Sham CME (Continuing Medical Education)

Continuing Medical Education in the United States is a sham—a massive fraud perpetrated against patients, who pay a high price for physician ignorance. If a doctor doesn't want to learn anything, he or she doesn't need to, thanks to a system in which CME credits can be earned simply by guessing answers to test questions. If a potted plant could blow in the breeze hard enough to randomly click a mouse, it could earn CME. I could program a website that enables doctors to obtain CME credits from sites offering such credits without the need to read even one word of CME, ever. I haven't programmed such a site for obvious ethical reasons, but doing it would be a piece of cake.

Who thinks easy CME is a good idea? Lazy doctors and the dingbats who develop CME courses. The latter are generally people who know their subject matter but virtually nothing about education or how to optimize it. They don't care that 99% of doctors forget 99% of what is presented in CME courses, which are often stuffed with virtually useless trivia that serves no clinical purpose; it is just informational clutter to obscure what is truly important.

A brutal but apropos analogy

If restaurants were to emulate how CME providers dilute the good stuff in a sea of junk, they would toss their food in a septic tank and give you a straw, forcing you to ingest lots of crap to find the good nuggets.

It's a myth that we use only 10% of our brains. In reality, many of us—including doctors—are so overwhelmed by information that our brains actively forget old info to make room for new facts. Furthermore, there is effectively a limit on the amount of information most people can readily access even if they don't fully forget it. The education that makes someone an expert in one subject often erodes his or her mastery of other areas. That explains why a professor of dermatology asked me what Dyazide^® was—and when I explained its indication and constituent ingredients, he looked at me as if I presented the findings of an alien autopsy. Dyazide^® is a combination of triamterene and hydrochlorothiazide used to treat high blood pressure and edema. At the time he asked me that when I was a medical student in Detroit in the mid 1980s, Dyazide^® was locally used more often than penicillin. Yet he didn't know it! Nor did he know what hydrochlorothiazide is. Or triamterene.

He also didn't know the definition of “tumor.” You might think this board-certified medical school prof would be head-and-shoulders above me, someone whose occupational ability three years before was limited to mowing lawns and performing odd jobs. However, the fiftyish Dr. What's Dyazide? thought “tumor” meant cancer and only cancer. Indeed it does in the minds of most laymen. However, between mowing yards and writing 62-page love letters years previously, I also read the frigging medical dictionary and hence knew that tumor meant swelling, often a neoplasm (abnormal new growth of tissue) but not necessarily a malignancy or cancer.

Now, we weren't discussing novel diagnostic approaches to detecting idiopathic hypertrophic subaortic stenosis; we discussed something less recondite than the medical info in Reader's Digest: I am Joe's pancreas, or brain, or lack thereof.

Various people—from medical colleagues to neuropsychologists and even lawn care customers—have asked me if I have a photographic memory. Sometimes I do, but generally no; I just have a very good memory. Considering how I scored on medical school exams versus the bottom of the class just getting by with their passing scores of 45% (reflecting how difficult the tests were), and factoring in the random chance guessing that enables people who know nothing to average scores of 25% on multiple-choice exams with four options, I learned about two to four times more than some others who now have “MD” after their names. However, even my memory is far from perfect. If I learn computer programming or electrical engineering, I forget some dermatology that I no longer use, now that I no longer work as an emergency room physician—and hopefully never will!

Like dynamic random-access memory that needs to be periodically refreshed, human memories often fade in time unless they are refreshed by recalling them. I remember the Pythagorean theorem because I often use it, but few adults recall it decades after they learned it in junior high or high school. Use it or lose it; they lose it.

This brings up a related point: the more you learn, the more time consuming it is to periodically access and hence refresh what you know. There are 24 hours in a day; you do the math and draw the obvious conclusion.

Next point: Memorizing useless trivia takes up just as much space in the brain (so to speak) as does vital information, just as it does on your hard drive. Hence, the more clutter in your brain, the less room you have for informational treasures. By analogy, putting old socks in your safety deposit box limits its ability to store gold.

Consider people with truly exceptional memories: folks who can, for example, tell you exactly what they did on February 12^th 1976 or October 22^nd 1992. The most surprising thing about them, other than their phenomenal memory, is how little they do with it. One might think that people with brains that are seemingly bottomless pits would have a tremendous advantage over others, yet I've never heard of even one such person who was an exceptional scientist, inventor, or doctor. That makes me wonder if those memories are valid or evidence of confabulatory hyperamnesia (link to original study).

