Commentary
CONTINUING MEDICAL EDUCATION DOUGLAS A. FENDERSON, Ph.D.
problems, "packaged" instructional units, audio and video programs complete with pre- and post-tests, programmed texts, interactive computer-assisted instruction, and now, video disc technology. Medical libraries now include "learning resource centers" as part of their mission. Medical students experience machine-mediated self-study as an intrinsic part of their education. Authoritative information at the time and place of need is a goal of the information specialists. Medical reference search, through local links wifh the National Library of Medicine, have often aided in the physician's search for current knowledge. Several medical schools have demonstrated impressively successful instant consultation services via special phone and paging linkages. The flood of published literature, thousands of educational courses, conferences and conventions present a bewildering array of choices to practicing physicians. Many state and professional societies require evidence of current knowledge through continuing education. All the major medical specialty societies are on record as favoring some continuing education requirements for maintenance of specialty certification. Eight states of the US have passed laws which permit sanctions against physicians who do not keep
From the Continuing Education Program, University of Minnesota Medical School. Minneapolis, Minnesota
Medicine is often considered the prototype of the learned professions, yet most of its practitioners seek "vocationaltechnical" information in continuing education courses. Evaluations received from some 4,000 physicians in our last program year indicate practical application to be the overriding concern. The American Medical Association and specialty societies foster this vocational view by requiring written statements of endsmeans relationships in "measurable" terms. Within the lifetime of most of us, many diseases, once treated on a symptomatic basis, are now understood at an explanatory level, allowing greater precision and control in diagnosis and treatment. This progress of scientific medicine is aided by the development of the systems sciences, which seek most favorable costto-benefit relationships. Educational Instruments The confluence of these forces has spawned an amazing array of educational technology devices and materials. These include computer simulation of case 584
No. 7
MEDICAL EDUCATION
up. Malpractice precedent now holds physicians responsible for practice norms for the profession at large, as opposed to local or regional custom and practice. Effectiveness
Controversy rages over the effectiveness of continuing medical educational programs as a means of assuring high standards of practice. Some evidence supports this view. The American College of Physicians has questioned the reasonableness of mandatory education and examination, and suggests that practice audit is a more logical approach to assuring competent performance. Others reject that logic as being too idealistic ^— requiring, as it does, a degree of intrusion into medical encounters. The Academy of Family Physicians takes a mixed procedure approach, requiring periodic recertification examination, mandatory accredited continuing medical education and case audit. Nor is the controversy limited to education as a requirement. The relative merits of various educational methods also stimulate vigorous debate, even though a major summary study of learning methods fails to demonstrate the consistent superiority of any.^ "Not Everything That Can Be Counted, Counts" As the profession continues to conform to the legal, scientific and technologic pressures for change, none of us would want to forgo the impressive clinical control now possible through the advances of the past quarter century. These advances had to be learned by physicians in practice — in the somewhat unique ways in which physicians learn—through reading, through teaching, through con-
Fenderson
585
sultation relationships, observation and personal experience and through organized programs of postgraduate study. Many of our participants tell us that lectures are their preferred mode of learning; many refuse educational technology unless it is personalized through the presence of a live teacher. However, lectures are often criticized in the literature as not being a legitimate form of instruction. Some data suggests that the belief of the instructor in his preferred methods is the best explanation of the "better" results in comparative studies. But most physicians (necessarily well educated), have demonstrated their skill in learning, both in their preferred modes, and perhaps, irrespective of method. The 1976 Minnesota State Legislature was debating mandatory continuing medical education. After a convincing supportive statement by a representative of one of the professional societies, a crusty old legislator asked, "And what is so out of control in your profession that you seek redress through public law?" After an embarrassing silence, the answer was that there are a few physicians who (presumably) do not acknowledge the value of learning as an intrinsic professional responsibility. Over and above the behavioral objectives—-learning systems, audits, accountability and legal requirements — is a history, tradition and value system which affirms that the pursuit of relevant knowledge is a part of the physician's way of life. Reference 1. Dubin, R., and Taveggia, T. C: The TeachingLearning Paradox of Comparative Analysis of College Teaching Methods. Eugene, OK, Center for the Advanced Study of Education in Administration, 1968.
