Editorials

Continuing medical education

Medical education is unfit for the millennium. Professional conservatism, inertia, and poor leadership have left it struggling to cope with rapidly changing health care systems. Those universities that have adopted new educational programmes may dispute this, but globally they are in a minority and their experiences have mostly not been evaluated or well disseminated. Too many education programmes at all levels continue to churn out "time honoured" material, present it boringly, and assess its absorption predominantly by written tests. Too few train doctors, both new and established, to acquire the skills that the new trends in health care demand.

Adult learning theory holds that a key element of good teaching is the ability to stimulate self learning. This message has been accepted at medical undergraduate level, where many universities have introduced variations on problem based learning curriculums. Continuing medical education has, however, lagged behind. More emphasis has been placed on quantity than quality, despite the fact that ever more credence is being given to the role of continuing medical education in maintaining professional standards.

In the first of a new series on continuing medical education (p 301), Angela Towle discusses the current trends and forces in health care and their implications for all forms of medical education.¹ She concludes that continuing medical education in particular needs radical change, to become accountable to both those who pay for health care and those who use it—and to reflect their needs and priorities as much as those of the medical profession.

In Europe, continuing medical education is largely a professionally driven activity based on "recognised" educational activities for a set number of hours a year. In America, pressure from health care providers has been a major factor in the establishment of formal recertification. Every 7-10 years doctors in most specialties have to renew their specialist licences. This usually entails completing multiple choice questionnaires. Although these are a poor measure of performance, more rigorous forms of assessment, such as practice visits and peer review, have proved too costly to introduce widely. Doctors who don't get recertified get paid less, may lose admission rights to hospitals, and are less favoured by patients. With such incentives it is not surprising that the development of education programmes geared to helping doctors pass recertification exams has become big business.

Unease about the vast "CME industry" is high. Costs are hard to measure but are estimated in billions of dollars in the United States alone. The lack of evidence that many of these programmes change doctors' performance or improve patient outcomes, and their heavy dependence on pharmaceutical industry sponsorship (with its inevitable emphasis on diagnosis and treatment), are widely acknowledged as problems. In response, educationalists, health care purchasers, and others have been looking more critically at the provision of continuing medical education, and a growing consensus exists on what methods are effective. Much of the published information is, however, descriptive rather than evaluative—but, as Dave Davis illustrates in the third article in the series, there is convincing if relatively sparse evidence that well crafted, targeted, continuing medical education programmes improve not only doctors' performance but also health care outcomes. He also says that continuing medical education is becoming more innovative, international, and relevant to patient care.

But isolated reports are not enough. For many clinicians, continuing medical education is a chore, and most go for the soft educational options.² Few are fully aware, or care about, which forms of education work best, and without clear guidance the call from medical educationalists for providers and consumers to recognise their professional obligations and commit themselves to effective, evidence based continuing medical education³ is unlikely on its own to effect change.

Internationally, the trend is to enforce rather than encourage continuing education and for reaccreditation and recertification to be introduced more widely in the belief, or hope, that this will guarantee professional standards. It is arguable, however, whether this approach is ever likely to be sufficient to do this, irrespective of how or by whom standards are set. Motivating doctors to improve their performance and adopt continuous learning as a way of life is just as important, if not more. It is equally important to introduce good methods of continuous assessment of performance.

The fact that most current models of continued medical education fall well short of the ideal has fostered the conceptually broader paradigm of continued professional development.⁴ While continuing medical education is largely designed to plug supposed gaps in knowledge, continuing professional development is rooted in self directed reflection and learning in practice. It thus involves multidisciplinary and organisational as well as individual learning. The fourth article in this series discusses the potential of programmes such as MOCOMP, a new computer based personal self learning system based on this approach. The authors propose that it could be used as the basis for a form of continuous recertification.

Such innovations warrant serious consideration. The profession must respond soon to the growing pressures for it to be more open about, and accountable for, maintaining professional standards. Continued education, learning, and professional development within an increasingly a multidisciplinary health care environment are pivotal. Those who are trying to persuade the profession of this obvious truth and point the way forward should be supported.

Tessa Richards, Associate editor, BMJ 

1. Towle A. Changes in health care and continuing medical education for the 21st century. BMJ 1998:316:301-4.
2. Toon P. Educating doctors to improve patient care. BMJ. 1997;315:326.
3. Booth B. Does continuing medical education make a difference? Med J Autralia. 1997;167:237.
4. Brigley S, Young Y, Littlejohn P, McEwen J. Continuing education for medical professionals: a reflective model. Postgrad Med J 1997;73:23-6. [Abstract]