Medical Education
Refer to: Manning PR: Continuing medical education in midpassage (Medical Education). West J Med 128:260-265, Mar 1978
Continuing Medical Education in Midpassage PHIL R. MANNING, MD, Los Angeles
Mandatory continuing education for physicians and other health professionals raises numerous problems. Issues that were considered academic when continuing education was voluntary now take on major practical and political significance. There is the risk that future legislation will mandate activities and methodologies which have not been proven. Research and development in continuing education must be accelerated so that decisions can be based on proper data. Centers of research and development should be established to encourage research and provide a sound foundation for the future of continuing education.
FOR GOOD OR ILL, formal continuing education is now a fact of medical life, required by the legislatures of an increasing number of states, including California. Because it is mandatory, a number of issues have now become pressing that were formerly of academic interest alone. These issues will have a significant impact on all practitioners. Until quite recently the degree of participation in continuing education was decided by the individual physician and, to some extent, by his professional society. As recently as 1955 Vollan stated, in an assessment of continuing medical education: "Since the public has seen fit to allow the profession to control its own affairs, it is the responsibility of organized medicine to insure the The author is Associate Dean, Postgraduate Affairs, and Professor of Medicine, University of Southern California School of Medicine, Los Angeles, and Chairman, Committee on Continuing Medical Education, California Medical Association. Reprint requests to Phil R. Manning, MD, Associate Dean, Postgraduate Affairs, 2025 Zonal Avenue, KAM-317, Los Angeles, CA 90033.
260
MARCH 1978 * 128 * 3
constant continuing education of its members." Dr, Vollan went on to say: "In the last analysis, however, it is the individual physician's responsibility to society to insure his own constant fitness to practice medicine at the highest possible level, which requires that he continue his education regularly throughout his career."' Now, two decades later, society is beginning to require proof that this responsibility has been met .
Shifting Responsibility for Continuing Education Thirty years ago the American Academy of General Practice became the first medical organization in this country to require participation in continuing education as a condition of membership. The Voluntary Physician Recognition Award by the American Medical Association was implemented in 1969. The same year, the California Medical Association initiated a voluntary pro-
CONTINUING MEDICAL EDUCATION
gram granting certification for approved continuing education. Mandatory continuing education for membership in state medical societies began in the State of Oregon in December 1970. At present medical societies in 15 states and the District of Columbia require continuing medical education as a condition of membership (Alabama, Arizona, District of Columbia, Florida, Kansas, Maine, Massachusetts, Minnesota, Montana, New Jersey, New York, North Carolina, Oregon, Pennsylvania, South Dakota and Vermont).2 Medical practice acts in 17 states give their respective state boards of medical examiners authority to require evidence of continuing medical education as a condition for reregistration of the license to practice medicine (Alaska, Arizona,
California, Colorado, Illinois, Kansas, Kentucky, Maryland, Michigan, Minnesota, Nebraska, New Mexico, Ohio, Rhode Island, Utah, Washington and Wisconsin).2 The mandate for formal continuing medical education is based on the presumption that some physicians, at least, have not continued their education and that continuing education will improve health care. Relationship of Continuing Medical Education and Patient Care Health care is a very complex endeavor. Besides the appropriate application of skills and knowledge, components of patient care include accessibility, availability, acceptability, affordability, continuity, prevention and comprehensiveness.3 Quality of patient care is contributed to by many professionals, administrators and workers in addition to physicians, nurses and pharmacists. The totality of care is greater and more complex than most of us realize. It is a team effort. It is profoundly difficult to evaluate. Continuing education for physicians cannot by itself be expected to alter dramatically all the multiple problems of patient care. For many years, patient care was believed to be governed almost entirely by physicians' competence in diagnosis and therapy. Recently, it has been realized that a physician's diagnostic and therapeutic skills are major but not exclusive ingredients of excellent patient care. With this realization, some writers have overreacted, tending to downgrade the importance of the competence of a physician in diagnosis and therapy. It is essential to continue to stress physician competence and skill, if patient care is to continue to improve.
