Continuing medical education (CME) has undergone enormous
changes in recent years in terms of its theoretical base, the
methodologies used, and the expectations of what it should deliver. It
has become an increasingly important concern for governments and
patients as well as doctors. As reaccreditation and quality
assurance programmes have become more widespread, the effectiveness of
continuing medical education in changing clinical behaviour has come
under closer scrutiny.
Davis defines continuing medical education as "any and all the
ways by which doctors learn after formal completion of their training."1 Grant and Stanton distinguish between
continuing medical education and continuing professional
development.2 Continuing medical education is seen as
representing a more teacher based, didactic style whereas continuing
professional development implies a more learner centred and self
directed approach to learning. These terms are used interchangeably in
the literature. For the purposes of this article we will refer to all
postgraduate educational events as continuing medical education.
In this review we aim to describe some forces for change in continuing
medical education, to summarise the findings of systematic reviews of
continuing medical education, and to examine the effectiveness of
postgraduate continuing medical education in general practice in
particular. Do educational interventions based on general practice change doctors' behaviour and improve patient outcomes?
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Summary points
The primary purpose of continuing medical education is to
maintain and improve clinical performance
Its effectiveness in changing clinical behaviour has come under
closer scrutiny as reaccreditation and quality assurance programmes
have increased
Continuing medical education for general practitioners should be
largely based on the work that they do
Needs assessment is an important component of continuing medical
education, but relying entirely on individual doctors' self assessments
of their learning needs may be problematic
Significant event audits, peer review, group based learning, and
reminders by computer have all been shown to be effective educational
strategies for general practice
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Methods |
We searched the bibliographic databases of Medline, BIDS, ERIC,
and Embase between 1990 and March 1999 for (a) systematic reviews of continuing medical education, (b) systematic
reviews of postgraduate continuing medical education for general
practitioners, and (c) postgraduate educational interventions based on
general practice. (The term "postgraduate" is taken to mean
educational events occurring after completion of general practice
vocational training.) We included intervention studies if they
contained a robust evaluation, which examined either the effects of the educational event on subsequent doctor behaviour or patient outcomes. We then retrieved selected references from these papers. The papers were graded by applying a standard hierarchy of evidence, with randomised controlled trials at the top and descriptive studies at the bottom.
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Results |
The pre-eminence of adult learning theory
Shifts in the underlying theoretical basis of continuing medical
education reflect the international changes in how medicine is
practised, regulated, and taught.3 The ideas of mainstream
educationalists4-6 have been widely incorporated into
undergraduate and postgraduate medical education, with the result that
adult learning theory has become the standard by which continuing
medical education is measured and appraised. The recognition that
learning not teaching causes doctors to change their practice has led
to a new educational focus.7 Self directed and lifelong learning are aspirations common to many curricula and educational programmes. Despite this theoretical shift in thinking, traditional styles of expert led teaching still prevail in postgraduate continuing medical education for general practitioners.8
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The expectations of continuing medical education |
The primary purpose of continuing medical education is to maintain
and improve clinical performance.9 Recertification and reaccreditation are part of an international trend to shift the purpose
of continuing medical education towards assuring adequate performance.10 The world in which doctors work has changed
enormously. Increasing consumerism and patient empowerment, growing
accountability to external bodies, and more emphasis on efficiency and
effectiveness have led to an intolerance of variance in medical
practice. Quality assurance and the maintenance of standards have
become powerful forces for change.11 In an evidence based
medical world it would seem prudent therefore for those planning
general practitioners' education to choose educational
methodologies that have been shown to work, and to evaluate those that
have not.
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Systematic reviews of continuing medical education |
There is a growing international consensus on what forms of
continuing medical education are most effective in stimulating behaviour change. Systematic reviews12-15 of the
educational literature found that although there were comparatively few
rigorous evaluations of educational interventions, there were
sufficient studies showing that continuing medical education could
improve clinical performance and patient outcomes, indicating which
methods were best at bringing about change in doctors' behaviour.
The most effective methods derived from these reviews include learning
linked to clinical practice, interactive educational meetings, outreach
events, and strategies that involve multiple educational
interventions (for example, outreach plus reminders). Less effective
strategies include audit, feedback, local consensus processes, and
the influence of opinion leaders. The least effective methods are also
the most commonly used in general practice continuing medical
education
namely, lecture format teaching and unsolicited printed
material (including clinical guidelines).
