Pediatric Annals

CME Article 

New Paradigms in Continuing Medical Education

Chelsey Megli, MA; Dewesh Agrawal, MD; Mary Ottolini, MD, MPH; Larrie Greenberg, MD

Abstract

Traditionally, continuing educational strategies have been intended to increase practitioner knowledge base in an attempt to alter provider behavior and improve patient care. But educational programs aimed at medical professionals often lack learner-centric curricula and outcome-based assessment. This leads to a culture that rewards superficial attendance but not participant-based learning.

Abstract

Traditionally, continuing educational strategies have been intended to increase practitioner knowledge base in an attempt to alter provider behavior and improve patient care. But educational programs aimed at medical professionals often lack learner-centric curricula and outcome-based assessment. This leads to a culture that rewards superficial attendance but not participant-based learning.

Chelsey Megli, MA, was Senior Staff Assistant, Graduate Medical Education, Children’s National Medical Center. Dewesh Agrawal, MD, is Director, Pediatric Residency Program; and Associate Professor of Pediatrics and Emergency Medicine, Children’s National Medical Center, The George Washington University. Mary Ottolini, MD, MPH, is Vice Chair, Medical Education; and Professor of Pediatrics, Children’s National Medical Center, The George Washington University. Larrie Greenberg, MD, is Internal Consultant, Faculty Development; and Clinical Professor, Pediatrics, The George Washington University.

Ms. Megli and Drs. Agrawal, Ottolini, and Greenberg have disclosed no relevant financial relationships.

Address correspondence to: Dewesh Agrawal, Medical Education Suite 3.5W-600, Children’s National Medical Center, 111 Michigan Ave. NW, Washington, DC 20010; fax: 202-476-4741.

Traditionally, continuing educational strategies have been intended to increase practitioner knowledge base in an attempt to alter provider behavior and improve patient care. But educational programs aimed at medical professionals often lack learner-centric curricula and outcome-based assessment. This leads to a culture that rewards superficial attendance but not participant-based learning.

Educational studies have demonstrated that, for learning to occur, curricula must include active participation and activate the existent knowledge of participants, but such curricula are rare in medicine. The medical lecture is designed to broadcast information from experts to the community, but all too often faculty do not determine what the community itself needs to know, where new information fits within existing learner competencies and how new developments will be implemented into medical practices.

We propose a paradigm shift, from continuing medical education (CME) to continuing professional development (CPD), for pediatricians to promote a more rapid uptake of evidence-based knowledge and ultimate improvement in patient care.

When many clinicians think of CME, they think of traditional medical conferences in which a lecturer provides passive education in a teacher-centered fashion to the audience, a scene familiar to medical students, residents, and seasoned physicians alike.1,2 CPD embodies a more holistic view of personal growth through lifelong professional learning. By incorporating adult learning theory, self-directed learning concepts and reflective practice, CPD’s focus is on the individual learner.

Characteristics of CME

History

CME first began as a result of patient advocacy. In the 1920s, polio patients who were dissatisfied with their care at Chambersburg Hospital in Pennsylvania approached the hospital administration with their concerns. This resulted in the implementation of a regular educational program to encourage physicians to make corrections, have more self-awareness, and work collaboratively.

These themes of improved patient care and physician performance resonated with early CME programs. CME was created to help health professionals update their medical knowledge and facilitate positive changes in clinical practice. As CME became more standardized at institutions, its goals shifted to establishing educational programs that ensured “all clinicians possess five core competencies, which include being able to provide patient-centered care, work in interprofessional teams, employ evidence-based practice, apply quality improvement, and utilize informatics.”3

Regulation

Hospitals, state boards, certification boards, accreditation agencies, national societies, and government bodies each create standards for CME, leading to a lack of national uniformity or coordination. For example, some states require physicians to attain few or no credits for licensure, while others mandate up to 50 annual credits.3 An organization’s individual requirements also have little correlation to the organization’s ability to provide access to the very curricula it requires. For example, the American Academy of Pediatrics (AAP) has no membership requirements for CME credits, yet offers hundreds of courses that are endorsed by the Accreditation Council for Continuing Medical Education (ACCME).4

