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Bridging the gaps
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Identifying practice gaps at core of move to continuous professional development, outcomes-based education

Dermatologists have attended continuing medical education (CME) meetings for more than a half century. But in the age of continuous professional development (CPD) and outcomes-based education (OBE), they are now being asked to demonstrate an improvement in competence, clinical performance, or patient outcomes as pearls of wisdom give way to identifying and filling practice gaps.

“Medicine is changing and it’s not a dermatology initiative. It’s across all medical specialties,” said Robert S. Kirsner, MD, PhD, vice chairman of dermatology at the University of Miami Miller School of Medicine and chair of American Academy of Dermatology’s Council on Education and Maintenance of Certification (MOC). Rising health care costs coupled with evidence that patients are not always treated using standards of care, and that the care they receive may sometimes be harmful, have given rise to a perfect storm in medicine, he said, citing the Institute of Medicine’s 1999 report To Err is Human among the evidence. “Medicine as a profession has said that we need to do better. There’s a desire for patients to be treated according to evidence and to improve the health of our nation,” he said. “To that end, physicians must not only have knowledge and be competent, they need to improve in areas that they’re weak, thus the practice gaps.”

Previously, education was based on changes in knowledge or competence, Dr. Kirsner continued. “Outcomes-based education is designed to change physician practice and patient outcomes.” For example, demonstrating knowledge is knowing that skin cancer is the leading type of cancer, he explained. Demonstrating competency is reflected in dermatologists showing how they conduct primary and secondary prevention in an idealized teaching setting. “The goal of OBE is performance, where dermatologists document in patient records that they provided this additional education to their patients after attending an educational event.” Down the road, dermatologists will, hopefully, be able to demonstrate that their patients have better outcomes or are diagnosed at an earlier stage of melanoma because of the additional education they provided. Ultimately, he said, dermatology will hopefully be able to show these results at the community or population-based level. 

CME focus, format shift

The perfect storm has created gale-force winds that are changing the educational focus and format of CME activities. Moving forward, CME activities will increasingly focus on more action-oriented education, according to Erik Stratman, MD, chair of the department of dermatology at the Marshfield Clinic and past chair of the Academy’s Council on Education. “Dermatology education planners are learning how to plan activities around areas that are most in need of change or in areas that have a substantial knowledge gap in how to correctly identify or manage a condition,” he said. [pagebreak]

Continuing professional development (CPD) moves beyond the traditional didactic CME to include the concepts of self-directed learning, personal development, leadership and communication skills, and consideration of organizational and systems factors. Additionally, maintenance of certification and licensure requirements continue to evolve in ways that parallel and reinforce the CPD model.

This shift is evident in the live sessions that were introduced at the AAD’s Annual Meeting in 2011. Some sessions are structured with a question-and-answer format. Attendees are able to assess their level of understanding and have immediate feedback in order to identify areas for further self-directed study. “For some educational activities, we give attendees a pre- and post-test and follow up with them three to six months later to either assess knowledge or competence retention, or ask whether they implemented what they learned into their practice,” Dr. Kirsner said, noting that the latter is a subjective way to demonstrate OBE.

These types of sessions also offer easy opportunities to identify personal knowledge gaps, Dr. Stratman added. At their conclusion, each attendee can purposefully and inwardly reflect on whether there was action-oriented advice that should change how he or she is currently practicing. “The physician can also take more formal self-assessment exams that explain areas of personal knowledge gaps,” he said. “Once a knowledge gap is identified, then the physician can select CME activities or other learning plans to close the gap.”

Dr. Stratman advised being selective when choosing CME activities to attend. “Podium shows can be entertaining,” he said, “but if you aren’t making any improvements in your approach to patient care, what is their true value?” Seek sessions that are somehow tied into self-assessment or practice performance, he said. Look for activities that provide evidence-based advice.

An example of a knowledge gap would be about the use of gabapentin, a neurologic medication, in combination with an anti-viral medication, such as valacyclovir, to minimize the development of postherpetic neuralgia in patients with herpes zoster, said Mark Lebwohl, MD, professor and chair of the department of dermatology at the Mount Sinai Medical Center in New York City. Even though an open-label study demonstrating the benefits of this was published in the spring of 2011 (Arch Dermatol 2011 Aug;147(8):901-7), only a small percentage of dermatologists are prescribing both medications, he said. The information needs to be presented in posters and at meetings to get the word out. “So if you’ve heard of gabapentin, but you haven’t started to use it because you are not sure how it is prescribed or what its side effects are,” Dr. Lebwohl said, “go to the session about management of herpes zoster.” [pagebreak]

The more objective method is participating in Performance Improvement CME, or PI CME, activities, which were launched in 2010, Dr. Kirsner said. The Academy’s PI CME activities are delivered under the Clinical Performance Assessment Tool (CPAT), which currently has guideline-based modules for melanoma, atopic dermatitis, and acne. (CPAT’s name is changing to PI CME in the near future; learn more at www.aad.org/education-and-quality-care/aad-professional-education/clinical-performance-assessment-tool-cpat.) “We are hoping to launch up to six modules in the next few years,” he said. Using a module, the dermatologist reviews, for example, 10 charts for patients with the specific disease which meets the inclusion criteria, answers 20 to 25 questions relevant to the condition as part of a self-audit, submits the data online, and receives a report back, explained Debra Gist, MPH, the AAD’s director of education. After reflecting on their results against their peers and completing Stage B of the activity (which includes a menu of educational activities and clinical application tools), the dermatologist develops and implements a personalized intervention and repeats a second set of chart audits in three to six months to determine whether care has improved by comparing the pre- and post-data, she said. Modules for this Web-based program have been approved by the American Board of Dermatology and qualify for credit for the part 4 of MOC.