From the standpoint of physicians, we can look at the problem in still another dimension. We can compare a physician's competence (that is, what he is able to do) with his performance (that is, what he actually does in a particular situation). Drs. Clement Brown and John Williamson are major pioneers who have found that many, it not most, patient care problems they have encountered in their extensive work in community hospitals are related to administrative and organizational problems rather than to lack of knowledge.4'5 It is therefore necessary to keep in mind that there are some unrealistic expectations about what continuing education can achieve, but this should not obscure the fact that some expectations relating to the competence of physicians in diagnosis and therapy are realistic and that continuing education can play an important role in this area. Properly conducted continuing education can alert a physician to significant new advances in medicine and help him to review important fundamental concepts. The physician can share and gain from the experience of experts. He can ask questions about specific patients under his care. He can gain direction for self study. He can renew the academic spirit and approach his practice with increased enthusiasm. As Professor Cyril Houle has said, "While continuing education will not cure all the problems of the profession, without it no cure is possible."6
Issues in Continuing Education There are several issues to consider in mandatory continuing education for physicians: * What types of education experiences are and should be acceptable to meet requirements? * Who should be the purveyors or providers of continuing education? * What should be taught and learned? * What are the costs of continuing medical education? What Types of Education Should Be Acceptable? There is a persistent idea that continuing education must be defined as a classroom activity. The Physician's Recognition Award (PRA) of the American Medical Association (AMA) requires a total of 150 credit hours over three years with a minimum of 60 credit hours in Category 1 (See Table 1 ) .7 The regulations appear to foster various types of educational activities; however, those THE WESTERN JOURNAL OF MEDICINE
261
CONTINUING MEDICAL EDUCATION TABLE 1.-Summary of Criteria for the American Medical Association's Physician's Recognition Award Category
1 2 3 4 5
5a 5b 5c Sd 6
CME activities with accredited sponsorship .No limit CME activities with non-accredited sponsorship .45 hours .45 hours Medical teaching Papers, publications, books and exhibits 40 hours Non-supervised individual .45 hours CME activities Self-instruction ...... (22 credit hours) Consultation ........ (22 credit hours) Patient care review ... (22 credit hours) Self-assessment ...... (22 credit hours) Other meritorious learning experiences 45 hours
CME - continuing medical education
which must be validated are considered Category 1. These are formal and didactic, and usually classroom approaches. Legislators have had practical difficulties in determining which components of continuing education to make mandatory. It is very difficult to validate that a physician has read a particular journal or that he has listened to a particular tape or, most important, that he has studied about specific problems of his own patients. If he is a captive student in a classroom one can at least verify his attendance. The need for verification is, of course, based on the presumption that the professional will not be accurate in reporting his activities and will not be aggressive in studying individual problems that occur in his own practice. Many within the profession feel that the whole hierarchy of categories imposes bureaucratic requirements which are not in keeping with the ethics of a scholarly profession. In fact, many feel that the requirement to attend formal programs may stifle interest in self-education-that a physician may feel, "I have done my hours for the year and therefore have no further educational requirements." The requirements for study should relate to the need for study as directed by actual problems in the physician's practice. This most important aspect of continuing education is difficult, if not impossible, to verify, let alone mandate. Who Should Provide Continuing Education? Since 1967 the Council on Medical Education of the American Medical Association has accredited providers or purveyors of continuing nedical education. The standards developed have
262
MARCH 1978 * 128 * 3
TABLE 2.-Composition of Liaison Committee on Continuing Medical Education American Board of Medical Specialties ..... American Medical Association ............ American Hospital Association ........... Association for Hospital Medical Education . Association of American Medical Colleges . . Council of Medical Specialty Societies ..... Federation of State Medical Boards ....... Federal representative ................... Public representative ....................
3 members 4 members 3 members 1 member 3 members 3 members 1 member 1 member 1 member
been used by state medical associations so that they in turn can carry out surveys and accredit activities locally, with ultimate action and decision by the Council on Medical Education. This has led to the beginning of a national standard of accreditation for purveyors of continuing medical education. The Liaison Committee on Continuing Medical Education (LCCME), formed in 1975 and working through the Coordinating Council on Medical Education (CCME), is a national organization which in July 1977 replaced the AMA in accrediting providers of continuing education.7 The LCCME has representatives of its eight parent organizations and of the public at large (See Table 2). Presumably, this organization will be the major accrediting agent of all purveyors. In the early stages, criteria for accreditation should be similar to the AMA criteria. However, the LCCME has no authority over state legislatures who may wish to preserve the right of accrediting purveyors for themselves via boards of quality assurance. Consequently, difficulties may arise in the future in identifying valid purveyors. Purveyors of continuing education include medical schools, medical societies, community hospitals and organizations such as pharmaceutical companies. Medical schools, which many feel should be the hub of continuing education as they are in undergraduate education, are not formally dominant in continuing education. Specialty societies can maintain a more dominant posture, as they deal with a membership which is relatively small and eager. Their advertising costs are lower than a medical school's and they have the great advantage of not having to pay faculty salaries. Instead, for a nominal honorarium they can obtain the services of a faculty member for a few hours, whose yearly salary is paid by the medical schools. In addition, courses offered
CONTINUING MEDICAL EDUCATION TABLE 3.-Approved Category 1 Hours Reported by Physicians to the Certification Program of the California Medical Association 1969
Hospital .13,000 Specialty societies .. 67,000 Medical schools
....