How more info can add up to less ability to use it

The more clutter there is, the more difficult it is to find the especially valuable information. Since the amount of information we can store and use to practical benefit is limited, storing trivia or less valuable information is often disadvantageous, carrying a high price tag especially in occupations like medicine in which not knowing something can mean the difference between life and death, or a patient who can live a happy life instead of a miserable one. Hence, I favor the no-brain-clutter approach to medical education. All the medical trivia, supporting data (e.g., “17% of patients in class 3 with two or more comorbidities responded to the drug … blah, blah, blah,” study designs and patient selection criteria, and all the stuff that can be housed in a peripheral (now often electronic) brain should not be memorized, and anyone who asks (or requires) you to do that is dangerously misinformed about education and hence poses a risk to your patients. Many CME tests are filled with questions quizzing doctors on trivial points that don't amount to a hill of beans in terms of patient care.

Another ridiculous—I mean reeeeeediculous—aspect of CME is that doctors are awarded credit based on the time they put into it, not how much they get out of it. This is absurd and markedly different from the standard in college and medical school. When I showed up for an exam, I was never asked how many hours I spent studying; the only thing that mattered was my score that reflected how much I learned. If I were more efficient in studying, I wasn't penalized for that in college and med school. It would be amusing to see some bureaucratic cretin attempt to justify the idiotic practice of awarding CME credit based on hours spent on it as opposed to knowledge gained from it. In terms of patient care, CME HOURS MEAN ABSOLUTELY NOTHING, whereas knowledge means everything.

In medical school, I noticed that most attending doctors who showed up for activities with CME credit left well before the activity (conference, grand rounds, etc.) ended. The doc would sign a card, slip it into the CME box and merrily scamper off, cheating his way to the 150 hours required every three years in Michigan for physicians after residency. The powers-that-be crafted a system in which cheating was—and is—incredibly easy, making CME credits often meaningless. Why not just make the doc raise his right hand and swear that he learned enough in the preceding three years to maintain or expand his knowledge and keep up with the latest drugs that often do more for their manufacturers than for patients?

In other articles (Medscape CME problems and The secret pact of silence in medicine), I documented some of the nightmarish problems I experienced with amateurish CME courses. Medscape has some superb content, but also too much garbage that succeeded in sullying their reputation in my mind. I've read countless articles on their site, but generally don't harvest (so to speak) CME credits until shortly before they are due. If I received an hour of CME credit for each hour of continuing medical education I engaged in, I'd usually have at least 1000 hours per year, with over 4000 hours in my peak years.

The importance of vaginal flora

Yes, I know: vaginal flora seems to be an icky topic that people don't want to read about. However, adults should know about it because women and men affect the vaginal flora in many ways, usually negatively, producing changes that can make the difference between life and death, and sexual bliss versus divorce court. However, the average doctor knows so little about this topic that he doesn't even know that he doesn't know (an example of metaignorance). The blind can't lead the blind, so don't look to ignorant doctors to multiply your sexual pleasure and maximize your health.

When I work on inventions or conduct research for my books, I dig much deeper than I did in medical school. For example, in writing The Science of Sex, I spent weeks learning about the vaginal flora and factors that affect it. While doing that, I bounced questions off various university affiliated ob-gyns, all of whom impressed me with their amateurish grasp of that subject. Their relevant base of knowledge was about as deep as what you'd find in a woman's magazine that glosses over topics to make room for brownie recipes.

After thousands of hours figuratively (and sometimes literally) putting a microscope on various topics, I learned that few people with an MD after their names dug as deep as I wanted. To find the gold, I generally had to peer into the deeper pits (so to speak) dug by various Ph.D.s, who are often impressively brilliant and incredibly knowledgeable, but often with such a myopically close focus that they lose sight of the overall picture and applicability of their research to topics other than the one or two they're hyperfocusing on. I can hyperfocus, too, but also step back, put 2 and 2 together, and connect the dots in ways only possible with a mental lens that can easily zoom in or out. That's one reason why inventing comes so natural to me. It's also why I wonder why anyone with at least a room-temperature IQ can't easily spot the many flaws in the continuing medical education ~~SCAM~~—umm, system.

