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BMJ No 7131 Volume 316
Education and debate Saturday 21 February 1998
Continuing medical education
Quality issues in continuing medical education
Hans Asbjorn HolmThis is the fifth in a series of seven articles looking at international trends and forces in doctors' continuing professional development
The need for continuous learning as part of a doctor's
professional career is evident. The best ways of introducing and
nurturing this learning have been the subject of much controversy, and
the quality of medical education at all levels is being questioned and
debated in many countries. This article looks at some trends and issues
that are being addressed in order to improve the effectiveness of
doctors' continuous learning.
Contribution of learning theory to medical educationInnovations in undergraduate medical education are influencing the whole spectrum of medical education. So too is the growing literature on adult learning(1-4) and the doctor as learner.(5,6) The works of Schön especially clarify the importance of the professionals' reflection on their everyday practice as a means of continuous change and learning.(7,8) |  |
Clinical problem solving has been identified as the core activity of how doctors learn and keep developing their competence. Creating an environment that provides practitioners with opportunities to explore and understand the personal theories underpinning their own practice is crucial for continuous professional development at all stages.(9)
| Summary points |
| A doctor's desire to be more competent in the delivery of health care is the most important motivating factor for continuous learning and change |
| Continuing medical education must be planned to meet the needs of doctor and based on both self assessment and peer review |
| The role of mandatory traditional programmes in maintaining competence is questionable |
| Medical colleges and societies need to improve their educational competence to be able to deliver high quality continuing medical education |
| More programmes should be linked to the workplace; they should include group based activities and use quality improvement tools |
Continuing medical education
Although a division of medical education into
stages - undergraduate, postgraduate, and continuing medical education
(CME) - seems sound from a regulatory and legal perspective, there are
no fundamental differences in the way people learn across the
continuum. The st
Most doctors work in teams with other doctors, other health
professionals, and administrators. Successful functioning depends not
only on the doctor but on the performance of the whole team. This
multiprofessional team represents a complex learning system which must
be reflected in the planning of CME.(11)
What is it that keeps doctors striving to maintain their
competence throughout decades of professional life? The driving force
among the outstanding doctors interviewed in different working
environments by Manning and DeBakey was "their pride in
performance - a desire never to be (or to be seen as) professionally
inadequate." (12) Similarly, in the physician change study
the desire to be more competent in the delivery of health care to
patients was the key force for change; regulations had little
impact.(13)
Strict legislative and regulatory measures are thus not likely to be an
effective way of maintaining professional competence. Reliable and
valid identification of those few doctors whose practice falls well
below accepted standards requires well planned and rather expensive
programmes.(14) These doctors undoubtably present a great
challenge to the profession and to the licensing bodies. For them CME
is hardly the "cure," and this must be
acknowledged.(15)
In the United States, most boards (licensing authorities) issue
specialists with time limited certificates.(16) The need for
doctors to get recertified every few years to retain their "board
certified" status has fuelled a multibillion dollar enterprise. This
consists mostly of didactic courses offered to doctors in need of
credit hours to meet recertification requirements.
The rationale for time limited certificates is twofold: firstly, to
encourage doctors to learn and keep up to date; secondly, to identify
those doctors who continue to meet the specialty boards standards - and
those who do not.(16)
In Europe, participation in CME programmes is largely voluntary, but
both the European Union of Medical Specialists and the Standing
Committee of European Doctors have adopted charters which state that
doctors have an ethical obligation or duty to undertake further
education.(17,18) The European Union of General
Practitioners, "recognising that moral responsibility alone is
insufficient," has suggested that doctors should be given incentives
to participate in CME activities.(19)
The impact of credit hours of traditional courses on the quality of
practice is, however, disputable, and traditional CME may have impeded
development of more effective ways of promoting continued
learning.(20) In one study the number of reported continuing
education hours was found to correlate positively with lower
competence.(21) The most important issue in continuing
medical education is the quality of the education programmes on offer,
not whether they are voluntary or mandatory.
