Continuing medical education (CME) has seen some changes in recent years that providers of continuing dental education (CDE) would do well to note. In September 2006, the Accreditation Council for Continuing Medical Education (ACCME) introduced new criteria for the accreditation of CME providers in the United States.¹ In addition, the American Medical Association and the American Academy of Family Physicians have made provision for CME providers to award CME credit to physicians for performance improvement activities or point-of-care learning in their practices.^2,3 In January, the Joint Commission⁴ revised its standards to require that hospital-based CME be linked to the findings of hospital performance improvement activities and advocated the development of a national performance measurement strategy that would facilitate the flow of information to health care providers.

The need for change has not gone unnoticed. Three Institute of Medicine reports have been critical of health care delivery and quality in the health care system in the United States.^5–7 In addition, a December 2007 report from the Josiah Macy Jr. Foundation⁸ was critical not only of the seemingly excessive support of CME by the pharmaceutical industry but also of the excessive use of lecture-based continuing education activities—which, while they may improve knowledge, may not be sufficient to result in changes in performance. The authors of the report recommended sweeping reforms of continuing education in the health professions, such as the implementation of practice-based improvement initiatives and just-in-time learning.

Certainly, these developments in CME should be noted by providers of CDE as well.

"Utility of an International Normalized Ratio Testing Device in a Hospital-Based Dental Practice," the article by Brennan and colleagues ⁹ in this issue of JADA, raises issues of quality of care and, by extension, of the necessary ongoing professional education that enables practitioners to deal with those issues. In responding to the request to comment on these issues, I am reminded of the opportunity for all health professionals to re-examine how they do their work and to reaffirm for themselves the importance of being well-informed, not just in terms of recent developments in their disciplines but also in terms of the constant assessment and reassessment of the effectiveness of the care they deliver. As I have been active in the North Carolina Area Health Education Centers program for more than 25 years and have had administrative responsibility for dental CE, it has not escaped my notice that the profession could benefit from using more creativity in its design of continuing education.

The salient features of the new ACCME system are that CME providers "generate activities/educational interventions that are designed to change competence, performance, or patient outcomes," "integrate CME into the process for improving clinical practice," "identify factors outside the provider’s control that impact on patient outcomes" and "participate within an institutional or system framework for quality improvement."¹ While some of these criteria are within the realm of achieving the highest level of CME commendation, the intent is clear: no longer is it sufficient to produce purely knowledge-based education. This issue’s article by Brennan and colleagues⁹ provides a launching pad for consideration of the relevance of the new ACCME system. What are the structural issues in the system of care that create the disconnect between what is and what should be?

A thoughtful reading of Brennan and colleagues’⁹ article raises numerous issues relating to the care of patients with complicated conditions in a complex health care system:

– the disjunction between physicians and dental providers;

– inconsistency in patient education;

– patients’ compliance or lack thereof;

– patients’ interpretation and misinterpretation of instructions;

– the role of substance abuse;

– the lack within the medical and dental professions of clear and appropriate guidelines (in this case, for international normalization ratio [INR] levels and dental care);

– the lack of a central locus of coordination of patient care;

– the challenges of delivering care to indigent people (transportation, housing, financing and logistics of medication administration, patients’ interpretation of instructions before receiving dental care, communication between providers [if any], and so forth).

It is not sufficient to say simply, "Let’s have a lecture on this." Rather, we must use these issues as a stimulus to begin to restructure the system of care for such patients. But restructuring the system of care is a complex issue. It requires a new set of skills for the dental practitioner and other members of the dental team, and it raises a number of questions, such as the following:

– Who are the patients at risk of experiencing excessive bleeding?

– Who on the health care team oversees and coordinates the care of patients who have complex medical illnesses?

– How do we best educate patients or their families or care-givers with regard to medication administration and adjustment?

– Is it possible, for example, to measure INR within a sufficient interval before surgery to allow for dosage or nutritional adjustment?

– What is our mechanism of communication with each patient when care involves a multidisciplinary team of professionals?

– Are databases as well as staff members available for entry of information into patients’ records?

– Are clinical care guidelines available for the condition under consideration?

– Who will change the system of credit generation for CDE to allow for credit accrual for quality improvement work?

Efforts to influence performance in dental care apparently have been attempted, but to date they have not reached a level of high priority within the profession.^10–13 There are many examples in medicine of practice-based educational initiatives,^14,15 however, and the prevailing environment has prompted more action in CME.¹ Dental professionals, likewise, should be aware of and begin to pursue practice-based CDE.

These challenges to the systems providing continuing education all are large and potentially daunting, as are the challenges to health professionals to improve their performance in practice. However, this new direction for continuing education is a necessary improvement.