Currently, CME is awarded via a credit system in which participation in accredited courses or activities counts toward a certain quota. The American Medical Association (AMA) divides CME activities into two tiers. Category 1 counts toward credentialing and is composed of activities such as getting published, presenting at national conferences, acquiring further degrees, conducting independent research, and participating in hosted attendance-based activities. Category 2 activities are harder to track such as peer consultations, small group work, self-assessment, and teaching. 3 This system in itself sets the culture for valuing participation over change and for attendance over outcomes.3

Design and Practice

Physicians and health professionals are expected to use CME to “keep their knowledge and skills up to date, with the ultimate goal of helping health professionals provide the best possible care, improve patient outcomes, and protect patient safety.”3 Courses are often sponsored by pharmaceutical and medical device companies, leading to potential conflicts of interest. CME also is largely implemented through didactic learning, driven by the availability and credentials of the instructors, unmodified for different audiences and unrelated to clinical settings.3 According to the ACCME, 82% of all instruction hours are didactic, with participants assuming a passive role.3 Blanket curricula also meet regulations as a whole, but sometimes neglect institutional and individual knowledge gaps, such as how to use technology. Also, it is possible that the curriculum is based on underdeveloped or fragmented science.3,5

Such a strong emphasis on the traditional lecture deemphasizes both the role and responsibility of the learner, valuing participation over performance improvement.3 Participant engagement has been shown to be highest in smaller-scale activities such as workshops, peer consults, and in-service training and tutorials.3 In addition, a lack of systematic evaluation has meant little improvement or change in CME programs; institutions rarely share best practices.6

There is also fragmentation that occurs when stakeholders of CME approach curricula with different goals. Many health professionals attend CME sessions to maintain licensure and credentialing. Employers create programs to improve quality and keep staff up-to-date. Regulators create standards aimed at health care as a whole to maintain competence and improve quality.3 Lack of collaboration between these parties is often reflected in participant outcomes. For example, medical grand rounds might offer unique lecture topics, but seldom reflect major CME educational objectives, often have inconsistent attendance, limit questions from the audience and do not always take into account a particular audience’s educational needs.5 CME does not always succeed in updating, improving, and developing clinical practices and patient outcomes; systems of care and quality improvement are not always emphasized.3,5,7,8

Paradigm Shift from CME to CPD

Learning Theory

Kolb described four learning styles along the continuums of perception and experience: divergence; assimilation; convergence; and accommodation.8 Learners tend to favor one style, but ideally use all four to acquire new information, internalize it, and make it practical for them. Most physicians have been found to fall under the “doing” end of the experience spectrum, meaning that some level of participation and contribution best facilitates their learning.8 This sheds light on why traditional CME didactics might have a limited effect on practices. Kolb’s model allows learners to develop individual strategies that challenge and engage their style of learning, resulting in better outcomes.9

Many types of education — didactics, unstructured learning, informal teaching, formal teaching, group discussion, etc — can benefit health care professionals if used strategically. Similarly, because learning theories teach that processing information must include a certain amount of reflection time, continuing education should include both structured and unstructured time for learners. Lack of time for reflection is commonly cited as a barrier to learning.10 Effective continuing education (CE), therefore, necessitates a variety of content and structures because learning itself occurs in stages and on many levels.

To truly engage learners, instructors must understand several additional interrelated and critical learning theories, a thorough review of which is beyond the scope of this article.3 These include theories of self-directed lifelong learning that assert that, during a physician’s career, the focus of learning moves from inquiry to instruction to performance to self-directed pursuits; theories of motivation, which argue that internal motivators are far more powerful for adult learners than external motivators (ie, certification requirements, exams, etc);11 experiential learning theory, which emphasizes the central role that experiences play in the learning stage by activating and applying prior knowledge;8 and social learning theory, which states that professional learning is facilitated through social exposure to the behavior, customs, and reactions of others in new situations.12

Paradigm in Practice

All methods of CE must incorporate participant engagement and interaction. Knowledge is a matter that must be constructed, and education should be a means of building actively on the experience and expertise of the participant.11 Long-term curricula devoted to linked topics rather than a series of repetitive lectures will contribute to a higher level of knowledge level and would have a larger potential effect on patient care.12 Part of this process must also include meaningful evaluations that develop over time, so that learner self-assessments, which might differ from those of educators, align with the broader objectives of the program and expectations for the learner.10 Education should be viewed not as a singular occurrence, but rather as a process that creates lifelong learners who are trained to apply solutions to new problems, adapt to new situations, and establish their own professional development.3

