SPECIAL EDITION
CME

By Deborah R. Dakins

It takes more than the ability to acquire and interpret images to be a competent radiologist. Until recently, however, those skills were the only ones that counted when it came to certification.

Historically, a radiologist could pass the American Board of Radiology exams, spend the requisite hours in continuing medical education courses each year, and practice for the span of a career without ever being asked to show further evidence of competence or skill. A major overhaul in the U.S. medical system is shaking up the status quo, however, by requiring physicians in every specialty to demonstrate skills that had been taken for granted in the past.

It's not as though radiologists have ever been able to let skills become outdated: Hospitals and patients expect them to stay ahead of imaging's ever-changing learning curve. State licensing boards, specialty societies, and even some health plans demand documentation of formal CME activities. Colleagues both inside and outside the radiology department expect a level of expertise attained only through continuous learning put into practice.

This year, the ABR for the first time will issue 10-year time-limited certificates to candidates who pass the board exam. It's the first step in a major effort to have radiologists demonstrate that their skills remain up-to-date over time. Even that change, however, may be superseded by a broader movement within medicine that emphasizes professional growth, curiosity, and communication.

When it comes to time-limited certification, radiology is solidly at the back of the pack. The American Board of Family Practice was the first specialty board to institute time-limited certificates in 1970, followed by the boards for surgery and thoracic surgery. Over the next 20 years, nearly all the remaining medical boards developed recertification mandates. As of 1998, the last holdouts included medical genetics, plastic surgery, otolaryngology, and diagnostic radiology (see chart).

That changes this year. In 2002, for the first time, diagnostic radiologists who become board-certified will receive 10-year time-limited certificates. They will join their colleagues in radiation oncology, which has had time-limited certification in place since 1995.

Radiology subspecialists in pediatrics, nuclear medicine, neuroradiology, and vascular and intervention who are awarded certificates of added qualifications (CAQs) in those fields are also on the 10-year plan, with the first round of CAQs expiring in 2003 and 2004.

The ABR has developed recertification exams in the above subspecialties and has begun working on the diagnostic radiology recertification as well, in case some radiologists wish to retake the exam before it is mandated in 2012.

PERPETUAL COMPETENCE

Just when radiology is beginning to catch up with other specialties, the rules of the game could change again. The American Board of Medical Specialties has decided to develop a "maintenance of certification" (MOC) to replace time-limited recertification. Instead of traditional test-taking to demonstrate competence, MOC relies on continuous certification, based on a range of activities that go far beyond a traditional test of clinical knowledge.

MOC has gained favor over recertification in part because of public and government perception about medical performance, based on key studies published in the past two years by the Institute of Medicine. The reports, "To Err is Human," released in 2000, and "Crossing the Quality Chasm," released in 2001, triggered a renewed interest in healthcare quality and prompted the ABMS to explore ways to make recertification more comprehensive.

MOC comprises four components intended to represent, collectively, the areas of professional life that physicians need to sustain and improve:

• maintenance of professional standing (professionalism);
• demonstration of lifelong learning and self-assessment;
• demonstration of cognitive knowledge (testing); and
• evaluation of practice performance.

So far, no one has figured out exactly what MOC will mean for the average radiologist, or for any physician, or when it might take effect. The ABMS plans to work with individual member specialty boards to craft standards and methods for assessment.

In radiology, the job falls to the ABR and its seven supporting societies: the RSNA, the American College of Radiology, the American Roentgen Ray Society, the Association of University Radiologists, the American Radium Society, the American Society for Therapeutic Radiology and Oncology, and the American Association for Physicists in Medicine.

Some of the measures will likely be easier to meet than others. Professional standing might be demonstrated by appropriate licensure, peer review, and evaluation of any malpractice claims. Lifelong learning could include CME and self-assessment exams linked to certification requirements. Evidence of cognitive expertise could come from a recertifying exam. And evidence of practice performance-perhaps the trickiest to measure-could be based on a demonstration of continuous improvement in practice, using feedback from peer reviews, and the employment of nationally accepted care standards.

To date, the group of seven organizations and the ABR have approved guidelines regarding demonstration of lifelong learning, self-assessment, and cognitive knowledge devised by the ABMS. They also approved general principles for evaluating practice performance but are still working on development of standards for maintaining professional standing.

Implementing MOC could take years. It's important that MOC standards be specialty specific, measurable, relevant to practice, focused on patients and continuous improvement, and above all, achievable, said Dr. M. Paul Capp, director of the ABR, following a MOC gathering earlier this year.