Although competence is often taken as an all embracing term, it is
important to distinguish between competence and performance. What the
doctor does in day to day practice (performance) does not always
corresponds to what he or she is assessed as being capable of doing
(competence). No simple and effective way of assessing doctors'
competence and performance has as yet been developed. The approach
developed by the College of Physicians and Surgeons of Ontario (Canada)
is probably the most systematic.(14)
The issue of professional accountability is crucial for doctors. Public
expectations and demands are growing, and people expect their doctor to
meet set standards. If they do not, it is right for the public to
expect these doctors to be identified and removed from practice. The
profession needs to acknowledge this fully and implement policies to
meet this challenge if it is to escape the imposition of external
regulations of doubtful benefit to continued learning. It is therefore
important that those responsible for continued medical education ensure
that their methods of assessment of doctors' competence and
performance are evidence based and promote self directed learning.
"A process in which learners take the initiative
... for increasing self and social awareness;
critically analysing and reflecting on their work ...
defining their learning needs ... formulating goals
... identifying human and material resources for
learning ... choosing appropriate learning strategies
... and reflecting on and evaluating their
learning." (4)
Identification of learning needs is the basis for planning of
continuing education - for individuals, organisations, and the
professional organisations responsible for medical training. The
medical competence of medical colleges and societies is high, but
professional educational expertise has until recently been rather
scarce. This may have impeded the planning, implementation, and
evaluation of more effective programmes.
Who defines the needs and how they do it is important. Medical audit in
its classic form is intended to assess practice against a set of
predetermined criteria. It is often carried out as a peer review and is
probably more often experienced as a quality control mechanism rather
than a basis for defining learning needs. A system of self assessment
is preferable if the emphasis is on education and continuous learning
rather than the identification of poor performers.
Whether self assessment leads to identification of real needs, and
whether these needs can be adequately met by CME, are research issues
of interest to the profession and the public.
"There is a need to develop tools to measure or assess the
presence of self-reflection or self-learning. The application of such
tools, passing methodological criteria hurdles, would ensure that
physicians at some internal level: (1) recognize their learning
deficiencies in the context of patient care or professionalism;
(2) possess the ability to reflect on their practices; and (3)
measure these needs against external and internal standards set by
peers, regulatory bodies, patients, policies, the literature, and
(perhaps most of all) themselves." (22)
In countries where recertification systems are in place, these are
based mainly on documented participation in formal educational
activities, while actual performance is seldom subject to assessment.
Some organisations, such as the Royal College of
Anaesthetists,(23) consider a wider area of activities as
eligible for CME credits.
These initiatives reflect a broader understanding of how doctors learn
and could be a step towards viewing CME as part of the quality
improvement systems that are being developed in hospitals and general
practice. There are arguments put forward, however, that the "narrow,
professional control of evaluation, buttressed by the quality assurance
and monitoring mechanisms of the Colleges, is inappropriate, given the
increasingly diverse accountabilities which affect medical
professionals." (24)
Portfolio-based learning
In Britain, portfolio-based learning has been recommended by a working
group appointed by the Royal College of General
Practitioners.(27) In the Sheffield region such a programme
has already been developed; it consists of a personal education plan, a
portfolio to document progress towards attainment of the plan, and
mutual support through a co-mentoring group.(28) Evaluation
of such programmes is vital to answer the questions such as whether
doctors who use PCDiary as a learning portfolio provide a more
objective assessment of their practice needs than their colleagues, and
whether we can trust self determined needs.
The way forward, therefore, is to find methods to improve doctors'
capacity to define their learning needs, and then to deal with these
needs (by asking the right questions and finding the right answers). In
terms of continuous quality improvement, this could be seen as a
bottom-up approach rather than the top-down approach that is
characteristic of traditional CME. Then the key challenge is to
establish whether this approach leads to improved performance and
improved patient outcome.
General practitioners in Europe are introduced to projects
representing various methodologies of quality improvement and learning
(assessment and audit, guideline setting, and small group peer review
and quality circles).(29) Regular and systematic data
collection and assessment as part of daily clinical work is, however,
still not very well developed.
In Canada, a practice based, small group learning programme for general
practitioners has been developed at McMaster University. The programme
offers educational material covering a range of topics, mostly based on
requests from the participants, and offers training workshops for
facilitators. Most of the 2000 or so doctors who have participated in
the programme have reported changing their practice as a result (J
Premi, personal communication).
In 1995 Danish general practitioners secured funding from their
national insurance company for decentralised, group based CME. About
70% of Danish general practitioners are enrolled on a voluntary basis.
One of the group members is appointed tutor by his or her peers. The
Danish Medical Association offers training for tutors. In addition,
each county has one or two specially trained facilitators (recruited
from general practitioners in the area) who help the groups in
organising their work. Otherwise the groups are self directed and
define their own learning needs.