In my medical career, and also as a patient or friend or relative of one, I've met more than a few physicians who impressed me with their lack of knowledge and brainpower, making me wonder how such mental midgets could have a license to practice medicine. To be a good doctor is likely more difficult than you think (unless you are one), but to be a half-ass, just-barely-passing doc with much of one's score more attributable to random-chance guessing than knowledge—well, it's not terribly difficult to pick off the low-lying fruit: the easy-to-master and difficult-to-forget knowledge. The arcane facts that are used less often, sometimes once per year or per career, separate the men from the boys. That often difficult-to-acquire and difficult-to-maintain (because it isn't often used and hence often isn't refreshed in one's memory banks) info typically takes much more time and effort to acquire and hold. Thus, the range from doctor to DOCTOR is as vast as the difference between a typical weekend golfer and Tiger Woods in his prime. Continuing medical education does nothing to close this gap, but it could, if it were designed by people with an ounce of common sense.

One of my pet peeves is when people only “kinda” know what they are doing at work. Superb CME topics could lop off the bottom half of the bell curve of competency and make every participant subsequently able to perform as masterfully as the best doctors. The current CME system can't even begin to approach this goal; the docs who only “kinda” know what they are doing typically remain that way throughout their careers.

Some doctors are slower than others and cannot master what they need to know during their training period. We need them regardless because of the physician shortage, so every state lets doctors work who graduated at or near the bottom of their class. Their educational deficiencies could be progressively remedied during their careers, but no effort is made to close the gap between the intellectual lightweights and heavyweights. Instead, everyone gets the typical bureaucratic one-size-fits all approach to CME. This system effectively rubber-stamps ignorance and relative stupidity (compared to the average no-nothing Joe Sixpack in America, even third-rate doctors are rocket scientists), when it could overcome it, especially when coupled with my tips that enabled me to go from a struggling “slow” student (according to my sixth-grade teacher) to the very top of my class in medical school.

America desperately needs a better educational system. We're falling behind other nations, and we're so fixated on the “America is great/Americans are great” propaganda we've been fed since birth that most of us can't even figure out why other nations outshine us.

Some of my sheds:

When I speak to various engineers about their company's products I might use in an invention, I am regularly stunned by how little these folks know even about bread-and-butter matters they should be experts in. They often have little knowledge of or concern about how their products are used in the real world, and how to make obvious (to me) improvements in them. They often reek of apathy, just perfunctorily going through the motions to get their paychecks. As someone who aspires for excellence in everything I do, from building a shed to inventing something, I find this half-ass attitude loathsome.

Considering how much money Americans spend on healthcare, we ought to get much better results. Why don't we? The foremost factor is that most people—and virtually everyone in power—think that the science of medicine is synonymous with health. Far from it. People want health, not medicine, but they and their doctors typically think that the path to health is paved with pills and occasional detours for surgery. If people were as similarly illogical about caring for their cars, they'd neglect them, letting their engines get rusty inside, and letting their bodies rot with rust. Then they'd merrily visit a mechanic, who with a wave of his magic wand could make everything as good as new. Dream on!

When doctors wave their magic wands—pens that write prescriptions—they have surprisingly little power to undo damage. They can often limit further damage, but usually do less good than what could be achieved by a healthy diet and lifestyle: something doctors give lip service to as they shovel garbage into their bodies—usually the same garbage others eat. Americans get weight loss advice from physicians who usually have too much blubber, which makes as much sense as getting ethical advice from criminals. Even most anti-aging doctors I've seen appear like they're aging just as quickly as everyone else. It is possible to slow the aging process and reverse certain manifestations of it, but few doctors have enough energy to dig deep enough to find and implement that information. That's a shame, because people don't want merely the absence of disease (generally about the best doctors can offer), they want to feel and look wonderful.

In a roundtable discussion, Funding CME -- As Pharma Retreats Who Pays the Price?, Dr. Robert W. Morrow astutely commented, “Has CME come to stand for commercial medical education? Many physicians recognize that the curriculum and content of continuing medical education are largely determined by those who pay for it. We currently face a rather fierce debate on the question of who should own the CME agenda. Certainly, when a resident goes into practice, the only CME available should not be for "product placement" or understanding disease categories that only serve a market. Nevertheless many CME activities, even those provided by our professional associations, receive industry funding, and must be designed around industry sales agendas.”

