Intended for healthcare professionals

Education And Debate Continuing medical education

Quality issues in continuing medical education

BMJ 1998; 316 doi: (Published 14 February 1998) Cite this as: BMJ 1998;316:621
  1. Hans Asbjørn Holm, deputy secretary general (hans.asbjoern.holm{at}
  1. Norwegian Medical Association, PO Box 1152 Sentrum, N-0107 Oslo, Norway

    Series editors: Hans Asbjørn Holm and Tessa Richards

    This 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 education

    Innovations in undergraduate medical education are influencing the whole spectrum of medical education. So too is the growing literature on adult learning1-4 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

    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 student often is told what to learn, but the qualified doctor is responsible for directing his or her own (lifelong) learning.10

    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

    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

    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

    Motivation for continuous learning

    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

    Mandatory or voluntary?

    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.

    Competence and accountability

    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.

    Needs assessment

    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.

    Research issues in self learning

    “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

    Continuous quality improvement

    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

    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

    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.

    Quality improvement among general practitioners

    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.

    SATS project, Norway

    Linking continuous quality improvement and continuing medical education: a project aimed at improving care in a general practice setting.

    Example: Acute sore throat

    Objectives: Antibiotics should be prescribed when the clinical picture points to group A streptococcal infection.

    Structure: (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?

    Process: 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?

    Results: Has a relapse been recorded within two weeks? Has the patient reported being unchanged or worse after 3-4 days despite antibiotic treatment?

    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.


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