Some reviews propose models for ensuring medical behaviour
change.
12 13
Three sequential strategies are described.
These are:
- Consideration of predisposing factors, which prepare doctors for
change
- Identification of enabling factors by which new knowledge and skills
are related to the learner's work environment
- Reinforcement of new behaviour through the use of reminders
and feedback.
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Innovations, guidelines, and behaviour change |
Lomas has described many of the factors that contribute to change
in doctor behaviour.16 These include educational,
personal, patient based, and economic factors. The context in which
doctors work may have a profound effect on their willingness and
readiness to change.
16 17
Local perceptions of an
innovation may affect subsequent behaviour change. Factors such as the
relative advantage the innovation offers over existing practice, its
complexity, and its trialability are all important
considerations.18
Grimshaw and Russell studied the relative effectiveness of
different strategies used to implement clinical
guidelines.19 They found that the most successful
strategies involved local rather than national guideline development
and dissemination combined with a focus on prompting (or
reminding) the doctor during the consultation. The least effective
methods were those most commonly usednamely, national guideline
development combined with unsolicited distribution.
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Reviews of postgraduate continuing medical education for general
practitioners |
Reviews of effective educational methodologies in primary care
generally concur with the findings of wider literature reviews of
continuing medical education. Combinations of educational interventions were found to be better than single interventions.
20 21
Wensing et al found that organisational and management support were
important additional factors in changing behaviour.22
Several authors highlighted the importance of relating educational
activity to the work that doctors do.
23 24
Peer review
and group learning models were proposed as particularly relevant in
general practice settings.22
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Needs assessment |
Prior needs assessment is important for informing and directing
the educational process.21 Relying on doctors to identify their own learning needs, however, may be problematical as Tracey et al
found in a study of doctors in New Zealand.25 They found a
poor correlation between doctors' self assessment of their knowledge and their subsequent performance in objective tests of their knowledge. Given the freedom to select which educational events to attend, doctors
often choose not to stray outside their "comfort zone." A
randomised controlled trial of continuing medical education in 1982 showed that if given the opportunity clinicians choose educational
events that fit in with what they already know.26 Furthermore, when the same clinicians were encouraged to cover topics
that were not their preferred choice, their quality of care rose
significantly compared with a control group. Needs assessment should
not therefore be based entirely on self assessment but should use
evidence from a range of sources.27
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Educational intervention studies in general practice |
We found 1032 articles describing educational or audit
activities in general practice between 1990 and March 1999. Of these, 69 papers described educational interventions that met the evaluative criteria outlined above. These included 18 papers describing audits with educational interventions, and 51 papers detailing educational studies. Twenty eight studies were of a before/after design, 16 were
randomised controlled trials, and 15 were controlled trials. Of the
remainder, six were exit only studies of sufficient robustness to be
included, and four were qualitative evaluation studies.
Seventeen of the 18 audits showed a positive influence on doctor
behaviour of which only one included data showing the behaviour change
was sustained.28 Publication bias is likely to have
influenced the rate of reporting of positive findings. Two audit
studies described significant event audits. This has been shown to be an effective model for linking educational intervention, practice, and
behaviour change.29
Seven audit studies described interventions that involved setting
standards by local consensus. This has been shown to be a very
appropriate method for implementing guidelines in general practice.19
The 51 educational intervention papers covered a wide variety of
learning events based on general practice. The methodologies included
14 studies using multiple educational strategies and 37 using single
strategies. Of these, seven studies did not succeed in changing doctor
behaviour. Useful lessons can be learned from these studies with
negative outcomes. For example, one recent study found no effect from
unsolicited feedback on doctors' prescribing behaviour, and concluded
that unsolicited and non-personalised feedback was
ineffective.30 A similar but effective intervention has
been described by Winkens et al, the difference being that the feedback
to doctors was preplanned and personalised.31
A randomised controlled trial that tested a patient centred approach to
the care of patients with type 2 diabetes failed to produce sustained
behaviour change because the educational intervention was too
complex.32 The authors recommended the piloting of complex educational interventions before embarking on large studies.