One way to achieve specificity might be to place a high premium on doctor/patient communication for interventional radiologists, for example. The Society of Interventional Radiology could develop appropriate measures for its members such as patient surveys, peer reviews, or direct observation.

Alternatively, a mammographer who recognizes the need for training in digital mammography might demonstrate to the ABR that she has undertaken such a program. This kind of directed self-learning would count toward MOC.

CME PREPARES FOR CHANGE

Technically, board certification is voluntary, but it is expected by so many hospitals, medical groups, and health plans that 85% of the nation's physicians are board-certified.

Thus, any change in the system by which physician knowledge, education, and performance are evaluated will likely have sweeping consequences for the specialty societies charged with providing continuing education for members, and on commercial CME providers.

Thanks to a 2000 revision made by the American Medical Association, CME now includes a wider range of activities that includes preparing course materials, evaluating peer-reviewed articles, teaching classes, and lecturing. Such self directed physician activities are likely to find their way into the MOC as well.

CME providers will not be required to change their offerings to suit the MOC standards, according to the Accreditation Council for Continuing Medical Education, which evaluates CME providers. Nor will the need for traditional seat time disappear once MOC is adopted. The new standards, however, will place more emphasis on subjective measures such as practice improvement. These changes represent new opportunity for CME providers, according to ACCME chief executive Dr. Murray Kopelow, but they will be a major shift for many others.

Some groups aren't waiting. The RSNA is already planning ways to redesign its CME offerings to assist radiologists in meeting both recertification and MOC requirements.

"While we're unsure of what the guidelines will dictate, I do expect that CME will become more popular in terms of preparing for maintenance of certification," said Dr. William Olmsted, RSNA education editor and editor of the continuing education journal RadioGraphics. "As a result, we will be gearing our education materials toward MOC. That means making a broader spectrum of educational materials available, and creating a way to make those materials searchable, especially in terms of the subspecialty areas."

Those searchable databases will allow visitors to the RSNA's education portal (www.rsna.org) to categorize their learning by subspecialty area as they prepare for the cognitive aspects of MOC evaluation.

The organization already provides a robust menu of traditional educational offerings anchored by its annual meeting and filled with refresher courses, cases of the day, plenary discussions, and popular image interpretation sessions (see related article). Olmsted is increasingly focusing the organization's CME energies on Internet projects such as the portal's InteractED. All in all, the RSNA offers 186 peer reviewed programs with interactive tests for category 1 CME credit online, and that number will soon expand to 350.

Since the inauguration of the site in August 2000, more than 6000 radiologists have registered for interactive educational programs, and the society has awarded more than 52,000 hours of category 1 credit.

The peer-reviewed courses have a life span of about three years, Olmsted said, at which time they are evaluated and updated or removed from the syllabus. The portal recently debuted the "residents' lounge," tailored for radiologists in training. That offering will be joined in the near future by a virtual journal club, featuring online articles in key subject areas with the authors available at set times for interactive discussions with readers.

INTERACTIVE EMPHASIS

The shift to interactive learning accompanies growing recognition that participatory activities are more effective than passive actions in helping physicians retain information.

"The more people have to participate and interact in the learning process, the more they retain the material and apply it to their practices," Olmsted said. "While there is still a place for lecture based learning and conferences, interactive learning is a better technique for a lifelong learning process."

The ARRS and the ACR also offer online CME, as well as nonaccredited learning opportunities such as cases of the day and teaching files. The societies' CME offerings are free to members; the ACR charges a fee. The ARRS and the ACR also offer interactive CD-ROMS that can be used to obtain credit.

Online CME providers are trying to make the task of managing educational credits even easier by offering online repositories that stash accrued credits in one place. The RSNA's version automatically tabulates credits earned through the activities on its Web site. Users can add credits earned through other, offline CME activities as well, Olmsted said.

Most online CME providers also offer an informal educational component that is nonaccredited, some relying on Edactic, an interactive authoring tool that emulates real-world radiology case presentations. Edactic was developed by Dr. Mark Frank, director of education at Indiana University School of Medicine.

Edactic is used by Massachusetts General Hospital, Washington University, Indiana University, and other online education providers. It can be configured to include assessment, certification, and credentialing by sponsoring sites. (For other online learning sites, see related article.)

