Continuous Professional Development/Continuing Medical Education Credit for 6IMCA in 11 easy steps
100% is easy, 99% is a bitch!
100% հեշտ է։ 99% շատ թժվար է։
AAMS (Լոս Անջելես) պետք է ցոյց տալ ոռ պատշաճ պլանավորում պատահել է։
The standards for offering CME credit are similar between United States, Europe and Armenia.
There is a process, a proper order of tasks that should be clearly stated.
Ultimately, the AAMS, or whoever offers the CME credit must document that they followed the steps below. It does not need to be fancy but it does need to be done.
In the United States, there has been a set of criteria, that are pretty easy to follow. My recommendation to you is to start at the beginning and work from there.
A very common trap is to find an interesting speaker and then work backwards, trying to argue why this person's lecture is worth our time.
Below, we describe 11 "steps" or criteria which ACCME requires for CME planning.
It is very instructive to work through these 11 steps. Otherwise you are stuck with the 3-step method:
- find an interesting speaker
- work with the CME planning committee to document that it was an important lecture
- close your eyes and hope that something changes in Armenia as a result.
Enough about that. Let's move on:
Step 1: your mission statement. Մեծ նպատակ
What is the purpose of this Congress? Is it to train physicians in basic medicine? To train physicians in specialty medicine? Train physicians in up & coming fields?
Perhaps, but it is probably not the main purpose.
There are several possible choices for your purpose:
⦁ improve collaboration between Diaspora and Armenia
⦁ contribute to social interaction, so that we meet potential partners with whom to work
⦁ initiate solutions to Armenia's most pressing problems (my favorite)
Perhaps it is a combination of these.
Step 2: The Professional Practice Gap
Ի՞նչ է բագաս։ Ի՞նչ է խնդիրը։ Ի՞նչ կ՛ւոզէնք լավեցնել։
Երբ մտածւոմ էք այս մասին, ինչ կրթւոթյւոն կարիք ւոնեն մեր բժիշկները։
The professional practice gap (PPG) is the difference between where we are now and where we want to be.
But more than simply stating the PPG, discuss the educational needs underlying the gap. What do we need to learn in order to close the gap?
It is very important to spell this clearly, and if possible, supported with facts and figures. I can think of many PPG's for Armenian healthcare. (but the important question is, what PPGs do you think are important?)
One easy trick is to survey your audience, colleagues, or others about what they believe to be the important problems in Armenia. The Ministry of Health is a valuable resource, since they have data of disease incidence, prevalence and trends. An informal survey will likely list the general structure of Armenia's medical system, smoking, rehab of war veterans, as important issues. And you may find some other valuable suggestions.
Here are some possibilities, with discussion of the underlying education needed to close the practice gap:
⦁ Wars. Certainly the wars with Azerbaijan and Turkey. But also the war in Ukraine. These require political solutions, rethinking of our defense system, civil training which may include defense and first-aid, geographic descriptions such as borders where Armenian and Azerbaijani villages alternate with each other on hilltops. It would probably help to review types of injuries encountered in the war, from cluster bombs and phosphorus. There are efforts to deliver first-aid packets to the borders. What do these contain? How should they be used? What about the Metsamor nuclear plant? Do physicians know how to respond if it is hit by a missile? What about hospitals? Can they be made safer, and resistant to attacks?
⦁ Pollution. The air is fouled with automobile and cigarette smoke. What kind of lung diseases are we encountering? How many hospitalizations? How are these handled the primary care level? It is very common to walk through nature admiring the green hills and streams, until we see a pile of trash draining into the stream. What kind of toxins are we releasing into our environment? What is happening to the used batteries, and why are we not recycling them? What other noncommunicable diseases are related to pollution?
⦁ COVID 19. Two years into a pandemic, why is it so difficult for smart people to wear masks properly? What difficulties has Armenia faced with vaccination? Where is our sense of collective thinking when it comes to preventing disease transmission on a crowded bus? What has been the pattern of Covid 19 resurgence in Armenia? How much can we let down our guard between waves? What is the status of the oxygen generating plant which was recently renovated?
⦁ Clinical skills and primary care. Diseases like diabetes and hypertension, commonplace in primary care practices around the world, are referred to specialists here in Armenia.
⦁ What are the government priorities and programs regarding healthcare in Armenia? Can we present an overview to the audience so we are all thinking along the same lines? What is the best way to share ideas? Has the Ministry of Health worked with other agencies such as FAST, the UN, others?
⦁ New techniques or new technology present themselves as an easy professional practice gap. PET/CT in Armenia would be an easy example, since it did not exist a few years ago and physicians are not trained in its use. Another example would be the concept of intrinsic bias, which has been recently recognized as a potential obstacle to healthcare equity.
⦁ The general area of collaboration has a few PPG's. AMIC's purpose is for diaspora groups to work together, but we don't really do that very well. Collaboration between Armenia and the Diaspora has been limited by cultural barriers, language barriers, differences in time zones, and others that we could name. What is the best way for us to communicate with each other? What is the best way to facilitate communication during crises such as war or Covid? How do we deal with Customs office in Armenia, which has been perceived as a bottleneck obstructing outside aid?
