Intended for healthcare professionals

Education And Debate

Continuing medical education: a personal view

BMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6985.994 (Published 15 April 1995) Cite this as: BMJ 1995;310:994
  1. T M Hayes, dean of postgraduate studiesa
  1. a Department of Postgraduate Medical and Dental Education, University of Wales College of Medicine, Cardiff CF4 4XN
  • Accepted 2 February 1995

Over many generations doctors have kept up to date in ways which reflect their own learning styles. The current fashion for formalised and policed continuing medical education may prove ineffective unless it is recognised that individual needs must be taken into account. Attendance at formal courses based on lectures and papers may not suit a large proportion of those who attend to acquire the necessary points to satisfy their royal college. The ability to show that health care teams are up to date should come from effective clinical audit, which should also identify local educational needs.

Medical education is in turmoil. The General Medical Council is rightly pushing universities to bring their undergraduate curriculums into line with the proposals that the council first made in 1980 (and they were hardly revolutionary then). Postgraduate education has seen greater changes in the past few years than in the 30 or so since the Christchurch conference of 1961, and with the implementation of the Calman proposals for a shorter structured training it will continue to change for at least the next five years. The third phase of medical education—continuing medical education or continuing professional development—has joined the turmoil in the past year or so, but some of the proponents of important changes in this area seem to be working from the premise that continuing medical education is new. Continuing medical education has been with us as long as there has been a medical profession. The provision of some central continuing medical education meetings has been recognised as a function of the royal colleges for decades and, in the case of the older colleges, centuries. Locally organised continuing medical education started with the development of local medical societies in the 19th century and became an integral part of medical life throughout Britain with the establishment of postgraduate medical centres in the 1960s.

What is new in the current proposals for continuing medical education is the requirement by the royal colleges and faculties for increasing regimentation and central accountability for continuing medical education activities. The various proposals put out by the colleges include formalisation of continuing medical education, making attendance (which is not the same as participation) mandatory, and recognition of “professional obligation” by inclusion in a list of specialists published by the college. Some colleges have suggested sanctions for doctors not complying with their diktats, such as removal of training approval from units where consultants have obtained insufficient points.

Why change?

The common excuse for these college proposals is that the public and politicians require doctors to be competent. One royal college president in the introduction to his college's statement on continuing medical education said: “There has been increasing pressure on medical practitioners to demonstrate that they are subject to continuing education.”2 But is this so? Patients rightly want their doctors' performance to be up to standard, but performance is not the same as competence. To perform satisfactorily a professional certainly needs to be competent, but many things can come between that competence and his or her performance: resources such as time, staff, or facilities may be inadequate; the team may not function satisfactorily; and behavioural factors may restrict performance. Performance could be measured by clinical or medical audit, and this would provide a much better basis for assessing individuals' and teams' needs for continuing medical education than the decisions of central committees.

Is continuing medial education effective?

Little evidence exists that formal continuing medical education—that is, attendance at traditional courses and conferences—has a significant effect on performance or competence. In the state of Illinois continuing medical education became mandatory in 1978, and then the law was repealed in 1984. Studies of the effect of implementing then repealing this law showed that the doctors in Illinois noted no difference in their participation in continuing medical education before, during, or after these periods.3 The institutional suppliers of continuing medical education, however, who clearly had an interest in ensuring attendance at their events, believed that attendance increased after the law was introduced and decreased after it was repealed. Eighty two per cent of the suppliers and 81% of the doctors believed that repeal of the law had no effect on the quality of the care that they provided for patients. An epidemiological study in Kansas showed no relation between attendance at continuing medical education events and perinatal mortality or the use of certain surgical procedures.4

Davis and his colleagues analysed 50 randomised controlled trials of continuing medical education.5 Only eight of the 18 studies that examined patient outcomes showed any benefit from continuing medical education. Most of the 43 studies that examined doctors' performance showed some significant changes. However, as no evidence was presented on the magnitude of change some of the reported changes may not have been significant in any practical sense. Continuing medical education that was concerned only with disseminating information had little or no effect on health outcomes and was less likely to alter the performance of doctors. The authors concluded that much of the criticism of formal continuing medical education is justified and emphasised that for effective education, learning needs had to be determined objectively. To find 50 satisfactory trials the authors had to review 777 papers. There is no doubt therefore that continuing medical education generates interest, but this interest may reflect the continuing uncertainty over the value of some types of continuing medical education.

Individual learning styles

Most doctors keep up to date largely through informal means that fit with their individual learning styles. The evidence from studies on the diffusion of information is that doctors change their practice as a result of information spread through interpersonal networks; findings are similar in other professions.6 Doctors learn most from contact with colleagues, bringing in specialists to consult, listening to junior staff, browsing through favourite journals, and reflecting on their practice. The most useful part of conferences and courses is commonly considered, even by ardent delegates, to be discussion in the bar in the evening or the “corridor effect.”

Adults learn best when they recognise the need to learn and perceive the relevance of what is to be learned to their work. They should also participate in the planning of their education. All these requirements could be met when continuing medical education is designed in response to audit findings and is based largely in the workplace. Audit would also help in ensuring that doctors do not confine their continuing education to topics that interest them and avoid those that may not interest them but are needed to ensure a high quality service to patients. Specially designed courses at special centres to meet identified needs which cannot be met locally—such as training in laparoendoscopic surgery—would be needed, although these would represent a small part of continuing medical education.

The way forward

In an ideal world, therefore, doctors and clinical teams would be helped to identify their learning needs through audit and peer review; the Royal College of Surgeons has already enabled surgeons to undertake personal audit of one part of their work—the results of their operations can be compared with those of their colleagues. Having identified his or her educational need, the doctor—or the team—would be helped to plan his or her continuing medical education by a clinical tutor, college tutor, or other colleague trained in the educational principles underlying continuing medical education and aware of the range of educational facilities available. A menu of educational opportunities would allow the individual or the team to take up the options that fit with their learning styles. This might include any combination of, for example, local activities, attendance at appropriate meetings, participation in distance learning courses, visits to colleagues, reading programmes, and courses. Resources for such activities could be made available by the royal colleges and specialist societies—indeed, some are already available from these bodies.

The full educational benefits of clinical audit have not been reached. Kerrison et al said: “In practice the connection between postgraduate medical education and audit appeared to be weaker than envisaged in the policy statements.”7 The opportunities to use audit as a method of both reassuring the public about doctors' performance and providing an assessment of educational needs should be taken up, and the development of a continuing medical education industry based on uncertain evidence of effectiveness, as has occurred in other countries, should be avoided. Linking audit and peer review to continuing medical education would allow anxieties about the effectiveness of continuing medical education to be addressed, would permit local ownership, and would allow doctors to choose learning methods that both meet their own educational needs and fit in with their personal learning styles. Such a link would avoid the need to introduce sanctions as, with audit as the monitoring instrument, participation and the attainment of satisfactory standards of performance would be documented. The emphasis on local provision would also help to overcome the conflict of interests that might arise when a royal college both approved or accredited continuing medical education programmes and also provided continuing medical education.

Conclusions

It is and always has been a fundamental requirement for any professional to keep up to date in his or her profession. Like breast milk and a high fibre diet, continuing medical education is without doubt good for use. Why then has activity erupted among those who wish to manage, control, and codify continuing medical education? Britain is rapidly moving down the road, well trodden in other countries, towards a rigid, formalised, and policed continuing medical education industry. Continuing medical education is in danger of becoming a behemoth, a lumbering, unbending monster, and this burgeoning industry is based on assumptions that remain unproved. A shift from centralised to local provision linked to peer review and audit will avoid these hazards.

References

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