• The Changing Role of CME

    Authors: Graham T. McMahon, MD, MMSc
    Ashok R. Asthagiri
    Alexander A. Khalessi, MD

    As the practice of neurological surgery becomes increasingly complex and specialized, it's more important than ever for continuing medical education (CME) to keep up with the rapid pace of neurosurgical progress. Practicing neurosurgeons rely on CME for more than updates on the latest clinical science. In the face of substantial time constraints introduced by clinical documentation requirements, quality reporting initiatives, and administrative burdens, physicians enjoy little protected time for enhancing their own clinical skills and knowledge base.

    With the explosion in information technology, users can access the latest guidelines more quickly on their cell phone than we can learn from an expert. The currency of CME programming is therefore no longer information transmission. Effective CME must become an educational home for neurosurgeons to efficiently find resources that translate scientific discovery into clinical practice. These curated programs provide an opportunity for problem-solving, skill development, mentorship, and peer-to-peer exchange that promotes insight and judgment.

    Self-contained educational approaches historically focused on information exchange must be replaced by programs that stimulate curiosity, create engagement, drive meaningful learning, and support behavior and practice change through feedback, opportunities for reflection, repetition, and reinforcement over time.

    Promoting Self-Awareness

    Key to this process is promoting self-awareness and insight into our own knowledge gaps. Misplaced confidence consistently leads to errors that clinicians may not be aware of and can result in poor patient outcomes. The average practicing neurosurgeon, by any standard, must distinguish themselves academically and professionally to even reach independent practice. After a lengthy residency training and oral board certification process, it's quite natural to entertain a sense of accomplishment. The confidence and mastery required to embolden neurosurgeons to operate on the human brain and spine may run counter to the humility and self-awareness of our limitations required to continuously improve.

    To become self-aware, we must step out of the apparent cocoon of self-confidence and become humble and open enough to assess our level of skill and areas where we need to grow. For neurosurgeons, this requires careful examination of those humbling
    cases when we achieve our technical goals but fail to alter the natural history of an unforgiving disease. As a specialty, we can push the intensive and extensive margin of our understanding. We must further look closely at those circumstances when our patients suffer complications, scrutinize our technique and medical management, identify opportunities for improved patient selection, and make sure we are appraised of changing technical approaches. Adaptive learning can promote self-awareness: educators can use adaptive learning to assess individual learner's needs, create personalized education aimed at addressing those gaps, provide formative assessment, and motivate ongoing progress.

    Innovation in Learning

    In previous iterations of CME content, lengthy didactics supported by enduring materials (journal articles, textbook accompaniments) required intensive effort to digest. The opportunity cost for practicing neurosurgeons to take time from their practice further limits the possibility of gold-standard access to face-to-face CME instruction. Web-based platforms provide specialty educational organizations with the ability to impact neurosurgical outcomes through the development of educational content that is relevant and accessible. This emphasis reconciles the changing demands of the neurosurgical learner with proven, high-yield educational approaches. Effective CME becomes integrated into neurosurgical workflow and is presented in a manner that mirrors the point-of-action needs of the end user. CNS offerings like NEXUS and clinical guidelines represent vanguard efforts to provide educational content in the moment patients receive neurosurgical care.

    Technology lends itself to learner-controlled training that accommodates diverse learning styles and is particularly well suited to surgical training for younger surgeons who are comfortable in the digital world. For example, a surgical procedure can be broadcast live via social media, affording neurosurgical teams around the world the opportunity to observe the procedure in real time, ask questions, and discuss their observations.

    To perform successful and safe procedures, neurosurgeons and their teams need to learn together. Educators need to identify opportunities to offer interprofessional continuing education (IPCE). Simulation technologies, for example, can provide safe, controlled environments where neurosurgeons and their teams can practice new neurosurgical techniques without posing risk to patients. This environment not only builds technical skill but allows teams to develop the competencies for interprofessional collaborative practice, such as communication skills, trust, and respect for each other's roles and responsibilities.

    Mentorship, where expert neurosurgeons support their peers in informal and workplace environments, is important for the development of high-quality professional practice. Connections between colleagues and peer-to-peer learning and support not only drives practice improvement but helps clinicians build resilience and mitigate burnout. Our professional societies help maintain these shared cultural experiences that begin in training and foster the comradery of our unique neurosurgical community.

    As CME evolves, faculty will need to learn to deliver education using innovative approaches and technology. Faculty development counts for CME-and CME can support faculty in this evolution. These CME programs could focus on the balance required for modern surgeon-scientists, the development of a clinical subspecialty practice, the evolving role of residency and fellowship in the training of a surgeon, and collaborations with foundations and industry partners in the development of new neurosurgical technology.

    Role of Accreditors

    Although accreditation systems are sometimes perceived as burdensome, with an excessive emphasis on compliance, they are evolving to better meet the needs of emerging generations of clinicians and to encourage continuous improvement in clinician competence and performance. Accreditors are developing education strategies that will enable health system leaders, educators, clinicians, and teams to respond quickly to changing practice in neurosurgery. For example, a new collaboration between the Accreditation Council for Continuing Medical Education (ACCME), which sets the standards for organizations that provide CME (including CNS), and the American Medical Association, which administers the AMA PRA Category 1 Credit system, has freed educators to customize their offerings and to more readily apply innovative education strategies that do not fall into traditional formats.1 With this collaboration, educators can employ approaches such as the ones described here, hybrid or blended learning, procedural training using virtual reality, gamification, online case discussions on social media, and other approaches, to meet the needs of their learners.

    The changing role of accreditors means they are not only responsible for establishing core standards for educational excellence and independence from commercial influence, but also for designing standards that serve as a guidepost for the future of CME.2 ACCME's new commendation criteria, for example, recognize the achievements of accredited organizations that support interprofessional collaborative practice; address priorities in patient safety, public health, and population health; collaborate with health systems and communities; create individualized learning plans; design education to optimize technical and procedural skills; leverage educational technology; and demonstrate meaningful educational and clinical outcomes.3 These changes are reflected in some of our existing neurosurgical offerings with an expansion of interactive, case-based educational formats, inverted classrooms with webinar components, hands-on surgical skills labs, and point-of-care educational platforms like NEXUS.

    Transforming CME means transforming the role of accreditors from compliance authorities to coaches and leaders that support the community of educators, provide services that respond to educators' concerns and needs, and create an environment where they can share best practices. With this new role, accreditors create a framework that motivates educators to achieve their full potential and empowers them to deliver CME that drives meaningful change in clinician performance and in the quality and safety of care for the patients we all serve.


    1. McMahon GT, Skochelak SE. Promotion of Continuing Medical Education: Promoting Innovation to Regulatory Alignment. JAMA. 2018;319(6):545-546.
    2. McMahon GT, Aboulsoud S, Gordon J, McKenna M, Meuser J, Staz M, Campbell CM. Evolving Alignment in International Continuing Professional Development Accreditation. J Contin Educ Health Prof, 2016 Summer;36 Suppl 1:S22-6.
    3. Accreditation Council for Continuing Medical Education (ACCME). Accreditation criteria. Available at: http://www.accme.org/accreditation-rules/accreditation-criteria. Accessed November 6, 2018

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