64,000
1975
1976
1,827,377 334,793 240,791
2,038,929 479,205 302,595
by specialty societies often are looked upon as more prestigious that those offered by medical schools. Community hospitals are in a strong position to organize continuing education for their staffs. Physicians congregate there each day; they have record systems and personnel who can assess records to determine educational and administrative needs. Table 3 shows the tremendous growth of community hospitals as locations for approved continuing education in California.8 Unfortunately, hospitals usually do not have a formal faculty and must depend on the abilities of local practitioners, often supplemented piecemeal by faculty members from nearby medical schools. These provider groups are, however, interdependent. A major contribution to continuing education may come through coordinating the activities of medical schools, medical societies, community hospitals and pharmaceutical companies. The ideal relationship has yet to be conceived, let alone implemented, but a rich opportunity exists for developing a cooperative organizational structure for the common good. What Should Be Taught and Learned? Several simple approaches help to determine the most significant issue: what to teach and learn. Many organizations use questionnaires to ask persons who attend formal courses what subjects they would like to hear discussed, and often they ask faculty members what practicing physicians should be taught. There are limitations to these methods: a physician may ask for subjects he likes but may not need and a faculty member may wish to display products of his research, which have little application to practicing physicians. There are more precise ways to determine educational needs. For example, the specialty boards and the National Board of Medical Examiners can provide information on how physicians are scoring on various test items, so areas of weakness can be emphasized. Health statistics, both
regional and national, can be used to better advantage. Leading physicians who act as major consultants in their community can be interviewed systematically to determine problems referred by physicians. All of these methods can be useful and all are underutilized. A still better approach to an individual physician's needs is accurate determination of his performance. Audit procedures as -they are being carried out may be valuable to determine administrative, organizational problems and problems of documentation, but are often not adequate as a basis for education. More research is needed to better identify educational needs and to satisfy these identified needs. What Are the Costs of Continuing Medical Education? The costs of providing continuing medical education have risen in recent years due to inflation, particularly in mail advertising and administration; payment to faculty has not been inflated to the same extent. These costs are reflected in tuition charges. However, the main cost to the practitioner is not tuition itself, but the expense of an office which must be maintained whether the physician is working or not. Time away from practice is clearly a major expense item. Miller estimates that the cost of physician time in continuing education is about $1.4 billion dollars annually in the United States. Even though this estimate includes time that would not be spent in seeing patients, the figure dramatizes the potential cost of physician time in continuing medical education.9 Those interested in continuing education must realize that a physician who comes to a postgraduate program is paying a very significant price, not only in tuition, but by losing income while his office expense continues. Most physicians and the public feel that it is proper for physicians to shoulder the cost of continuing education.
What Are the Frontiers for Development? In the course of designing and implementing concepts of continuing medical education, several additional major issues or frontiers need to be studied carefully: * Improvement of existing educational activities. * Educational television satellite. THE WESTERN JOURNAL OF MEDICINE
263
CONTINUING MEDICAL EDUCATION
* Identification of educational needs and provision of feedback. * Use of computer technology. Improvement of Existing Educational Activities Since continuing education activities are no longer voluntary but are mandatory, there is an obligation on providers of physician education. There is also a burden of obligation on those who have passed laws. The physician must participate in formal education. It is no longer his choice. We, therefore, have no choice but to do things better than we have ever done them before. The move toward better formal continuing education has started. In standard classroom programs there has been a trend to improve technical aspects of instruction, to organize programs by behavioral objectives, to emphasize better audiovisual content, to improve material to be handed out, to select faculty who are good speakers and to involve physicians in active learning such as problem solving activities.