MANDATED SELF-AWARENESS

The Internet has proved to be a dynamic medium for communicating the visual vocabulary of radiology. Use of educational Web sites such as www.ctisus.com has soared. That site, developed by Dr. Elliot K. Fishman, director of diagnostic imaging and body CT at Johns Hopkins University, has seen traffic double in the past year. More than 5000 different users from 50 countries log on each week.

That sort of self-motivated learning and curiosity will be one of the most crucial elements of MOC, particularly for the tough-to-evaluate physician self-assessment, a component of lifelong learning. While CME credit accrual is one way to document continuous learning, it may fall short of targeting aspects of practice outside the scope of cognitive knowledge.

In that regard, radiology might want to take notes from the American Board of Internal Medicine, which unveiled its continuous professional development (CPD) program earlier this year. The program involves periodic self-evaluation of clinical skills, practice improvement, and up-to-date medical knowledge using a combination of Web, CD-ROM, and voice-activated response technologies.

The CPD program requires about 100 hours to complete and is intended to be spread over the 10-year certification period. Physicians accrue CME credit with each completed module and are awarded recertification at the end. Program modules include medical knowledge, clinical skills, patient and peer assessment, and practice improvement.

The ACR offers a self-evaluation program for radiologists called Continuous Professional Improvement (CPI), although it is not tied to any specific MOC initiatives. The program involves cognitive testing based on mail-in modules to be completed six times a year. The modules cover the 10 categories found on the ABR certification exam. Six to eight weeks after the tests are returned to the ACR, participants receive a scoring report and a key to the correct answers. In areas where skills appear sketchy based on test scores, the ACR provides a list of references and Web sites related to the specialty area. The program is CME-accredited and fee-based. In place for the past six years, CPI has 1355 subscribers, according to Sally Amsel, director in the ACR's education division. The ACR compiles CME credits accrued through the program on its Web site.

CATCH THE LEARNING BUG

The prospect of recertification in 10 years is likely to encourage newly minted radiologists to take advantage of self-evaluation tools, but the sea change may be a more difficult adjustment for radiologists already entrenched in practice.

Research into physician learning preferences demonstrates that the most popular educational forms are those that can be tied directly to practice. In a study conducted at the University of Alabama, Birmingham, researchers found that the same problem-based learning methods used in resident education can and should be adapted for use with practicing physicians. Moreover, they found that problem-based learning fosters a greater awareness of the benefits of self-assessment, resulting in changes in clinical practice behavior and an improvement in patient care outcomes.

Other research, presented at a 2001 symposium sponsored by the ABMS on lifelong learning and its relationship to MOC, found that one of the most effective ways to ensure continuous learning throughout a physician's career is to instill the habit during residency.

The seeds for lifelong learning have already been sown among radiology residents at the University of Arkansas for Medical Sciences. There, Dr. S. Bruce Greenberg, an associate professor of radiology, has incorporated the online version of RadioGraphics and the RSNA's InteractED into the formal residency training program. Pre- and post-tests document just how much students are learning from the online forums, Greenberg said, and are helping to establish a pattern of self-education that should carry over to the radiologists' professional lives.

"This is the first time that RadioGraphics has been used in this way," Olmsted said. "It's important because it gets residents thinking about lifelong learning well in advance of getting out into practice."

It may be years before MOC shakes up the way radiologists think of learning, but the move toward self-evaluation, performance assessment, and proof of skill seems unavoidable. If learning techniques evolve along with new criteria for professional assessment, radiology's next frontier may lie where it is least expected: between the ears.

Essentials pack category 1 punch

At its December meeting this year, the RSNA will unveil a new addition to its CME menu: a compact, two-day session on the essentials of radiology. The program, which has been in development for the past year and a half, packs a category 1 CME credit punch of 12 credit hours.

The refresher course is designed for general radiologists and subspecialists who wish to brush up on breast, chest, liver, and shoulder imaging, as well as pediatric and trauma imaging, ultrasound, and uroradiology.

The course was designed as an alternative to the traditional RSNA tracks that are spread over a six-day period, according to Dr. Ronald J. Zagoria, chair of the organization's refresher course committee. The course block will provide a comprehensive education in the topic areas, including up-to-date information, without becoming "entrenched in minutiae," he said.

Course registration began in June. See htttp://www.rsna.org/rsna/advanceregistration for more information.-DD

Questions about CME

What is CME?