Performing practice assessments is a more time-consuming, but far more impactful, method for identifying personal knowledge gaps that impact patient or process outcomes, Dr. Stratman added. He believes that gathering practice assessment data will become more efficient as the medical world converts to electronic health records (EHRs). “In my practice, our EHR allows much population health data to be seen for my patient population without me personally having to rummage through all the charts,” Dr. Stratman said. “The data is automatically abstracted because of the data field entry into the EHR.”

More ways to identify gaps

In addition to attending CME sessions and conducting practice assessments, other ways to identify practice gaps (though these methods may not meet MOC requirements) include reading about new techniques or treatments in the literature and participating in journal clubs and webinars. [pagebreak]

Some journals, such as Archives of Dermatology, have a “practice gaps” section, noted June K. Robinson, MD, research professor of dermatology at Northwestern University Feinberg School of Medicine in Chicago and editor of Archives. These sections enable physicians to break down different studies to see how they affect one’s practice. (Dermatology World offers a similar feature each month in the Acta Eruditorum column.) For those who prefer chatting about the significance of the articles with others who are in the trenches, rather than reading a journal cover-to-cover, there are journal clubs. Usually a dermatology department runs a journal club, Dr. Robinson said, but sometimes groups of practitioners who are not affiliated with a department take it upon themselves to meet with their colleagues, either in person or online.

Another online option is to join an Internet discussion group, noted Steven Feldman, MD, PhD, professor of dermatology at Wake Forest University Baptist Medical Center in Winston-Salem, North Carolina. Among them are RxDerm-L run by Arthur Huntley, MD, out of the University of California, Davis. These groups can afford dermatologists an opportunity to get outside of their solo or small practices to learn what their colleagues are doing that they otherwise might not be privy to, he said.

Additionally, being an outpatient specialty doesn’t allow dermatologists the opportunity to spend time in the hospital lunch room talking with other specialists. But attending multi-specialty aesthetic meetings with facial plastic surgeons, otolaryngologists, and ophthalmologists does. “There are things we know that plastic surgeons don’t know and I’m not so arrogant to believe that they don’t have anything to teach us,” Dr. Feldman said. “We all have things we can learn from each other.”

Expectations, roles change

The change in CME focus and format also suggests a significant change in physician expectations and roles in the education process. The move to PI CME and the move to MOC are happening at the same time, which is no coincidence; the new format of PI CME closely parallels the requirements of part 4 of MOC. The PI CME activities the AAD is developing are both certified for CME credit and approved by the American Board of Dermatology for MOC credit, allowing members to make progress toward meeting two requirements with one activity. [pagebreak]

It’s important that dermatologists view these educational activities through a continuous quality improvement lens, Dr. Robinson noted. They should ask themselves how this new information will be of value to their practice. They should consider what actions or processes need to be changed in order to adopt a proposed intervention, and weigh the barriers and benefits of the proposed change. What are the resources and costs associated with the change? For example, will protocols need to be developed? Will staff need additional training? Will new equipment be necessary? Before the intervention can be implemented, staff buy-in must be obtained. After it has been implemented for six to eight weeks, the physician must determine if the intervention has had a positive impact. If the change affects patients directly, then the dermatologist should conduct a patient survey. If it affects staff, then staff members should be surveyed. “If you implement a great idea, but you don’t find out what effect it has had, then you haven’t done continuous quality improvement,” she said.

Dr. Stratman concurred. “Plan some time with each activity to reflect on what you heard and determine if there is something you should be doing differently because of it,” he said. “Then write down the changes you think you should make.” Every quarter, review the list of changes to determine if they were made. If not, why not? “If we formulate habits of purposefully interpreting CME education into meaningful changes in practice,” Dr. Stratman said, “we begin down the path of better outcomes for patients.”

Keeping on that path requires perseverance and leadership, according to Dr. Robinson. “You can’t get there by thinking the change, you have to do it,” she said. What breaks the back of most change is that resources and sustained support are lacking. “It takes two to six months to incorporate a behavior change before it feels natural,” Dr. Robinson noted. “That’s why we reassess the change in six to eight weeks — because it gives an additional boost to want to continue.” She also said dermatologists should not let themselves get tripped up by the new terminology, such as OBE. “It doesn’t matter what we’re calling it. It’s what we do as professionals. We continually evolve and assimilate new ideas and put them into practice in order to provide our patients with cutting-edge care.”

Dr. Kirsner harkens back to the day when CME didn’t exist. “When CME was introduced, physicians were very uncomfortable with the concept of having to demonstrate that they continue to educate themselves. Today, we all go to meetings and get CME. Right now, some of these concepts feel very foreign, but they are just the next steps in helping improve the health of the nation,” he said, adding, “This movement is occurring across medicine, and it’s important for dermatology to be in step with it.”