CONTINUING MEDICAL EDUCATION DOUGLAS A. FENDERSON, Ph.D.
problems, "packaged" instructional units, audio and video programs complete with pre- and post-tests, programmed texts, interactive computer-assisted instruction, and now, video disc technology. Medical libraries now include "learning resource centers" as part of their mission. Medical students experience machine-mediated self-study as an intrinsic part of their education. Authoritative information at the time and place of need is a goal of the information specialists. Medical reference search, through local links wifh the National Library of Medicine, have often aided in the physician's search for current knowledge. Several medical schools have demonstrated impressively successful instant consultation services via special phone and paging linkages. The flood of published literature, thousands of educational courses, conferences and conventions present a bewildering array of choices to practicing physicians. Many state and professional societies require evidence of current knowledge through continuing education. All the major medical specialty societies are on record as favoring some continuing education requirements for maintenance of specialty certification. Eight states of the US have passed laws which permit sanctions against physicians who do not keep
From the Continuing Education Program, University of Minnesota Medical School. Minneapolis, Minnesota
Medicine is often considered the prototype of the learned professions, yet most of its practitioners seek "vocationaltechnical" information in continuing education courses. Evaluations received from some 4,000 physicians in our last program year indicate practical application to be the overriding concern. The American Medical Association and specialty societies foster this vocational view by requiring written statements of endsmeans relationships in "measurable" terms. Within the lifetime of most of us, many diseases, once treated on a symptomatic basis, are now understood at an explanatory level, allowing greater precision and control in diagnosis and treatment. This progress of scientific medicine is aided by the development of the systems sciences, which seek most favorable costto-benefit relationships. Educational Instruments The confluence of these forces has spawned an amazing array of educational technology devices and materials. These include computer simulation of case 584
No. 7
MEDICAL EDUCATION
up. Malpractice precedent now holds physicians responsible for practice norms for the profession at large, as opposed to local or regional custom and practice. Effectiveness
Controversy rages over the effectiveness of continuing medical educational programs as a means of assuring high standards of practice. Some evidence supports this view. The American College of Physicians has questioned the reasonableness of mandatory education and examination, and suggests that practice audit is a more logical approach to assuring competent performance. Others reject that logic as being too idealistic ^— requiring, as it does, a degree of intrusion into medical encounters. The Academy of Family Physicians takes a mixed procedure approach, requiring periodic recertification examination, mandatory accredited continuing medical education and case audit. Nor is the controversy limited to education as a requirement. The relative merits of various educational methods also stimulate vigorous debate, even though a major summary study of learning methods fails to demonstrate the consistent superiority of any.^ "Not Everything That Can Be Counted, Counts" As the profession continues to conform to the legal, scientific and technologic pressures for change, none of us would want to forgo the impressive clinical control now possible through the advances of the past quarter century. These advances had to be learned by physicians in practice — in the somewhat unique ways in which physicians learn—through reading, through teaching, through con-
Fenderson
585
sultation relationships, observation and personal experience and through organized programs of postgraduate study. Many of our participants tell us that lectures are their preferred mode of learning; many refuse educational technology unless it is personalized through the presence of a live teacher. However, lectures are often criticized in the literature as not being a legitimate form of instruction. Some data suggests that the belief of the instructor in his preferred methods is the best explanation of the "better" results in comparative studies. But most physicians (necessarily well educated), have demonstrated their skill in learning, both in their preferred modes, and perhaps, irrespective of method. The 1976 Minnesota State Legislature was debating mandatory continuing medical education. After a convincing supportive statement by a representative of one of the professional societies, a crusty old legislator asked, "And what is so out of control in your profession that you seek redress through public law?" After an embarrassing silence, the answer was that there are a few physicians who (presumably) do not acknowledge the value of learning as an intrinsic professional responsibility. Over and above the behavioral objectives—-learning systems, audits, accountability and legal requirements — is a history, tradition and value system which affirms that the pursuit of relevant knowledge is a part of the physician's way of life. Reference 1. Dubin, R., and Taveggia, T. C: The TeachingLearning Paradox of Comparative Analysis of College Teaching Methods. Eugene, OK, Center for the Advanced Study of Education in Administration, 1968.