Educational Television Satellite As the new educational television satellite program being coordinated by the Lister Health Center becomes available, many of the things we traditionally have done in the classroom can be done equally well via a medical television network.10 This could cause a major change in traditional classroom programs throughout the country. The impact might be as significant as the effect of sound motion pictures on vaudeville and could result- in a complete restructuring of the
classroom expenrence. Identification of Educational Needs and Provision of Feedback Despite the attraction of satellites and the challenge of devising new ways to package classroom education, more important and fundamental issues await consideration. How can we perfect a system to identify needs and develop a nonpunitive feedback mechanism, which will help a physician profit from his own experience while learning about his practice? The difficulty with developing a feedback mechanism in medicine is that society is perceived to be, and often is, critical and harsh when it comes upon an error by a professional, either in judgment or in fact. This is a major limiting factor in developing a proper feedback mechanism. In its desire to see things go perfectly, society will 264
MARCH 1978 * 128 * 3
undoubtedly overreact to shortcoming, punish the physician who made -the error and make it altogether inadvisable for him to expose himself. I am not concerned solely about the welfare of a physician in a punitive situation, although he has a difficult job and needs support. I am concerned that medical care will suffer. When a person is defensive and guarded, real issues are obscured and therefore it is impossible to solve real problems. A nonpunitive feedback mechanism has a much greater prospect for long-term success because a physician need not be defensive. He is able to find out his problems and react to them without undue criticism or punishment. Therefore, it is imperative to develop a feedback mechanism responding to identified needs. This mechanism must be nonpunitive, not just for the good of the physician but for the good of health care. A physician must look openly at things he does with the motive to improve his competence and performance in dealing with patient problems. His attention should not be diverted by threatening, criticizing, punishing regulations or mounds of irrelevant paper work. This is a crucial issue which must be faced at every step of medical education. Using Computer Technology At present, formal continuing education for the physician is being pursued from two fundamentally different approaches. We teach a physician facts in traditional postgraduate courses so that at the proper time, perhaps weeks or months later, he may recall them and carry out an activity in response. We may notify him retroactively of problems that are derived from audit. This latter procedure usually applies to groups of physicians. An advance in continuing education is now possible through the technology of computers, which will make available information to help solve a problem of diagnosis or management at the time a physician identifies the problem. In other words, it is now possible to weave continuing education into office practice or hospital practice by having a computer terminal as part of the practice environment. Dr. Lawrence Weed has developed a computer program and system now being tested on the medical floors at the University of Vermont. This system, among other things, allows a physician to review displays that help him form treatment plans at the time he is solving his diagnostic and therapeutic problems. Many other partial systems are being developed that utilize
CONTINUING MEDICAL EDUCATION
computers. Immediate continuing education based on real problems at the time that diagnostic and therapeutic plans are formulated should become a reality. Old habits are hard to change and the use of computers will, of course, be resisted by some. Some legal and social problems, such as patient record confidentiality and central control of patient care, will need to be solved. Still, the computer as a tool can make possible immediate continuing education on real issues. This is an objective worth striving for.
The Need for Centers of Research and Development No issue in education is more important than continuing education in the professions. All the professions need better methods of continuing education. As for medical continuing education, efforts should be made to develop several research and development centers around the country to develop and test ideas and approaches in continuing education for health professionals. Since strong and well-motivated desires to see things get better and get better quickly may pressure state legislators to mandate educational activities that are ahead of the state of the art, it is essential to test methodologies and approaches before legislation goes further. Research and development in this field can give us data on which to
base such legislation. For the present, we should be content to improve our methods to comply with current requirements to the best of our abilities. But we must press for accelerated research and development before further laws and regulations mandate methods whose validity needs to be substantiated. Those who pass laws mandating educational activities and those in medical education have a profound responsibility to foster further research to define and develop educational principles and methods that will aid the physician and other health professionals to offer ever-improving health care. REFERENCES 1. Vollan D: Scope and extent of postgraduate medical education in the United States. JAMA 157:703-708, Feb 1955 2. Continuing Medical Education Fact Sheet. American Medical Association, Apr 1, 1977 3. Petit D: Testing for clinical competence-Is there need for multiple examinations? Federation Bulletin 5:71-77, Feb 1972 4. Brown CR Jr, Fleisher DS: The bi-cycle concept-Relating continuing education directly to patient care. N Eng J Med 284: (Supplement) 88-87, May 20, 1971 5. Williamson J, Alexander M, Miller G: Continuing education and patient care research. JAMA 201:118-122, Sep 1967 6. Houle C: The lengthened line. Perspect Biol Med, 37-51, Autumn 1967 7. Essentials for Accreditation of Institutions and Organizations Offering Continuing Medical Education Programs. American Medical Association, Jun 1970 8. Manley RD: Department of Continuing Education Report. California Medical Association, Jan 1977 9. Miller LA: The current investment in continuing medical education, chap 14, In Egdahl RH, Gertman PM (Eds): Quality Health Care. Germantown, MD, Aspen Systems Corporation, 1977, pp 143-160 10. Biomedical Communications Experiment-Communications Technology Satellite Program. Communications Engineering Branch, Lister Hill National Center for Biomedical Communications, Apr 1977
THE WESTERN JOURNAL OF MEDICINE
265
Refer to: Manning PR: Continuing medical education in midpassage (Medical Education). West J Med 128:260-265, Mar 1978
Continuing Medical Education in Midpassage PHIL R. MANNING, MD, Los Angeles
Mandatory continuing education for physicians and other health professionals raises numerous problems. Issues that were considered academic when continuing education was voluntary now take on major practical and political significance. There is the risk that future legislation will mandate activities and methodologies which have not been proven. Research and development in continuing education must be accelerated so that decisions can be based on proper data. Centers of research and development should be established to encourage research and provide a sound foundation for the future of continuing education.