CPD Defined

Given the limitations of CE, the IOM has suggested that CPD is a better solution. The IOM defines CPD as “teaching how to identify problems and apply solutions, and allowing health professionals to tailor the learning process, setting and curriculum to their needs” and “the system for maintaining, improving and broadening knowledge and skill throughout one’s professional life.”3

CPD emphasizes learner-driven development, patient-care improvement, and accountability.3 CPD allows learners to become more responsible for their own curriculum and targets care through its underlying principles guiding cross-professional collaboration, fostering sponsorship, and collective means of incorporating innovation and creating meaningful changes.13 It currently takes 14 to 17 years for evidence and innovations to be broadly implemented into health care systems. Incorporating these changes more rapidly through individual mobilization is imperative to advance modern patient care.3,5,14,15

The early introduction of self-directed learning and self-assessment is critical for the foundation of future lifelong learning. It is too late to “convert” most practitioners who have lived through the traditional way of learning in medical school and residency as they assess their needs in CME. CPD implies that the authority to create curricula and content should be neither centrally decided and delegated, nor achieved through collective consensus. Leadership in CPD will make decisions, establish protocols, and set agendas through the direction of an early majority of learners and their collaboration therein.13 CPD programs will have a variety of stakeholders contributing to curriculum and requirements while avoiding the delays of seeking absolute consensus.

Challenges to Implementation of CPD Curricula

The IOM called for a CME research agenda that identifies theoretical frameworks, demonstrates proven methods, defines outcome metrics, and determines influences on learning;3 but, there are several challenges inherent in these recommendations.

Financial Concerns and Constraints

Currently, individual physician CME costs $150 to $550 annually to meet low- to medium-level CE requirements.3 Moves to eliminate pharmaceutical and corporate sponsorship or, at the very least, decrease their involvement could result in CME funding being provided through professional societies and organizations, groups that often cater directly to specialties and sub-specialties. This could narrow the scope and result in knowledge gaps.

Without external support, CME activities could cost $3,500 a year per physician, an amount that is within the realm of individual or department funding. 3 The problem is that there are no concrete costs for CPD, nor is it clear which stakeholders will be willing to participate and sponsor its development. Also, without a national regulatory call for the transition forcing institutions to comply, hospital administrators are unlikely to incorporate CPD until a clear cost projection is available that delineates how individual physicians would share part of the costs.

Faculty Development

To be effective, CPD instructors and leaders must know learning theory and have both the time and resources to direct their courses to the appropriate audiences and learners.6 A step-wise strategic plan is necessary to change the way faculty and consumers currently experience CME, making the case for a new format for learning and teaching.

Metrics

Reliable, comprehensive metrics are critical to determine what works and what does not in CME. There must be a comprehensive metric system in place so that institutions and individuals can reinforce strategies that are working and modify those that are not. The Jefferson Scale of Physician Lifelong Learning has shown that it is possible to measure qualitative traits of educational development and performance;13 however, implementing this system, or one similar to it, requires a rapid, adaptive technology development. Similarly, there must be some form of evaluation of the metrics themselves as these systems are developed.

Transformation of Culture

Perhaps the largest barriers to a meaningful implementation of CPD are cultural. Since all of us are learners regardless of our level of experience, CPD allows faculty and trainees to deviate from the hierarchical form of education. Physicians and trainees of all levels would be expected to collaborate and contribute to education and curriculum regardless of background. Attendings and other teachers should be more attuned to challenging, stimulating and inspiring trainees rather than trying to fill in their knowledge gaps. Similarly, learners must match their ambition for a positive review with enthusiasm for filling their own content deficits.

Conclusion

As evidenced by the IOM’s report, there is a need to reform CME programs, regulation, and implementation. For such reform to be successful, basic principles of learning must be incorporated, transforming CME into CPD emphasizing active, long-term participation in education. For the principles of CPD to be realized, institutions must be willing to address several obstacles to meaningful change: financial sponsorship, instructor training, establishment of an adequate metric system, and cultural shifts to self-evaluative constructivism and collaborative critique.

