Violation puts CME honor system in the spotlight

Charges brought against a high-ranking Medicare official raise the issue of greater CME monitoring for all physicians.

By Myrle Croasdale — Posted May 9, 2005

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As continuing medical education has come under increasing scrutiny in recent years, CME leaders are now keeping a watchful eye to gauge whether momentum is building for a credit monitoring system.

In a high-profile case that became public in April, the Maryland Board of Physicians charged a top Medicare policy-maker with falsifying his CME credits, prompting a small number of critics to call for changes to a system that is based on self-reporting. They want to see the current system replaced with one in which an outside organization tracks and records doctors' CME credits. They also want every state to make CME a relicensure requirement. Eleven states don't require it now.

The discussion comes shortly after critics helped change CME rules so that speakers have to disclose and resolve their conflicts of interest and three years after CME took hits for providing meals and gifts to attendees. It also comes at a time when lawmakers are pushing for medical licensing boards to step up their disciplinary efforts.

CME leaders who see no need to change the self-reporting system say it's rare for physicians to falsify the CME records they file. And physician leaders say the burden of running a CME monitoring system would outweigh the benefits.

"Do we need stronger safeguards? Do we need to ring the bell, lock the door and take roll call?" asked Robert Addleton, EdD, the Medical Assn. of Georgia's medical education director. "I don't want to put CME staff members in the place of telling doctors, 'No, you can't have a certificate because you came five minutes late.' "

But Arthur Caplan, PhD, the University of Pennsylvania Medical School's medical ethics department chair, disagrees, saying that the CME system needs upgrading.

"The requirements are too flimsy," Dr. Caplan said. "In this day and age when doctors are asking for malpractice relief, they need to do what they can to beef up the expertise of the profession. When the [chief medical officer] of Medicare fudges on his CME, it doesn't do much for public confidence."

Trouble at the top

On April 8, the Centers for Medicare & Medicaid Services put their chief medical officer, Sean R. Tunis, MD, on indefinite administrative leave with pay after the Maryland Board of Physicians' accused him of falsifying documents.

The board alleged that Dr. Tunis altered the CME documents he needed to keep his privileges at Mercy Medical Center in Baltimore, where he moonlights in emergency medicine. It accused Dr. Tunis of falsifying two CME certificates that accounted for 54 credits. The board also alleged that he claimed 60 credits for grand rounds at Johns Hopkins that the hospital has no record of him attending.

Dr. Tunis did not return e-mails or phone calls seeking comment. But during an interview with the Maryland board, Dr. Tunis admitted to altering the two documents.

The public charges filed against him state that Dr. Tunis "acknowledged that he had altered the American College of Physicians documentation, because of all the meetings he had attended." The charges further state that Dr. Tunis "asked his assistant at CMS to help him alter the documents." But Dr. Tunis "denied sending the altered documents to Mercy and stated that one of his colleagues, whom he had not promoted, had faxed them," according to the Maryland board's written allegations.

A closed administrative hearing is scheduled for July. If Dr. Tunis is not cleared, the board's disciplinary actions could range from a letter of reprimand put in his file to permanent revocation of his medical license. Dr. Tunis could be fined up to $50,000.

Random audits

CME providers say very few physicians falsify CME credits, cut out early from CME lectures or otherwise game the system.

Most state medical boards randomly audit CME credits, said Dale Austin, the Federation of State Medical Boards' senior vice president and chief operating officer.

Austin said the FSMB typically sees 50 to 80 CME-related disciplinary actions a year for the whole country, and few, if any, are tied to faking CME certificates.

Florida now throws off that average, though. In 2004, the state's CME violations jumped to more than 400 as it started issuing citations for minor issues such as late submissions of CME credits.

Austin said auditors would contact CME providers for CME credit verification only if documentation looked suspicious. In the Maryland case, a whistle-blower brought the altered documents to the board's attention.

One reason physicians are unlikely to falsify CME records is that those who are caught risk having their license revoked, Austin said.

No reason for change, doctors say

Physicians are loath to see the CME honor system change.

Dr. Tunis' case doesn't "invalidate the system by any means," said Steven E. Weinberger, MD, the ACP's senior vice president for medical knowledge and education.

Dr. Caplan disagrees. Physicians' CME efforts should reflect their ability to provide high-caliber care to the public, he said. Many physicians are board-certified, which requires periodic testing, but board certification is not mandatory. In the 11 states without CME requirements, physicians can practice without keeping their skills current, Dr. Caplan said

Organized medicine is listening closely to CME critics. The American Medical Association owns the Physician Recognition Award CME credit system, which is the basis for most physician CME.

"I'm sure this [CME monitoring] will continue to be a topic for quite a while," said Alejandro Aparicio, MD, the AMA's director of continuing physician professional development. "If it seems in the conversation that we need to do something to maintain the public trust in the CME enterprise, then the AMA will step up."

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CME-free states

These state medical boards don't require physicians to take continuing medical education classes to maintain their licenses: Colorado, Connecticut, Washington, D.C., Hawaii, Indiana, Montana, New York, Oregon, South Dakota, Vermont, Wyoming.

Note: Hawaii's DOs do not have CME licensing requirements. Vermont's MDs do not have CME licensing requirements. Most state boards have jurisdiction over MDs and DOs, but 14 states have separate osteopathic boards for DOs.

Source: The American Medical Association's 2005 edition of "State Medical Licensure Requirements and Statistics"

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CME violations

The Federation of State Medical Boards keeps a record of state disciplinary actions against physicians. The 2004 jump is due to Florida cracking down on physicians who file their continuing medical education credits late.

2000 2001 2002 2003 2004
Falsifying records 0 2 5 5 4
Failure to comply with CME requirements 54 56 42 59 571
Failure to maintain or submit CME documentation 7 13 4 17 10

Source: Federation of State Medical Boards

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