FOR GOOD OR ILL, formal continuing education is now a fact of medical life, required by the legislatures of an increasing number of states, including California. Because it is mandatory, a number of issues have now become pressing that were formerly of academic interest alone. These issues will have a significant impact on all practitioners. Until quite recently the degree of participation in continuing education was decided by the individual physician and, to some extent, by his professional society. As recently as 1955 Vollan stated, in an assessment of continuing medical education: "Since the public has seen fit to allow the profession to control its own affairs, it is the responsibility of organized medicine to insure the The author is Associate Dean, Postgraduate Affairs, and Professor of Medicine, University of Southern California School of Medicine, Los Angeles, and Chairman, Committee on Continuing Medical Education, California Medical Association. Reprint requests to Phil R. Manning, MD, Associate Dean, Postgraduate Affairs, 2025 Zonal Avenue, KAM-317, Los Angeles, CA 90033.
260
MARCH 1978 * 128 * 3
constant continuing education of its members." Dr, Vollan went on to say: "In the last analysis, however, it is the individual physician's responsibility to society to insure his own constant fitness to practice medicine at the highest possible level, which requires that he continue his education regularly throughout his career."' Now, two decades later, society is beginning to require proof that this responsibility has been met .
Shifting Responsibility for Continuing Education Thirty years ago the American Academy of General Practice became the first medical organization in this country to require participation in continuing education as a condition of membership. The Voluntary Physician Recognition Award by the American Medical Association was implemented in 1969. The same year, the California Medical Association initiated a voluntary pro-
CONTINUING MEDICAL EDUCATION
gram granting certification for approved continuing education. Mandatory continuing education for membership in state medical societies began in the State of Oregon in December 1970. At present medical societies in 15 states and the District of Columbia require continuing medical education as a condition of membership (Alabama, Arizona, District of Columbia, Florida, Kansas, Maine, Massachusetts, Minnesota, Montana, New Jersey, New York, North Carolina, Oregon, Pennsylvania, South Dakota and Vermont).2 Medical practice acts in 17 states give their respective state boards of medical examiners authority to require evidence of continuing medical education as a condition for reregistration of the license to practice medicine (Alaska, Arizona,
California, Colorado, Illinois, Kansas, Kentucky, Maryland, Michigan, Minnesota, Nebraska, New Mexico, Ohio, Rhode Island, Utah, Washington and Wisconsin).2 The mandate for formal continuing medical education is based on the presumption that some physicians, at least, have not continued their education and that continuing education will improve health care. Relationship of Continuing Medical Education and Patient Care Health care is a very complex endeavor. Besides the appropriate application of skills and knowledge, components of patient care include accessibility, availability, acceptability, affordability, continuity, prevention and comprehensiveness.3 Quality of patient care is contributed to by many professionals, administrators and workers in addition to physicians, nurses and pharmacists. The totality of care is greater and more complex than most of us realize. It is a team effort. It is profoundly difficult to evaluate. Continuing education for physicians cannot by itself be expected to alter dramatically all the multiple problems of patient care. For many years, patient care was believed to be governed almost entirely by physicians' competence in diagnosis and therapy. Recently, it has been realized that a physician's diagnostic and therapeutic skills are major but not exclusive ingredients of excellent patient care. With this realization, some writers have overreacted, tending to downgrade the importance of the competence of a physician in diagnosis and therapy. It is essential to continue to stress physician competence and skill, if patient care is to continue to improve.
