Prior to publication of my article on the proposed new standards on “content validity” from the Accreditation Commission for Continuing Medical Education (ACCME), I circulated it to a few leaders in the field for comments. In the process, I learned that a team from the Academic Consortium for Integrative Medicine and Health (“the Consortium”) recently had a conference call with Graham McMahon, MD, MMSc, ACCME president and chief executive officer. Saturday morning, January 25, 2020 I spoke with Rick Hecht, MD, the Consortium chair, who was part of the conference cal. He has had other recent discussions with key colleagues in the CME office of his home institution. Hecht’s comments offer some perspective on ACCME’s current areas of focus in CME. I have assembled his comments in the following interview format and secured his approval prior to publication.
The Integrator article on ACCME’s “content validity” proposal is here.
Hecht is the director of research at the UCSF Osher Center for Integrative Medicine where he serves as the Osher Foundation Endowed Chair in Research in Integrative Medicine. He is also a professor of medicine at the UCSF School of Medicine.
Integrator: It is great to hear at least indirectly more about some areas of concern with the ACCME’s changes. I did not reach out to ACCME before I wrote the article so particularly good to hear.
Hecht: Dale ([West, Consortium executive director] and Francoise [Adan, MD, Consortium chair-elect] and I had a half hour conference call with the ACCME. From this call and from discussions with colleagues leading CME work at UCSF, it is clear that for the past decade or more, there has been focus on addressing conflict of interest in CME offerings, especially issues of potential commercial bias influencing CME. More recently, there is growing attention to “content validity” in CME– the standard you were writing about.
Integrator: I gather that integrative medicine is not the only field that is in the sights of ACCME in the content validity area.
Hecht: Graham McMahon offered reassurance that integrative medicine was not being specifically targeted, and that the standards that are being applied go across all CME offerings. Colleagues at UCSF have also talked about the greater focus on ensuring that practices recommended in CME course have a good evidence base. Their concerns are not with integrative medicine at UCSF but with other disciplines that have less training in evidence-based medicine. Another area of concern is promotion of off-label uses of drugs. Although pharmaceutical companies are prohibited from directly promoting off-label uses of drugs, there has been concern that some CME courses offer back-door routes for encouraging off-label use of drugs even when safety or efficacy has not been well established.
Integrator: I’d asked in my article what happens with the ACCME’s idea of “generally accepted” when we may have a guideline that includes an integrative practice yet that practice is still not “generally accepted” in the practices of regular medicine.
Hecht: It is pretty clear that where there is a guideline like the American College of Physicians [guideline for chronic low back pain] that the content would make the cut for providing CME credit for training physicians how to refer for practices such as acupuncture for low back pain. What I’ve heard from these discussion is that if you have systematic reviews and practice guidelines, this is not what is going be questioned for CME credit.
Integrator: Yet there is so much emerging in this field.
Hecht: Definitely one challenge for us is that – and I put it this way in the meeting — the day before the ACP produced its guideline the evidence base was the same as the day after. Yet a CME provider who wanted to teach people how to use those non-pharma approaches the day before might be questioned for advocating a practice that is not generally accepted. With the guideline, suddenly it’s now okay. This is a challenge for a field like integrative medicine that is always working to change practice so it is pushing boundaries. It seems clear, however, that the situation where there is a good evidence-base but practice guidelines have not yet caught up with the evidence is not likely to be a key concern.
Integrator: So for the most paranoid – I think this bears repeating – this is definitely a diagnostic rule out; the ACCME guidelines were not made to target integrative medicine. Yet for many integrative approaches, and much of integrative practice, a systematic review is a high bar.
Hecht: Yes. While the rules are definitely not specifically there to target integrative medicine, integrative medicine CME can definitely run into issues with it. Again, there is no problem with educating people on the science about an integrative practice. The issue is if you are recommending specific treatments that are not “generally accepted.” If you happen to have a segment that is more practical but doesn’t meet the “generally accepted” bar, you can offer it – you just can’t offer CME credit for it. It’s not saying you can’t provide the education. A session might provide exceptional scientific evidence on the microbiome, for instance, that may be brilliant. Yet then it can be followed by recommendations for testing and prescribing that don’t hit the same scientific bar because of a lack of clinical trials evidence supporting these clinical practices.
Integrator: To be clear, the Consortium is in a unique place relative to evidence and CME. Your main CME offering is your International Congress on Integrative Medicine and Health every two years that typically draws 1000 or more – coming up in Cleveland in April. That was originally only a research meeting, targeting researchers not clinicians. It’s deeply science based with typically over 450 abstracts and backing from the NIH National Center for Complementary and Integrative Health. In contrast, virtually all the rest of CME in the field focuses on educating clinicians who are seeking to develop and better integrative or functional medicine practices. For those providers and attendees, the focus is on practical change. How can you enhance your practice the following Monday. If one of these conferences removed CME from everything that was practical and aimed at practice change that doesn’t meet the bar of a systematic review of meta-analysis, a very high percent would not hit such a “generally accepted” bar.
Hecht: Yes, the ACCME’s guidelines, while not directly targeting integrative medicine, are definitely more challenging for integrative medicine CME providers who are advocating clinical practices with a weaker evidence base. I think the ACCME stance underlines the importance of expanding the evidence base for promising integrative medicine practices. I also think they underline the importance of making sure those of us providing CME understand both the principals of evidence-based health care, and the rules that govern CME credit.
Integrator: To be utterly clear, I gather from your comments that coming out of the meeting you were reassured that, in the ACCME, the integrative medicine field will not be seeing the kind of prejudice that the field has frequently witnessed from leaders of academic medicine.
Hecht: The discussion with Graham McMahon reassured me that leadership in ACCME is open to the contributions that evidence-based integrative medicine can make, and is not going to support using ACCME to unfairly target integrative medicine. I still think that we need to watch and monitor issues that may come up carefully to ensure that rules that cover continuing medical education do not get unevenly applied to integrative medicine. We need to be following this closely.
Integrator Well it is good that you and the Consortium have had this discussion. It is important in this time that integrative medicine leaders be in relationship with ACCME. Any next steps?
Hecht: We are seeking to developing a number of steps to educate our members and others in integrative medicine about how to make sure that we are delivering high quality CME on integrative medicine topics that follows the guidelines ACCME is using. Look for more on this soon!
First article in this series is here: Is Integrative Medicine Continuing Education Threatened by Proposed ACCME Guidelines? Part 1 “Content Validity