⦁ Noncommunicable diseases. Armenia has gotten rid of smoking in public places. What comes next? What is the scope of lung disease? Do we need to consider screening for lung cancer? What about diabetes? What is its prevalence? How is it being diagnosed and treated? What is availability of insulin? Again, what can we teach other specialties besides the endocrinologists? What do the doctors already know about diabetes treatment? How much hypertension is there, and why is khorovatz so salty? ;-)
These are just suggestions, and there is no requirement about choosing these or other PPG's to address. The only requirement is that we give proper consideration to our practice gaps and state clearly what we want to improve.
Step 3: creating learning objectives
there are four basic levels of learning in the CME vocabulary:
⦁ knowledge-awareness or understanding
⦁ competence-ability to do something
⦁ performance-actual measured changes in how physicians are practicing
⦁ patient outcomes-actual measured changes in how patients are faring
To grant CME credit, we must address competence, performance or outcomes. An easy way to think about it is to form this sentence: At the end of this educational activity, physicians will be able to ...
This will address changes in competence, which is skills that the physician is now able to so after the learning experience
Changes in performance (what the physicians actually are doing better) or patient outcomes are usually collected behind the scenes, probably with Ministry of Health or with hospitals and clinics. That is more work and takes more planning, but gives you better success.
A common mistake is to create learning activities that simply address knowledge. An example might be teaching the harmful sequelae of hypertension, without teaching our doctors how to measure blood pressure or prescribe medications.
Measuring competence is very easy. When we rate what we are able to do differently on an evaluation form or online survey, we are self-rating our changes in competence. It gives us some quick feedback on how the conference went. However it has limited utility in terms of changing our healthcare system. An example of teaching competence might be teaching physicians to measure blood pressure or choose proper treatments.
Measuring performance is a little more difficult. With computerized order entry systems, we can measure how physicians are ordering tests or medications, before and after an educational activity. This is very commonly done by hospital systems which rely on electronic medical records. An example might be measuring how many times physicians measured blood pressure at an office visit or other patient encounter.
Measuring patient outcomes is even more difficult, it is typically more labor-intensive than simply collecting evaluation forms. But improved blood pressures in our patient population, or improved blood sugars, would be extremely useful data to collect, with a reasonable amount of effort.
Step 4 is to choose our target audience. Step 4 has been eliminated from CME in the United States, but it is still useful to consider our audience when creating learning activities. One concern is that CME is designed for physicians. The M stands for Medical. Nurses and other non-physicians can often use CME credits for their own licensing etc, but it's more complicated than this. As a physician, I don't always know what practice gaps or learning objectives apply to nurses, pharmacists, physical therapists or dentists. They have a different role in healthcare than my physician target audience.
Step 5 is to choose the proper venue for teaching. Lecturing (I talk, you listen) is one of the most common means of teaching, but it has limited success in changing how physicians practice. In the example of hypertension, the best way to teach blood pressure measurement is to actually have the physicians measuring blood pressure. The best way to teach blood pressure treatment might be a programmed exercise rather than a simple lecture.
An important lesson is to recognize that step 5 should be addressed after steps 1, 2 and 3 have been thoroughly considered. A major mistake is to start with "bringing in a speaker".
Step 6 is to identify the physician qualities we are trying to develop. Most of our presentations have to do with patient care, and that is fine. But there are other physician qualities that are very important, such as professionalism, use of informatics, communication, and others.
Steps 7, 8, 9 and 10 have to do with independence from commercial influence. Briefly, we want to identify and resolve any potential conflict of interest, and we want to make sure that the conference will educate doctors about things that are important to us and not simply indoctrinate them to use particular medical products.
Step 11 involves the evaluation of our conference. Did we make the changes that we were hoping? Most of the time we evaluate this with evaluation forms or online surveys. An old term for the evaluation forms is "smile sheets" as the audience tends to tell us what a great job we did. It would be more useful to actually see changes in physician performance or patient outcomes. We should spend a lot of time discussing this.
During the AMIC meeting you mentioned a few areas of focus:
- Cancer
- Non-communicable Diseases
- Military and emergency medicine
- Innovation
- Vaccination
These are large areas, but it is a very good start. As we develop learning objectives in each of these areas, we should focus on developing physician skills. What do you want the physicians to do differently, or at least have the ability to do differently? These are discussions that you can share with your planning committees.
For example, with cancer, let's focus on breast cancer:
- What are the breast cancer incidence and death rates, and how do they compare to western countries
- What is the state of breast screening and where do we need to improve
- What strategies can we develop to improve screening (advertisements on TV, training nurses, better government funding)
- and you can think of others.
for lung cancer:
- What are the incidence and death rates, how much of it is in nonsmokers, how does it compare to the west?
- How well are anti smoking campaigns working?
- How will low dose CT screening work in a country like Armenia?
- What are smoking patterns in Armenian diasporan communities?
- What does the average Armenian know about COPD or lung cancer?
- and you can think of others.
You see how this approach is very different from the "bring in a speaker" strategy. When we ask these questions, we can guide the speaker to offer more useful information in a shorter lecture. Or we may decide that there are better ways than a lecture to teach the information.