From the standpoint of physicians, we can look at the problem in still another dimension. We can compare a physician's competence (that is, what he is able to do) with his performance (that is, what he actually does in a particular situation). Drs. Clement Brown and John Williamson are major pioneers who have found that many, it not most, patient care problems they have encountered in their extensive work in community hospitals are related to administrative and organizational problems rather than to lack of knowledge.4'5 It is therefore necessary to keep in mind that there are some unrealistic expectations about what continuing education can achieve, but this should not obscure the fact that some expectations relating to the competence of physicians in diagnosis and therapy are realistic and that continuing education can play an important role in this area. Properly conducted continuing education can alert a physician to significant new advances in medicine and help him to review important fundamental concepts. The physician can share and gain from the experience of experts. He can ask questions about specific patients under his care. He can gain direction for self study. He can renew the academic spirit and approach his practice with increased enthusiasm. As Professor Cyril Houle has said, "While continuing education will not cure all the problems of the profession, without it no cure is possible."6
Issues in Continuing Education There are several issues to consider in mandatory continuing education for physicians: * What types of education experiences are and should be acceptable to meet requirements? * Who should be the purveyors or providers of continuing education? * What should be taught and learned? * What are the costs of continuing medical education? What Types of Education Should Be Acceptable? There is a persistent idea that continuing education must be defined as a classroom activity. The Physician's Recognition Award (PRA) of the American Medical Association (AMA) requires a total of 150 credit hours over three years with a minimum of 60 credit hours in Category 1 (See Table 1 ) .7 The regulations appear to foster various types of educational activities; however, those THE WESTERN JOURNAL OF MEDICINE
261
CONTINUING MEDICAL EDUCATION TABLE 1.-Summary of Criteria for the American Medical Association's Physician's Recognition Award Category
1 2 3 4 5
5a 5b 5c Sd 6
CME activities with accredited sponsorship .No limit CME activities with non-accredited sponsorship .45 hours .45 hours Medical teaching Papers, publications, books and exhibits 40 hours Non-supervised individual .45 hours CME activities Self-instruction ...... (22 credit hours) Consultation ........ (22 credit hours) Patient care review ... (22 credit hours) Self-assessment ...... (22 credit hours) Other meritorious learning experiences 45 hours
CME - continuing medical education
which must be validated are considered Category 1. These are formal and didactic, and usually classroom approaches. Legislators have had practical difficulties in determining which components of continuing education to make mandatory. It is very difficult to validate that a physician has read a particular journal or that he has listened to a particular tape or, most important, that he has studied about specific problems of his own patients. If he is a captive student in a classroom one can at least verify his attendance. The need for verification is, of course, based on the presumption that the professional will not be accurate in reporting his activities and will not be aggressive in studying individual problems that occur in his own practice. Many within the profession feel that the whole hierarchy of categories imposes bureaucratic requirements which are not in keeping with the ethics of a scholarly profession. In fact, many feel that the requirement to attend formal programs may stifle interest in self-education-that a physician may feel, "I have done my hours for the year and therefore have no further educational requirements." The requirements for study should relate to the need for study as directed by actual problems in the physician's practice. This most important aspect of continuing education is difficult, if not impossible, to verify, let alone mandate. Who Should Provide Continuing Education? Since 1967 the Council on Medical Education of the American Medical Association has accredited providers or purveyors of continuing nedical education. The standards developed have
262
MARCH 1978 * 128 * 3
TABLE 2.-Composition of Liaison Committee on Continuing Medical Education American Board of Medical Specialties ..... American Medical Association ............ American Hospital Association ........... Association for Hospital Medical Education . Association of American Medical Colleges . . Council of Medical Specialty Societies ..... Federation of State Medical Boards ....... Federal representative ................... Public representative ....................
3 members 4 members 3 members 1 member 3 members 3 members 1 member 1 member 1 member
been used by state medical associations so that they in turn can carry out surveys and accredit activities locally, with ultimate action and decision by the Council on Medical Education. This has led to the beginning of a national standard of accreditation for purveyors of continuing medical education. The Liaison Committee on Continuing Medical Education (LCCME), formed in 1975 and working through the Coordinating Council on Medical Education (CCME), is a national organization which in July 1977 replaced the AMA in accrediting providers of continuing education.7 The LCCME has representatives of its eight parent organizations and of the public at large (See Table 2). Presumably, this organization will be the major accrediting agent of all purveyors. In the early stages, criteria for accreditation should be similar to the AMA criteria. However, the LCCME has no authority over state legislatures who may wish to preserve the right of accrediting purveyors for themselves via boards of quality assurance. Consequently, difficulties may arise in the future in identifying valid purveyors. Purveyors of continuing education include medical schools, medical societies, community hospitals and organizations such as pharmaceutical companies. Medical schools, which many feel should be the hub of continuing education as they are in undergraduate education, are not formally dominant in continuing education. Specialty societies can maintain a more dominant posture, as they deal with a membership which is relatively small and eager. Their advertising costs are lower than a medical school's and they have the great advantage of not having to pay faculty salaries. Instead, for a nominal honorarium they can obtain the services of a faculty member for a few hours, whose yearly salary is paid by the medical schools. In addition, courses offered
CONTINUING MEDICAL EDUCATION TABLE 3.-Approved Category 1 Hours Reported by Physicians to the Certification Program of the California Medical Association 1969
Hospital .13,000 Specialty societies .. 67,000 Medical schools
....
