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BMJ No 7128 Volume 316
Education and debate Saturday 31 January 1998
Continuing medical education
Global health, global learning
Dave Davis
This is the second in a series of seven articles looking at international trends and forces in doctors' continuing professional development
|
CME - continuing medical education - has become an international discipline. Defined as any and all ways by which doctors learn after the formal completion of their training,(1) CME is being shaped by several forces. Foremost among these are the globalisation of health(2); cross disciplinary movements such as evidence based medicine; common trends in medical education and the assessment of professional competence; and the impact on health care and professional education of the identification of the determinants of health.(3, 4) Add to these electronic mail and the internet allowing instant global communication and virtually unlimited access to medical information and it is not hard to see why CME has become an international concern.(5) This paper reviews the main published work on CME, identifies major themes in its development, and points to ways that may help standardise and support the provision of CME internationally. |  |
| Summary points |
| Health is a global issue; hence continuing medical education is an integral phenomenon |
| International CME is more than conferences and courses - it includes projects in needs assessment, a wide variety of formats and strategies, and evaluation of doctors' performance and health care outcomes |
| Its delivery and organisation can be altered by social, political or financial, professional, technological, and educational forces |
| Trends include changing content to meet societal, demographic, and cost effectiveness demands; relicensure, recertification, and mandatory CME; and the emphasis on learner centred methods and new educational technologies, especially those linked with practice or patients' data |
| Providers of CME are trying to increase the professionalisation of this "discipline" and to share findings about doctors' learning world wide |
| CME may be seen as an essential "effector arm" in complex healthcare systems, whether in developed or developing countries |
Methods
To gather information for this article, I searched the Research and Development Resource Base in CME extensively for articles (published 1986-96) that describe CME activities worldwide, excluding North America and the United Kingdom.(6) At the time this article was written, it contained references to over 7000 articles and monographs devoted to continuing health professional education. I also searched Medline, eric, embase, and other databases for articles (published 1986-96), using terms and phrases such as world health, global health, international cooperation, and international educational exchange and continuing medical education terms combined with geographical names. Then I circulated the results of the literature searches and a brief questionnaire to key informants in the field, to identify other articles and to add their opinions about forces for and trends in continuing medical education.
Results
I found 68 articles that met these criteria (table).(7-74) Fourteen focused on determining the learning needs and patterns of clinicians(7-18)(73,74); 22 articles described in general terms an intervention such as a CME teleconference, programme, or course(19-39)(72); 12 evaluated the effect of the CME intervention on doctors' competence or performance or change in health care outcomes(40-51); and 20 studies provided an overview of the structure, role, or trends concerning CME within the region or country of origin of the article.(52-71) The last section has been enhanced by the addition of comments from key informants in selected countries.
| Studies of international continuing medical education | ||||
| Region | Type of study | |||
|---|---|---|---|---|
| Surveys, needs assessments (n=14) | Description of activity or intervention (n=21) | Evaluation of outcomes (n=12) | Overview or trends (n=20) | |
| Africa (n=5) | 1 | 3 | 1 | |
| Asia (n=6) | 3 | 2 | 1 | |
| Australia/New Zealand (n=7) | 3 | 1 | 3 | |
| Caribbean (n=1) | 1 | |||
| Central Europe (n=26) | 4 | 6 | 4 | 12 |
| Central and South America (n=2) | 2 | |||
| Eastern Europe (n=2) | 1 | 1 | ||
| Scandinavia (n=5) | 1 | 4 | ||
| Transnational (n=13) | 3 | 7 | 3. | |
Surveys of needs
The studies of needs assessment used tools such as surveys or
focus groups to determine knowledge and practice gaps in potential
learners. Needs have been analysed by multifocused surveys of rural
practitioners in Australia(8)(11) and by broad, topic
specific studies in Germany in psychogeriatrics(9) and in
Egypt in HIV and AIDS.(13) Beyond standard surveys of needs,
educators in Sri Lanka have used Delphi techniques to help
practitioners evaluate their own clinical skills.(16)
Interventions
While the formal conference or short course remains the staple of
organised CME in both developed and developing nations, a variety of
alternative educational formats and interventions have been described.
Skills training has been studied in the Caribbean in advanced trauma
life support(40) and in Japan(17) and in
Italy(49) in laparascopic surgery. Innovative educational
delivery techniques were exemplified by interprofessional educational
experiences in Bulgaria,(41) problem based learning in
Sweden,(23) self instructional programs in
China,(25) and small group learning in
Ireland.(28) Learning contracts for continuing education in
radiology have been used in the Urals in Russia (V Sharov, personal
communication). Providing potential links for distance education and
patient care, teleradiology and telemedicine have been extensively
reported, reflecting the issue of geographic isolation in the Middle
East(24) and in other developing countries(21);
and patient education programmes as a component of CME initiatives have
enjoyed some success in
Germany.(19)(26)(44)
Shaped by the twin challenges of doctors' remoteness from medical information and the opportunities which new technologies present, Monash University in Australia has developed a trial project using the internet to link isolated doctors to university resources.(72) This project has more clearly defined both academic and non-academic (technical and logistical) issues and has developed a model which includes user training, technical support, the role of the internet service, and appropriate categorisation and configuration of healthcare information.