A much quoted study of a multifaceted educational intervention to
improve doctors' management of depression and thus reduce suicide
rates on the island of Gotland near Sweden showed very positive early
results including a reduction in the suicide rate.33 A
3 year follow up study, however, showed that the doctors'
management of depression had deteriorated and that the suicide rate had
returned to almost preintervention levels.34 The authors
stressed the importance of reinforcing learning. Few studies in this
series of 69 did any follow up beyond 3 months.
A group learning approach was the main educational methodology in seven
studies. Moran et al describe an interesting learner based group, which
was designed to help poorly performing general practitioners.35 They were placed in a learning
group with 10 other doctors as controls. The group met for 10 sessions. Follow up included clinical care, preventative care, and the
use of drugs at 6 and 18 months. The study subjects were initially
scoring much lower than controls but later improved significantly
during the continuing medical education programme.
Two studies looked at the use of computers as a decision support
aid36 and reminder system.37 Both studies
showed that the use of computers during consultations could both
initiate and maintain behaviour change. These findings are similar to
those of Grimshaw and Russell who studied the factors leading to the dissemination and application of clinical guidelines in
practice.19
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Why do doctors change their behaviour? |
In addition to the literature on doctor behaviour described above,
two recent studies shed further light on why general practitioners change their clinical behaviour. Allery et al used analysis of critical
incidents to study why doctors and consultants change their clinical
behaviour (for example, changes in therapeutic management or use of
investigations).38 They found that most changes were
brought about by a combination of factors. Formal continuing medical
education was partly responsible for behaviour change in only one third
of cases. Organisational factors and contact with other healthcare
professionals were equally important factors.
Armstrong et al studied why doctors change their prescribing
behaviour.39 They postulated three models of behaviour
change (box). These models have a face validity but need to be tested more rigorously.
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Postulated models of behaviour change
- Accumulation model: when evidence exceeds a threshold
behaviour change is triggered
- Conflict model: behaviour is changed by a critical event
- Continuity model: doctors who constantly update their
practice and are sensitive to outside influences
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Evaluation of continuing medical education for doctors |
The most striking feature of this review is the lack of robust
evaluations of general practice based educational interventions. Of
those who did produce "generalisable" findings, a very small proportion of the evaluative studies were designed to test whether behavioural change was sustained. Is this something to worry about or
does it simply reflect the problems inherent in educational research
and evaluation?
Grant funding for educational research is not easy to obtain and
evaluation can consume a lot of time and
resources.41T42The designers of educational programmes may
prefer, therefore, to spend their limited funds on developing and
implementing educational innovations rather than evaluating them.
Educational evaluation studies are not often published in general
readership journals. They are often rejected because they are not
sufficiently rigorous or are not deemed to be of "general
interest." Controlled trials of educational events are particularly
difficult. There are often problems finding appropriate control groups.
Furthermore; evaluation studies are not easily generalised to other
settings because of the singular nature of each learning environment.
Despite these difficulties, evaluation remains an important part of the
educational cycle. Widespread dissemination of educational ideas is
problematic without it, and other workers may be reluctant to try
innovations that have not been rigorously tested. Valuable lessons from
interventions with negative outcomes may be lost.
32 34
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The way forward |
Educators of doctors should take account of the literature on
effectiveness of educational interventions as described above. Guides
to the planning and evaluation of educational events are available.
42 43
General practice educational activity should be based on the work that
doctors do. Standard (and significant event) audits have been shown
to be effective strategies for behaviour change if they include
targeted feedback. This review has highlighted the importance of
building reinforcement strategies into educational planning. Group and
peer review type interventions have also been shown to be feasible and effective.
There are several very positive trends in continuing medical education
in primary care, which seem to incorporate both adult learning
principles and the findings of the "what is effective in continuing
medical education" literature. Calman, for example, has proposed that
the present financially driven credit based system in the United
Kingdom be replaced by a new approach in which continuing education,
audit, research, and clinical effectiveness are aligned in a unified
educational strategy.44 The educational programme as
envisaged will be self directed, practice based, and multiprofessional.
There are similarities between this proposed system and the quality
assurance and continuing education programme in
Australia.45 Much, however, of the adult learning theory underlying these and other innovations has not been adequately evaluated.2 These ground breaking programmes will be all
the more valuable therefore if their coordinating bodies establish rigorous and continuing evaluation.
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