At its core, our profession helps others to improve healthcare.
At our best, we reduce errors, streamline systems, and advance the field of medicine. At our worst, we can spread misinformation under a label of integrity. On average, we do amazing things, often for little credit, never enough money, and too much stress — but we do it because it needs to be done. I love this community for that reason. We do what needs to be done.
Now, I think it’s time we discuss ethics in continuing education.
“Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other form a million different centers of energy and daring those ripples build a current which can sweep down the mightiest walls of oppression and resistance.” —Robert F. Kennedy
Delivering high quality continuing education requires us to develop a very particular set of skills. CE professionals cultivate abilities in adult education, compliance, fiscal oversight, logistics, public policy, human and organizational management, culture change, and communication. Each of these are entire professions, but it’s our unique charge to harness this constellation of skills to achieve results, especially when these areas appear at odds.
There’s something that happens at nearly every organization, and to most CE professionals, but it’s something we don’t discuss enough. Over the years, I’ve come to refer to it as “the battle” — as in, when people say to “pick your battles,” this is the battle.
The battle is a culture-setting exercise, and one you have to win for the sake of your organization. It usually transpires when CE leadership or organizational leadership has a transition; these are the moments when practices and policies are examined, questioned, and tested. The battle transpires because, superficially, the organizational priorities of compliance, production, and growth can appear at odds with one another.
Over 75% of colleagues questioned during the research of this piece shared stories of their struggles, and patterns began to emerge.
The battle transpires in two ways: overt actions and “soft pressure.”
Overt actions include actions like open directives to falsify information or demands to certify for CE information you know to be dangerous, false, or unsubstantiated.
Soft pressure is more insidious, but usually involves a practice of repeatedly being asked to question compliance decisions, even when the proper course of action has been outlined for the other party. Often, it involves the improper receipt or use of funding, certifying content that isn’t up to par, or ignoring situations created by conflicts of interest.
As told by Erin Schwarz, principal with Vivacity Consulting:
I’ve experienced soft pressure to blend the lines between what is commercial support and what is promotional support. This typically happens through repeated questions such as, “Are you sure that is classified as commercial support?” Again, there is usually no ill intention behind these types of questions. It is a result of the different forces working on the staff members, including the need for funding to support the organization and/or the expectations of the physician leadership. I usually ask, "Why are you asking me these questions?" and the client is able to name some of these forces. After they notice all of the external forces at work, the right decision can be made. There has been one instance when I felt direct pressure to falsify information, and I discontinued working with this client. They are no longer accredited.
This is a very real aspect working in CE. We talk occasionally of communication strategies and conflict resolution, while neglecting to mention the kinds of conflict that need resolving.
I’ve worked at several CE organizations, and under dozens of accreditation systems. I won my first “battle” at the American Academy of Ophthalmology and didn’t understand at the time how important that was. Over the years, I’ve become increasingly adept at navigating the issue, but it’s not always a battle that can be won. In spite of that, it’s always a battle worth fighting, and we should make it easier for our comrades in arms.
Galvanizing Our Values
For two years, the Almanac has produced articles connecting the CEhp National Learning Competencies (NLCs) to daily practice. We’ve received wonderful feedback on the series and are thrilled that readers value the content, but we’ve hit a snag.
Our profession needs a code of ethics.
In continuing education, we often discuss how something needs to be done, but we often need to explain why a course of action should be taken. And, we know this.
When the NLCs were revised in 2013, the first component — the most important aspect — of Leading the CE Program (NLC 6) was to “conduct all affairs with high standards of professionalism and ethics by:
- Adhering to ethical standards for CEhp professionals and related fields.
- Providing resources to help others learn about ethics and professionalism in CEhp.
- Providing mechanisms and support to help others identify and address ethical dilemmas.”
That’s well and good, but we forgot to outline our ethical standards. Certainly, we can “adhere to ethical standards for … related fields.” The AMA, ANA, ACPE, APA, and Advamed have codes of ethics. Good ones, too. The closest applicable code from within our profession is NAMEC’s Code of Ethics, but that code falls short of the standards established by the professions for which we serve.
Good ethical standards, like the AMA’s and ANA's Codes of Ethics, provide concrete examples and articulate expectations both in terms of what to do, and what not to do.
The first behavior outlined in our competencies to demonstrate professionalism and ethics at a novice level is to “describe the ethical standards of behavior that are expected.” Yet, without a code of our own, how can any of us truly say we’re capable?
Building a Suit of Armor
Members of the Alliance are supposed to mentor and cultivate new leaders, but leadership is more than expertise. Leaders make hard choices, and we should be making those choices easier and providing reinforcement when difficult judgements are made for valiant purposes.
“Leadership involves the heavy burden of responsibility, and the fear of getting it wrong can paralyze a leader.” —John C. Maxwell
Remember NLC6.1 c: Provide mechanisms and support to help others identify and address ethical dilemmas. Having ethical guidelines would provide members our community a document they could point to and say “these are the standards I’m tasked to uphold; these are the expectations cast upon me by the profession for the sake of our learners.” It would give them armor when they fight the battle. It would give them reinforcement.
Quite simply, it’s easier to win the “battle” with support. Sometimes, there’s support within your organization. But what happens when an organization is young or small, when organizations have corporate cultures more prone to volatility? Or, what about established firms in need of serious work to get back on track? In these instances, support needs to come from outside.
We need to support our colleagues.
Acting With Integrity
“The world is not changing if you don’t shoulder the burden of responsibility.” —Ai Weiwei
NLC6.1, Demonstration of Proficient behavior:
- Influence people to adhere to agreed-upon standards.
As a profession, let’s agree to some standards.
The ability to care for the sick, the injured, and the infirm is a hallmark of post-industrial societies. Healthcare matters, and so too does the process of improving healthcare. That’s our focus, our calling, and our cause. What we do matters.
According to the ACCME, CME providers alone offered nearly 159,000 educational activities in 2016, delivering over one million hours of instruction to over 27 million healthcare professionals. And those figures are from a single accreditation system.
The better we do our jobs, the better every single healthcare professional can perform theirs. We have a moral imperative to perform at our best. We desire to be recognized as a “true profession” and “part of the healthcare enterprise,” but I’ve never met a clinician who doubts the need for improved patient outcomes — and that’s what we help them achieve. If there’s any doubt, it’s about us as professionals.
In the mind of many healthcare providers, the duties of continuing educators are still clerical in nature. Understaffed departments and underpaid administrators get told to “get this certified” as if it were akin to booking a meeting room. We have a lot of work ahead of us to be taken seriously as part of the healthcare community, but one of those steps will be to take ourselves seriously.
Let’s each strive to be our best for each other, to better ourselves in order that we may better support our colleagues, our friends, and our communities.
Let’s do the job of setting standards for each other, and helping our colleagues to get there.
Let’s define our values.
“In that daily effort in which intelligence and passion mingle and delight each other, the absurd man discovers a discipline that will make up the greatest of his strengths. The required diligence and doggedness and lucidity thus resemble the conqueror's attitude. To create is likewise to give a shape to one's fate. For all these characters, their work defines them at least as much as it is defined by them.” —Albert Camus
I don’t have all the answers; it’s not my place to. We have to do this together. What I will say is: It’s time for us to get this done.
Jacob S. Coverstone
Almanac Editor-in-Chief, 2015-2018