The term refers to educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses to provide services for patients, the public, or the profession. These include the basic medical sciences, the discipline of clinical medicine, and the provision of healthcare to the public.

Where do I get CME?

Formal CME is obtained through accredited CME providers such as specialty societies, universities, and commercial CME companies. Accreditation is obtained from the Accreditation Council for Continuing Medical Education (ACCME).

How much CME is required?

State requirements for CME vary, but physicians who participate in at least 50 hours of educational activities that meet the American Medical Association's standard are eligible to receive a physician's recognition award (PRA). At least half of the credits earned must be within the physician's specialty or area of practice.

What is the AMA's PRA?

The PRA credit system established by the AMA has become the CME standard for licensing boards and specialty organizations nationally. The CME required to earn the PRA is equal to or greater than the amount necessary for licensure in states that mandate CME. Many organizations accept the PRA certificate as evidence of participation in CME, and some states' licensing boards and hospitals will accept the PRA as proof of having completed the required CME.

What types of CME credit are available?

The AMA defines CME credit at category 1 and category 2. Category 1 credit involves activities designated by an accredited provider and include attendance and presentations at conferences, publishing in a peer-reviewed journal, completing an accredited educational course, be it online, videotaped, printed, or computer-assisted, completion of a read-and-test accredited journal article, and specialty board certification and recertification. Credits accrue on an hourly or activity-specific basis.

Category 2 activities include reading journal articles, consulting with colleagues, and medical research. Credit claimed for category 2 should be commensurate with the amount of time spent on the activity.-DD

Best bets for learning onsite and online

Because the quality of educational materials online varies widely, top choices include offerings from radiological societies, universities, and Web sites that have been accredited by the Accreditation Council for Continuing Medical Education.

Educators named the following as some of the best informal educational opportunities on the Web:

• www.ctisus.com Developed by Dr. Elliot K. Fishman at Johns Hopkins Medical Center in Baltimore, this site makes the most of Web-based technology to deliver a lively, comprehensive resource for practicing radiologists. The CT-centric site provides exam protocols and techniques, teaching files, atlases, a question-and-answer forum, the popular monthly "You don't know radiology" quiz, and a journal club. The site is frequently updated, with CT angiography, multidetector CT, and 3D CT featured as hot topics.
• The University of Iowa's Virtual Hospital and Children's Virtual Hospital (www.www.vh.org), includes a multimedia medical library, online CME on topics such as pediatric radiology, and entire courses focused on chest radiology. Teaching files, images, and other materials make this a practical, useful resource for radiologists.
• BrighamRad (http://brighamrad.harvard.edu/educati-on.html), a professional education site hosted by Brigham and Women's Hospital in Boston, features a host of informal (nonaccredited) resources, from a teaching case database to a problem-based guide to diagnostic imaging strategies in the emergency room.
• The Whole Brain Atlas, also found at BrighamRad (www.-med.harvard.edu/AANLIB/home.html), demonstrates normal anatomy, normal function, and structural change caused by age and various disease processes. The site relates clinical information to MRI, CT, and SPECT images.
• UCLA's Laboratory of Neuroimaging (www.loni.ucla.edu) takes advantage of Web technologies to illustrate neuroanatomy, demonstrating relationships, dynamic processes, and clinical imaging traditionally difficult to represent within the constraints of lecture and text.
• At the University of Washington, Dr. Michael Richardson offers www.rad.washington.edu/mskbook, an online tutorial on musculoskeletal imaging.
• The online atlas of anatomy, "David," created by Dr. J.C. Oberson, is another dynamic educational resource, found at www.cid.ch/DAVID/Mainmenu.htm.
• www.edactic.com offers a choice selection of neuroradiology cases from Massachusetts General Hospital and a wide range of teaching files from the New England Roentgen Ray Society, St. Luke's Medical Center in Milwaukee, and Indiana University.

For online CME and onsite education offered at annual conferences, visit the following radiology society Web sites:

• Radiological Society of North America www.rsna.org
• American College of Radiology www.acr.org
• American Roentgen Ray Society www.arrs.org
• Diagnostic Imaging magazine www.diagnosticimaging.com

A sampling of commercial CME providers offering traditional onsite CME programs include:

• Educational Symposia, founded by radiologist Dr. Lawrence Muroff www.educationalsymposia.com
• Harvard Medical School www.mgh.harvard.edu/education/cme.html
• University of California, San Francisco www.som.ucsf.edu/som/education/cme/index.asp -DD