She is qualified to be a cheerleader, but is she qualified to teach doctors? Drug companies think ex-cheerleaders are qualified after a short course that industry insiders have admitted is little more than brainwashing them into thinking their drugs are best. Hence, this is more propaganda than education.

The American CME system has multiple glaring flaws that should have been targeted long ago by leaders in that profession, but they are either too stupid to recognize what is wrong, too spineless to speak up, or too willing to be medical whores for the pharmaceutical industry. I discussed medical whores in an article, Hospitals mandating flu vaccines. Money has warped the practice of medicine so much that big-name physicians are willing to lie through their teeth to please pharmaceutical manufacturers, who hire ex-cheerleaders to “educate” doctors. This situation would be comical if people weren't suffering and dying as a result of it, but they are.

It's tough to get justice when your sheriff is corrupt, and it is tough to be optimally healthy and happy when your doctor acquiesces to a system that values profits more than patients.

The American medical education system does not encourage physicians to think for themselves; instead, it heavily pressures them to believe what the leaders believe. However, what the leaders believe is often what the pharmaceutical industry wants them to believe. Doctors who are willing to be pharmaceutical whores can live like kings on the money they are paid for pulling the wool over the eyes of the doctors too stupid to think for themselves.

The average medical student is very bright—a borderline genius, in fact—so how do such intelligent people become too stupid to think for themselves? By being educated in an antiquated system in which almost everyone teaching knows little about teaching in ways that maximize learning. After years of exposure to this third-rate system, most doctors can't spot even glaring fundamental problems in the CME system. The docs just merrily participate in this educational fraud to obtain the credits they need to renew their medical licenses every two or three years (depending on the state).

Medical and surgical residencies are not designed to maximize learning; they are engineered to exploit doctors as slave workers, and to continue brainwashing them into submitting to authority.

I never met many of the doctors supposedly teaching me. Their names were on the chart as the attending doctors, and they were paid as the attending doctors, but all of the work was done by the residents. We did everything: histories, physicals, order and interpret lab tests, EKGs, x-rays, CT scans, make diagnoses, do procedures and surgery, write prescriptions, and discharge patients—all without the attending present! The junior residents could learn from the more senior residents, but who is teaching them? The tacit rule of this twisted system is that people must not complain about it so the attending doctors who profit from it can spend their time golfing instead of teaching.

Now, some attending doctors teach: I did, when I became an attending ER doctor, but it isn't easy to turn an emergency department over to residents without making local funeral homes very busy. If I had a reasonably competent chief or senior resident to work for me, I could have stayed home, collected the money for patient care delivered by residents, and made it all official by going to the hospital every now and then to sign charts.

I will explore the medical education and residency scam in another article. If patients knew how they are being harmed by it, they would be furious.

American doctors are supposedly the best in the world, so how can our educational system be so pathetic? American doctors aren't the best without burning countless billions of dollars as technological crutches: tests and procedures that help remedy their many educational gaps. This helps explain why Americans spend so much on healthcare and yet have worse health than people in nations who spend a fraction of what we do.

Wise people are looking for ways to economize on healthcare without hurting patients. One of the best ways to do this is to revamp the medical educational system, from med school to CME. However, the medical education system is controlled by people who profit from it being just the way it is. Meaningful change won't come from within; pressure to produce that change must originate from patients demanding that politicians do what they should have done long ago. Had they done that, the United States might not be teetering on the edge of bankruptcy.

So what are we waiting for? More people to suffer and die? More national debt that we cannot repay? More years of putting American businesses at a competitive disadvantage against companies in countries with lower healthcare costs?

The American healthcare system is raping Americans and ruining America. Isn't it time we demanded change?

I am not one to evade responsibility. After high school, I dearly wanted to enlist in the Army or Navy and serve my country, but was rejected because of a prior peptic (“stomach”) ulcer. I contacted my Congressman, William Broomfield, who wrote to the Pentagon on my behalf (without them budging, unfortunately). I feel a similar never-give-up responsibility to expose the American CME system that turns a blind eye to how it is too often a sham and usually oblivious to best teaching practices.

Kevin Pezzi, MD