64,000
1975
1976
1,827,377 334,793 240,791
2,038,929 479,205 302,595
by specialty societies often are looked upon as more prestigious that those offered by medical schools. Community hospitals are in a strong position to organize continuing education for their staffs. Physicians congregate there each day; they have record systems and personnel who can assess records to determine educational and administrative needs. Table 3 shows the tremendous growth of community hospitals as locations for approved continuing education in California.8 Unfortunately, hospitals usually do not have a formal faculty and must depend on the abilities of local practitioners, often supplemented piecemeal by faculty members from nearby medical schools. These provider groups are, however, interdependent. A major contribution to continuing education may come through coordinating the activities of medical schools, medical societies, community hospitals and pharmaceutical companies. The ideal relationship has yet to be conceived, let alone implemented, but a rich opportunity exists for developing a cooperative organizational structure for the common good. What Should Be Taught and Learned? Several simple approaches help to determine the most significant issue: what to teach and learn. Many organizations use questionnaires to ask persons who attend formal courses what subjects they would like to hear discussed, and often they ask faculty members what practicing physicians should be taught. There are limitations to these methods: a physician may ask for subjects he likes but may not need and a faculty member may wish to display products of his research, which have little application to practicing physicians. There are more precise ways to determine educational needs. For example, the specialty boards and the National Board of Medical Examiners can provide information on how physicians are scoring on various test items, so areas of weakness can be emphasized. Health statistics, both
regional and national, can be used to better advantage. Leading physicians who act as major consultants in their community can be interviewed systematically to determine problems referred by physicians. All of these methods can be useful and all are underutilized. A still better approach to an individual physician's needs is accurate determination of his performance. Audit procedures as -they are being carried out may be valuable to determine administrative, organizational problems and problems of documentation, but are often not adequate as a basis for education. More research is needed to better identify educational needs and to satisfy these identified needs. What Are the Costs of Continuing Medical Education? The costs of providing continuing medical education have risen in recent years due to inflation, particularly in mail advertising and administration; payment to faculty has not been inflated to the same extent. These costs are reflected in tuition charges. However, the main cost to the practitioner is not tuition itself, but the expense of an office which must be maintained whether the physician is working or not. Time away from practice is clearly a major expense item. Miller estimates that the cost of physician time in continuing education is about $1.4 billion dollars annually in the United States. Even though this estimate includes time that would not be spent in seeing patients, the figure dramatizes the potential cost of physician time in continuing medical education.9 Those interested in continuing education must realize that a physician who comes to a postgraduate program is paying a very significant price, not only in tuition, but by losing income while his office expense continues. Most physicians and the public feel that it is proper for physicians to shoulder the cost of continuing education.
What Are the Frontiers for Development? In the course of designing and implementing concepts of continuing medical education, several additional major issues or frontiers need to be studied carefully: * Improvement of existing educational activities. * Educational television satellite. THE WESTERN JOURNAL OF MEDICINE
263
CONTINUING MEDICAL EDUCATION
* Identification of educational needs and provision of feedback. * Use of computer technology. Improvement of Existing Educational Activities Since continuing education activities are no longer voluntary but are mandatory, there is an obligation on providers of physician education. There is also a burden of obligation on those who have passed laws. The physician must participate in formal education. It is no longer his choice. We, therefore, have no choice but to do things better than we have ever done them before. The move toward better formal continuing education has started. In standard classroom programs there has been a trend to improve technical aspects of instruction, to organize programs by behavioral objectives, to emphasize better audiovisual content, to improve material to be handed out, to select faculty who are good speakers and to involve physicians in active learning such as problem solving activities.