Among interventions that were explicitly international and exemplified collaborative efforts were the Wellcome Tropical Institute's attempt to deliver problem based learning materials to rural practitioners in Ghana, Kenya, and Pakistan(21); telemedicine projects linking the United States, United Arab Emirates, and Saudi Arabia(24); the intervention by Project HOPE (an American non-government organisation) in neonatal education in the Chinese province of Zhejiang(25); and a multicountry satellite television project described as the TransMed experience.(38)
One example of an international network was an international clinical epidemiology programme designed to build clinical epidemiology expertise and infrastructure in countries by developing clinical epidemiology units in medical schools.(73) By means of on-site learning at host universities and distance learning by email and visiting teachers, the programme uses clinical epidemiology, biostatistics, health economics, health services research, and other methods to develop rational approaches to health care and clinical decision making.
The Center for Public Service Communications for the US National Aeronautics and Space Administration has surveyed telemedicine projects and interests on a global basis.(74) The survey highlights projects in Europe, Japan, the United Arab Emirates, and Australia, as well as Canada and the United States.
Evaluation
Forces and trends in CME
Many social forces such as changing demographics and lifestyle have an
impact on the content of CME - for example, increasing its emphasis on
geriatrics and disease prevention. The increasing number of
practitioners in rural or isolated settings, along with change in
educational technologies, has led to a decentralisation of CME. With
tighter governmental financing of health care in both developed and
developing nations, cost efficiency is emphasised, rather than broader,
more conceptual learning. Interlocking pressures from social,
political, and regulatory sources have given rise to recertification,
relicensure, and mandatory CME.
The issue of mandatory or obligatory CME itself, requiring physicians
to attend a fixed number of hours of educational sessions, has
generated some debate.(75) Although the movement seems to
have gathered momentum in Europe,(57) much of this kind of
learning is not effective(76) and doctors are dissatisfied
with a regulatory approach (particularly well documented in
Switzerland(62-70)). As a result, more sophisticated
programmes and learner centred programmes have emerged, such as the
maintenance of professionals standards programme of the Royal
Australasian College of Physicians.(71)
A cluster of forces have been identified in the profession of medicine
itself, including the barriers that keep doctors from participating in
CME, the growth in appreciation of the principles of adult learning at
undergraduate and CME levels, the availability of data on patients, and
evidence based medicine. These forces seem to have produced an
increased awareness of the doctor as learner and the need for multiple
modalities of CME interventions, and have given rise to studies of the
impact of continuing medical education on doctors' performance and on
healthcare outcomes. Many of these modalities are now much more linked
to practice and data, such as computer generated reminder systems, or
are practice based, such as small group learning experiences. A few
articles touched on what may be termed the maturation or
professionalisation of CME itself, studying its problems and
practices(57) and the development of policies on commercial
funding.(53) Technological forces for change include the
advent of computer based learning methods, such as material
available on CD ROM; access to the medical literature and information
on the internet; and distance learning, either solely educational
(satellite television, for example) or primarily oriented to
patient care, but with potential for CME (such as teleradiology).
This paper does not contain every article published on CME
globally - my search covered only English language articles published
between 1986 and 1996. The categories used here are not mutually
exclusive; some articles touch on several areas.
Even so, the articles retrieved show, both across and within nations, a
variety of types and efforts and point to the breadth, scope, and
impact of CME interventions and to their basis in patient care and
learners' needs. It also seems that CME can be applied to problems of
health services delivery and healthcare outcomes to good effect: the
Swedish study of suicide rates(50) is a good example of the
importance of the part that well crafted CME programmes may play in the
delivery of health care. Given that healthcare delivery in any country,
developed or developing, is an example of a complex, adaptive system,
it is clear that CME may play an important "effector arm" role
within it (R Woolard, J C Leist, personal communications).