References

  1. Davis D, Evans M, Jadad A, et al. The case for knowledge translation: shortening the journey from evidence to effect. BMJ. 2003 5;327(7405):33–35. doi:10.1136/bmj.327.7405.33 [CrossRef]
  2. Miller GE. Continuing education for what?J Med Educ. 1967;42(4):320–326.
  3. Institute of Medicine. Redesigning Continuing Education in the Health Professions. Washington, DC: The National Academies Press; 2010.
  4. American Academy of Pediatrics. CME Frequently Asked Questions. www.pedialink.org/faqs-view.cfm#top. Accessed Nov. 4, 2011.
  5. Hager M, Russell S, Fletcher SW, eds. Continuing Education in the Health Professions: Improving Healthcare Through Lifelong Learning. Proceedings of a Conference Sponsored by the Josiah Macy, Jr. Foundation. ; 2007 Nov. 28–Dec. 1. ; Bermuda. . New York: Josiah Macy, Jr. Foundation; 2008. www.josiahmacyfoundation.org. Accessed Nov. 4, 2011.
  6. Davis D, Taylor-Vaisey A. Two Decades of Dixon: The Question(s) of Evaluating Continuing Education in the Health Professions. J Contin Educ Health Prof. 1997;17:207–213. doi:10.1002/chp.4750170403 [CrossRef]
  7. Davis D, Thomson O’Brien MA, Freemantle N, et al. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes?JAMA. 1999;282(9):867–874. doi:10.1001/jama.282.9.867 [CrossRef]
  8. Armstrong E, Parsa-Parsi R. How Can Physician’s Learning Styles Drive Educational Planning?Acad Med. 2005;80(7):680–684. doi:10.1097/00001888-200507000-00013 [CrossRef]
  9. Fox RD, Bennett NL. Learning and change: implications for continuing medical education. Br Med J. 1998; 316(7129):466–468. doi:10.1136/bmj.316.7129.466 [CrossRef]
  10. Sargeant J, Armson H, Chesluk B, et al. The processes and dimensions of informed self-assessment: a conceptual model. Acad Med. 2010;85(7):1212–1220. doi:10.1097/ACM.0b013e3181d85a4e [CrossRef]
  11. Office of Continuing Medical Education and Professional Development. Principles of Effective CME: Background Information for Facilitators of Small Group Learning. University of Calgary. July2004.
  12. Kearsley G. Social Learning Theory (A. Bandura). The Theory Into Practice Database. Available at: tip.psychology.org. Accessed Nov. 4, 2011.
  13. Berwick DM. Disseminating Innovation in Health Care. JAMA. 2003;289(15):1969–1975. doi:10.1001/jama.289.15.1969 [CrossRef]
  14. Hosansky T. Opening Doctors’ Ears: How to make CME work in an Outcomes-Driven World. Medical Meetings. 1997:32–39.
  15. Balas E, Boren S. Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical Informatics. 2000. Stuttgart: Schattaver Verlasgesellschaft.
Editor’s Note:

Slack Inc., publisher of Pediatric Annals, is the sister company of Vindico Medical Education, a CME provider.

CME Educational Objectives

  1. Propose a shift in post-graduate medical education from continuing medical education to a lifelong process of continuing professional development.

  2. Revisit the origins of traditional CME, pointing out the original intended objectives and outcomes.

  3. Point out the deficits of traditional CME and contrast those with the advantages of continuing professional development.

Authors

Chelsey Megli, MA, was Senior Staff Assistant, Graduate Medical Education, Children’s National Medical Center. Dewesh Agrawal, MD, is Director, Pediatric Residency Program; and Associate Professor of Pediatrics and Emergency Medicine, Children’s National Medical Center, The George Washington University. Mary Ottolini, MD, MPH, is Vice Chair, Medical Education; and Professor of Pediatrics, Children’s National Medical Center, The George Washington University. Larrie Greenberg, MD, is Internal Consultant, Faculty Development; and Clinical Professor, Pediatrics, The George Washington University.

Ms. Megli and Drs. Agrawal, Ottolini, and Greenberg have disclosed no relevant financial relationships.

Address correspondence to: Dewesh Agrawal, Medical Education Suite 3.5W-600, Children’s National Medical Center, 111 Michigan Ave. NW, Washington, DC 20010; fax: 202-476-4741.

10.3928/00904481-20111103-08

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