In Norway, more than 95% of eligible laboratories in general
practitioners' surgeries are enrolled on a voluntary basis in a
quality improvmeent project of laboratory analyses. Every year since
inception in 1993, quality has improved. A mentoring service, carried
out by specialist doctors and medical technologists, gives feedback to
the team working in the surgery on how they work and how they can
improve. Currently, the programme is moving further, challenging the
doctors to examine the rationale behind their choices of analyses in
given cases.(30)
Another Norwegian project, SATS (quality indicators in general
practice), which also has its parallels in other countries, is aiming
at developing continuous quality improvement in primary health care by
introducing indicators (pertaining to structure, process, and result)
for the assessment of quality and setting of standards in the local
practice; developing software to simplify the collection of data and
generation of reports from computerised medical records; and supporting
peer groups of 5-10 practitioners willing to discuss results, agree on
local standards, and plan improvements.(31) Participants
earn credits for certification or recertification as general practice
specialists.
Linking continuous quality improvement and continuing medical
education: a project aimed at improving care in a general practice
setting.
Example: Acute sore throat
Structure: Process:
Results:
Although medical decision making is seldom based solely on
"pure" evidence, using the best available evidence is a challenge
and an ethical obligation that needs to be addressed at all stages of
medical education. "Good doctors use both individual clinical
expertise and the best available external evidence and neither alone is
enough." (32) It is likely that the ability to
systematically reflect on clinical problems, which underpins the
ideology of the SATS programme, may improve doctors' "reflective
competence" in other spheres of their work.
The challenge of maintaining professional competence in an
environment characterised by rapid organizational change, information
overload, and increasing public expectations is forcing doctors to
think hard about medical education. Adult learning theory and knowledge
of how professionals maintain and develop competence are placing
increased emphasis on self directed learning and pointing to clinical
practice and problem solving as key areas of interest. The ability to
work in teams is also recognised as essential.(33)
Academic institutions and medical organisations need to improve their
educational competence, show a stronger commitment to educational
research, and value faculty members who take on these duties.
Certification and recertification requirements must be tuned to support
continuing professional development and continuing quality improvement
if they are not to be rejected. CME must become a more visible,
integrated, and well planned activity for which both protected time and
adequate funds must be provided.
Norwegian
Medical Association,
Correspondence to: Hans Asbjorn Holm and Tessa
Richards
Series editors: Hans Asbjörn Holm and Tessa Richards
References
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Publications, 1996.
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21 Caulford P G, Lamb S B, Kaigas T B, Hanna E, Norman G R, Davis D A.
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22 Mast T, Davis D. Concepts of competence. In: Davis DA, Fox RD,
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23 http://www.ncl.ac.uk/~nrcoa/cme.html
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Gilman N J, et al. A method of self-directed learning in continuing
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Motivation for continuous learning
Mandatory or voluntary?
Competence and accountability
Self directed learning Needs assessment
Research issues in self learning Continuous quality improvement
Ten years ago it was shown that doctors could meet specialty board
requirements for recertification by setting up their own learning
plans.(25) The Canadian Maintenance of Competence Programme
(mocomp), a portfolio-based documentation of individual
learning, takes this further. It acknowledges that learning takes place
daily in the practice environment, and it provides a system for
documenting such learning.(26) To facilitate entries and
comparison with peers a computerised diary (PCDiary) has been
developed.(16)
Quality improvement among general practitioners
SATS project, Norway
Objectives:
Antibiotics should be prescribed when the
clinical picture points to group A streptococcal infection.
(The indicators describe how the clinic is
equipped to facilitate optimal diagnostic procedure.)
Does the
clinic have guidelines for the condition?
Is the
streptococcal test available, as well as guidelines for its
use
Is there a positive antigen test or
are clinical criteria fulfilled when antibiotics have been given and
ICPC (international classification in primary health care) diagnosis is
R72 or 76?
If antibiotic other than penicillin V has been
prescribed, does the patient suffer from penicillin allergy or
relapse?
Has a relapse been recorded within
two weeks?
Has the patient reported being unchanged or worse after
3-4 days despite antibiotic treatment? Conclusions
PO Box 1152 Sentrum,
N-0107 Oslo,
Norway
Hans Asbjorn Holm,
deputy secretary general
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