues that does not include a direct patient care component.”4

Enhancing cultural and linguistic competency (CLC) in physicians addresses clear needs. There is ample evidence that disregard and/or ignorance of cultural factors worsens medical care5,6. Language barriers are an obvious impediment as well. Unfortunately, AB 1195 falls short in practice.

Many CME topics that “include a direct patient care component” lack CLC content to teach. E.g., most procedure-focused education in surgery, interventional radiology, and anesthesiology; advanced cardiac life support and other emergency procedures; and management of comatose patients. Presenters of these topics can artificially add CLC — say, by briefly discussing the demographics of stroke incidence in a presentation that is actually on the use of systemic thrombolytic drugs in stroke. But this begs the question of why CLC must be included in every CME.

As chair of the CME committee at California Pacific Medical Center in San Francisco for the past 14 years, I witnessed how the legislature’s good intentions collide with practicality. Our committee struggled from the start to include CLC where there was no obvious role for it.

We turned to the state accreditor, the California Medical Association, for guidance. CMA assured us that the requirement — the law — to include CLC was not absolute; we should “do our best.” This confirmed for us that it’s not realistic to include CLC in all CME with a direct patient care component. CMA’s 2023 report7 bears this out: over half of the CME providers accredited by CMA admit to not including CLC in all clinical CME. I suspect the honest answer is higher. Efforts to abide by AB 1195’s unrealistic mandate spark a number of problems in practice.

1. Non-expert presenters

CME planners choose speakers for their expertise in specific medical or surgical domains. Very few are also experts in cultural or linguistic issues. Thus, non-experts convey nearly all CLC material that physician audiences hear or see. Even with the best of intentions, such presenters may be unaware of important CLC teaching points. They may over- or under-emphasize the importance of cultural issues, or provide only superficial attention to cultural and linguistic challenges that deserve a deeper look. Most are simply not well equipped to teach CLC.

2. Unmotivated presenters

The best CME presenters exude enthusiasm for their topics. They speak in a lively manner, and offer clinical “pearls” that add interest to the presentation. In contrast, many CME speakers look and sound coerced when reciting CLC material. Some make little effort to hide their feelings about what they view as an unwanted digression.

3. Tokenism

In order to include CLC material, speakers often resort to a quick review of the ethnicity, age, and/or gender of the patient population under discussion. Sometimes they mention increased disease incidence in a particular group. These token efforts surely fall short of what AB 1195’s authors had in mind. But since they (barely) fulfill the law’s mandate, they have become the norm.

4. Unwanted by audience

Since the physicians in the audience sought education on non-CLC topics when they chose to attend, they may experience its inclusion as intrusive. Consider how expectations would differ for CME devoted specifically to CLC, even if mandated. The audience would arrive expecting this education. It would not be a distraction or digression.

More recently, California added a requirement to include teaching about implicit bias in medicine as well. Assembly Bill 241 (Kamlager-Dove, 2019) established that all CME courses “shall contain curriculum that includes the understanding of implicit bias.”8

AB 241’s language parallels AB 1195, and shares AB 1195’s limited exclusion criteria.

Like AB 1195, the newer law is well-intentioned and aims to address a real problem. But it falls prey to all the same drawbacks. It is hard to identify, and thus teach, implicit bias (IB) material that relates to much procedure-focused and technical CME, even that which concerns direct patient care. The same problems of non-expert, unmotivated presenters resorting to token facts arise here as well.

Is there a better way? Several other states think so. They condition licensure or license renewal on CME dedicated specifically to CLC or IB. Connecticut requires one hour of CME on cultural competency every six years. Maryland requires one hour on implicit bias. Michigan requires two. New Jersey requires six CME hours on cultural competency. Washington DC requires two hours on LGBTQ cultural competency.3

Presented by knowledgeable, motivated experts, dedicated CME on these topics can teach what’s really important about CLC and IB — not begrudgingly recite a few token facts in a talk about something else. Dedicated presenters can convey enthusiasm to the audience, offer clinical pearls, and make the material interesting and memorable.

Teaching medical audiences about implicit bias, and about cultural and linguistic issues related to medical practice, is both possible and well worth the effort. What fails in practice is California’s attempt to infuse all CME with this material. Replacing these unrealistic requirements with workable ones would enhance the teaching of cultural competency and implicit bias, make it feasible to obey state law, and improve CME throughout California.

References

1. Steinman MA, & Baron RB. Is continuing medical education a drug-promotion tool?: YES. Canadian Family Physician Medecin De Famille Canadien, 2007;53(10):1650–1657.

2. Davis NL, Lawrence SL, Morzinski JA, & Radjenovich ME. Improving the value of CME: Impact of an evidence-based CME credit designation on faculty and learners. Family Medicine, 2009;41(10):735–740.

3. Federation of State Medical Boards. Continuing Medical Education Requirements. https://www.fsmb.org/siteassets/advocacy/regulatory/licensure/continuing-medicaleducation-requirements.pdf. Accessed February 4, 2023.

4. AB-1195 Continuing education: Cultural and linguistic competency., 2005. https://leginfo.legislature.ca.gov/faces/ billNavClient.xhtml?bill_id=200520060AB1195

5. Saha S, Korthuis PT, Cohn JA, Sharp VL, Moore RD, Beach MC. Primary care provider cultural competence and racial disparities in HIV care and outcomes. J Gen Intern Med, 2013;28(5):622-629.

6. McQuaid EL, Landier W. Cultural Issues in Medication Adherence: Disparities and Directions. J Gen Intern Med, 2018;33(2):200-206.

7. California Medical Association. Annual Report: Cultural Linguistic Competency and Implicit Bias Standards. https:// www.cmadocs.org/Portals/CMA/files/cme/clc/CLC.IB%20 Annual%20Report%202023%20(050923).pdf Accessed May 18, 2023.

8. AB-241 Implicit bias: Continuing education: Requirements., § 2190.1., 2019. https://leginfo.legislature.ca.gov/faces/ billTextClient.xhtml?bill_id=201920200AB241