There seems to be a movement to develop conjoint, transnational
CME activities and projects. This movement parallels efforts to
increase the professionalisation of CME providers by establishing clear
accreditation guidelines, articulating policies on ethical delivery of
CME, and determining and promoting the competencies of the CME
provider. This in turn is mirrored by movements in professional
organisations - those represented by national medical associations or
transnational organisations devoted to medical education - to include
CME on their agendas. Among such attempts, increasing over the past
decade, have been meetings sponsored by the UK-Nordic Medical
Educational Trust, the Norwegian Medical Association, the European
Academy of Medical Training, and the Royal College of Physicians in
England. These meetings have addressed topics of increasing
sophistication in CME and doctors' learning and have explored
questions of the organisation and value of CME, its evaluation, and the
conceptual base for CME, adult learning theory. In addition, North
American organisations, notably the Alliance for CME and the American
Medical Association, have been instrumental in bringing together CME
providers and others interested in CME from across the world to share
experiences - doctors and educators learning about learning. Finally,
there have been transnational studies of the organisation of CME, such
as the CME in Europe Project conducted by the World Federation for
Medical Education,(77) which act to fortify the movement to
study CME.
UK-Nordic Medical Educational Trust
Some common features seem to be shaping the future agenda of CME
providers on an international scale. These include changes in
undergraduate education; the role of professional and governmental
regulations in response to the question of accountability; new
understandings of the effectiveness, modes of delivery, and
technologies of CME; and a growing understanding of the shape and
regulation of CME itself.
Conclusions
I gratefully acknowledge the input of Ralph Bloch
(Switzerland), Alan Hewson (Australia), Terry Kemple (United Kingdom),
Jana Krejcikova (Czech Republic), Dennis Wentz, Charles Sherman, James
Leist (United States), Gunter Ollenschlager (Germany), Neil Paget
(Australia), Peter Pritchard (United Kingdom), Linda Snell (Canada),
Josef Vysohlid (Czech Republic), Mickey Weingarten (Israel), Robert
Woollard (Canada), and Vyacheslav Sharov (Russia). Anne Taylor-Vaisey,
the researcher/librarian in continuing education, Faculty of Medicine,
University of Toronto, conducted the literature searches.
Continuing
Education,
Series editors: Hans Holm and Tessa Richards
Correspondence to:
Hans Holm and Tessa Richards
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Twelve papers described extensive attempts to evaluate CME
activities at the level of doctors' performance or healthcare
outcomes. They are reported in Mexico,(45)
Italy,(49) Latin America,(42)
Israel,(43) Denmark,(46)
Sweden,(48)(50) Tanzania,(36) and
Nigeria.(37) One study of particular in
What forces operate to effect change in CME in the future? What
future directions might we expect CME to take as a result of these
forces? Answers to these questions form the fourth part of the findings
of this article, derived from articles that focused on the role or
direction of CME within countries or across regions,(52-72)
complemented by the views of the key opinion leaders canvassed. Here,
forces for change and their consequences are numerous and often
overlap, since many trends or directions are
multicausal.
Forces for and trends in continuing education on a global
basis Forces Trends Social
and demographic Changing
content of CME
Decentralisation of CMEGovernmental (financial; public
accountability) Content of CME
driven by evidence based principles
"Managed care"
CME
Obligatory or mandatory
CME
RecertificationMedical professional
(evidence based movement; availability and importance of data on
patients; incorporation of principles of adult education; doctors'
barriers to learning (time, funding)) Evaluation of effectiveness of
CME
Linkage to doctor's performance and healthcare
outcomes
Quality assurance methods
Multiple modalities in CME
diversityEnhancement of CME
provision Studies of CME provision or
intervention
Establishment of policies and standards in
CME
Research emphasis
Skills development for CME
providersEducational (incorporation of
principles of adult educational in CME and in undergraduate
education) Problem based learning, small groups, self directed
methods Technological
Enhanced distance learning capacity (eg, provision by
satellite television)
Computer assisted technologies (CD ROM,
etc)
Linkage to patient care, both distant (teleradiology, etc) and
local (computer generated reminder systems, etc)
Discussion
Education organisations concerned with CME
Norwegian Medical
Association
European Academy of Medical Training
Royal College of
Physicians [England]
Alliance for CME [United
States]
American Medical Association
World Federation for
Medical Education
Much has been learned about continuing medical education
across and within countries, and much more can be learned by sharing
findings and directions on an international level. The challenges and
impediments to such a movement are numerous - including different
languages, variations in training and culture, and disparity in
economic and healthcare delivery realities - but the opportunities are
even more so. These opportunities include the use of the internet as a
learning and communication tool, the establishment of common principles
of CME, and others that may be shaped by the shared goal (just as in
the case of infectious disease) of improving health care on a global
level. The ingredients for such a movement exist - individuals,
motivation, and projects - and form the basis at least for an ongoing
dialogue and at best for a shared vision of improving global population
health by means of an interlinked, mutually informing, and supportive
CME system.
Faculty of Medicine,
University of Toronto,
Toronto,
ON M5S
1A8,
Canada
Dave Davis,
associate dean
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