Educational Television Satellite As the new educational television satellite program being coordinated by the Lister Health Center becomes available, many of the things we traditionally have done in the classroom can be done equally well via a medical television network.10 This could cause a major change in traditional classroom programs throughout the country. The impact might be as significant as the effect of sound motion pictures on vaudeville and could result- in a complete restructuring of the
classroom expenrence. Identification of Educational Needs and Provision of Feedback Despite the attraction of satellites and the challenge of devising new ways to package classroom education, more important and fundamental issues await consideration. How can we perfect a system to identify needs and develop a nonpunitive feedback mechanism, which will help a physician profit from his own experience while learning about his practice? The difficulty with developing a feedback mechanism in medicine is that society is perceived to be, and often is, critical and harsh when it comes upon an error by a professional, either in judgment or in fact. This is a major limiting factor in developing a proper feedback mechanism. In its desire to see things go perfectly, society will 264
MARCH 1978 * 128 * 3
undoubtedly overreact to shortcoming, punish the physician who made -the error and make it altogether inadvisable for him to expose himself. I am not concerned solely about the welfare of a physician in a punitive situation, although he has a difficult job and needs support. I am concerned that medical care will suffer. When a person is defensive and guarded, real issues are obscured and therefore it is impossible to solve real problems. A nonpunitive feedback mechanism has a much greater prospect for long-term success because a physician need not be defensive. He is able to find out his problems and react to them without undue criticism or punishment. Therefore, it is imperative to develop a feedback mechanism responding to identified needs. This mechanism must be nonpunitive, not just for the good of the physician but for the good of health care. A physician must look openly at things he does with the motive to improve his competence and performance in dealing with patient problems. His attention should not be diverted by threatening, criticizing, punishing regulations or mounds of irrelevant paper work. This is a crucial issue which must be faced at every step of medical education. Using Computer Technology At present, formal continuing education for the physician is being pursued from two fundamentally different approaches. We teach a physician facts in traditional postgraduate courses so that at the proper time, perhaps weeks or months later, he may recall them and carry out an activity in response. We may notify him retroactively of problems that are derived from audit. This latter procedure usually applies to groups of physicians. An advance in continuing education is now possible through the technology of computers, which will make available information to help solve a problem of diagnosis or management at the time a physician identifies the problem. In other words, it is now possible to weave continuing education into office practice or hospital practice by having a computer terminal as part of the practice environment. Dr. Lawrence Weed has developed a computer program and system now being tested on the medical floors at the University of Vermont. This system, among other things, allows a physician to review displays that help him form treatment plans at the time he is solving his diagnostic and therapeutic problems. Many other partial systems are being developed that utilize
CONTINUING MEDICAL EDUCATION
computers. Immediate continuing education based on real problems at the time that diagnostic and therapeutic plans are formulated should become a reality. Old habits are hard to change and the use of computers will, of course, be resisted by some. Some legal and social problems, such as patient record confidentiality and central control of patient care, will need to be solved. Still, the computer as a tool can make possible immediate continuing education on real issues. This is an objective worth striving for.
The Need for Centers of Research and Development No issue in education is more important than continuing education in the professions. All the professions need better methods of continuing education. As for medical continuing education, efforts should be made to develop several research and development centers around the country to develop and test ideas and approaches in continuing education for health professionals. Since strong and well-motivated desires to see things get better and get better quickly may pressure state legislators to mandate educational activities that are ahead of the state of the art, it is essential to test methodologies and approaches before legislation goes further. Research and development in this field can give us data on which to
base such legislation. For the present, we should be content to improve our methods to comply with current requirements to the best of our abilities. But we must press for accelerated research and development before further laws and regulations mandate methods whose validity needs to be substantiated. Those who pass laws mandating educational activities and those in medical education have a profound responsibility to foster further research to define and develop educational principles and methods that will aid the physician and other health professionals to offer ever-improving health care. REFERENCES 1. Vollan D: Scope and extent of postgraduate medical education in the United States. JAMA 157:703-708, Feb 1955 2. Continuing Medical Education Fact Sheet. American Medical Association, Apr 1, 1977 3. Petit D: Testing for clinical competence-Is there need for multiple examinations? Federation Bulletin 5:71-77, Feb 1972 4. Brown CR Jr, Fleisher DS: The bi-cycle concept-Relating continuing education directly to patient care. N Eng J Med 284: (Supplement) 88-87, May 20, 1971 5. Williamson J, Alexander M, Miller G: Continuing education and patient care research. JAMA 201:118-122, Sep 1967 6. Houle C: The lengthened line. Perspect Biol Med, 37-51, Autumn 1967 7. Essentials for Accreditation of Institutions and Organizations Offering Continuing Medical Education Programs. American Medical Association, Jun 1970 8. Manley RD: Department of Continuing Education Report. California Medical Association, Jan 1977 9. Miller LA: The current investment in continuing medical education, chap 14, In Egdahl RH, Gertman PM (Eds): Quality Health Care. Germantown, MD, Aspen Systems Corporation, 1977, pp 143-160 10. Biomedical Communications Experiment-Communications Technology Satellite Program. Communications Engineering Branch, Lister Hill National Center for Biomedical Communications, Apr 1977
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