719
TOWARD A CONTINUUM IN MEDICAL EDUCATION*
THOMAS C. MEYER, M.D. Chairman, Department of Continuing Medical Education University of Wisconsin Extension Associate Dean for Education University of Wisconsin Medical School Madison, Wis.
MMEDICAL education is concerned with the communication of knowledge, techniques, and attitudes and with teaching students the use of the scientific method of solving problems in the unique setting of the clinical encounter. This is a continuous process which begins with premedical training and ends with retirement or death. The continuum is divided, perhaps too sharply, into three phases: i) Premedical and medical education in the university, which usually lasts eight years. 2) The period of residency training, based in the teaching hospital, which varies from three to seven years, depending upon the residency requirements of the specialty board. 3) The phase of continuing education, the duration of which is variable-usually between 3o and 4o years. The form this phase takes is amorphous and multifaceted but it is critical indeed. In this domain lie the problems of ensuring the continuous flow of scientific information while attempting to change the attitudes of overburdened individuals toward their roles, responsibilities, and traditional functions in a demanding and critical society. I shall dwell for a moment on the traditional role of continuing medical education. During the second and third decades of this century medical schools industriously made available to their students a well-circumscribed, well-accepted body of knowledge, taught them a limited number of skills, and then evaluated the students' competence. The schools could, with pride, award their graduates the M.D. degree and allow them to practice medicine with some confidence that these *Presented as part of a Symposiwun on Continuing Medical Education held by the Committee on Medical Education of the New York Academy of Medicine October 10, 1974.
Vol. 51, No. 6, June 1975
720
720
T. C. MEYER
graduates possessed enough scholarship to keep abreast of the small volume of literature which reported the snail's pace of advances in knowledge. Equally, the necessary skills changed but little, and the hazard of a physician or surgeon not acquiring new skills was comparatively unimportant to the patient in terms of the care he received. Continuing education had, therefore, the comfortable role of reinforcing, updating, and expanding the scientific base upon which practitioners delivered care to the sick. Programs of continuing education were based on the intuitive assessment of the need by teacher, programmer, or student, and evaluated by the satisfaction of those involved. In I920 and 1930 these were probably fairly accurate, relevant, and helpful methods. The discoveries of Paul Ehrlich, L. Landsteiner, Frederick G. Banting, C. H. Best, Edgar D. Adrian, and many others made profound changes in the microstructure of medical-school curricula, but had little impact on continuing education. The changes affecting clinical practice appeared relatively uncomplicated, even though the results were frequently dramatic. The infrequency with which these changes were introduced allowed for a gradual change in performance. Thus, continuing medical education was equal to its task, not because it was effectively planned and implemented, but primarily because the task was so limited. I need not document the profound changes in medical science since World War II. I shall only mention the well-known graph depicting, as a function of time, the exponential increase in the number of scientific papers, journals of original publications, review articles, and thematic monographs. Admittedly, a similar graph depicting the rate of discovery of significant remedies that should be implemented immediately would not show such a rapidly rising curve, but the impact on the continuum of medical education is substantial and all-encompassing. The first two phases of medical training have, to a great degree, made adjustments for this burgeoning of scientific knowledge. The student physician-at the premedical, medical school, or residency level -is kept informed of significant new developments by his peers, the journals, the medical faculty, and the medical library. Through a delineation of specialties and subspecialties, the structure of residency training has changed so that each physician need not attempt to absorb all the scientific knowledge available. Bull. N. Y. Acad. Med.
TOWARD A CONTINUUM
TOWARD
A
CONTINUUM
72I
721
This is not true in the field of continuing medical education. The traditional roles of reinforcing, updating, and expanding the scientific base upon which practitioners deliver care has become a much more diverse and demanding one. The problems for both the educator and the practitioner have become much more complex. Accomplishing this traditional role now brings continuing medical education face-to-face with the same issues challenging every other branch of education today: developing methods of identifying needs and priorities, establishing objectives, planning educational methodology, and evaluating the effectiveness of these methods in terms of behavioral change. In addition to the exacting educational role, I shall explore a new "nonscientific" role which is being thrust on continuing education. This new role seems to lie in two principal areas: effecting changes required within the setting of the medical practice and effecting changes required for the physician to function within the social structure in which medicine is practiced. The changes within the setting of the medical practice for which continuing education must prepare the physician include the following: i) The assessment of the quality of the care which is delivered. We have heard and will hear more of the evaluation of medical care in this conference and many of us are familiar with the wondrous new language of the Professional Standard Review Organizations (PSROS) -Patient Care Appraisal (PCA), Concurrent Admission Certification (CAC), Continued Stay Review (CSR), and many others. There remains the baffling problem of measuring the quality of ambulatory care. This has been attempted in Hawaii with some success. The application of the problem-oriented medical record has aided this process immensely in the offices in which it is used. 2) The change from intervention in times of crises to continuous, comprehensive care. Again, we are struggling with the results of increased knowledge and specialization while trying to preserve the comfortable human interchange which seems essential to the patient's feeling of well-being and trust in the physician. 3) The team approach. Higher levels of competence of allied health personnel-along with the physician's lack of time and of competence in specialized technical areas-dictate a change from benevolent autocracy to a team approach to the delivery of medical care, Vol. 51, No. 6, June 1975
7722 2
T. C. MEYER T.C EE
with the physician serving as supervisor and consultant in many aspects of care to insure that the correct quality and quantity is received by the patient. While the eventual solution may lie earlier in the continuum of education, there is currently little opportunity for the physician to develop these managerial skills during his formal training. These are difficult, often traumatic, adjustments for the physician to make. If he is to receive assistance in making these changes, it appears that it must come initially through the vehicle of continuing education. I shall return now to the expanded role of continuing education in carrying out its traditional tasks and also continue to develop the thesis that it has new nonscientific responsibilities. At the University of Wisconsin we have taken the first step in attempting to devise a method by which the physician can identify his individual educational needs in terms of the health care he is called on to deliver. We started with the hypothesis that no two practices are alike in that the background, fund of knowledge, and experience of every physician differs from that of his colleagues. Therefore, it is no longer comfortable to plan programs of continuing education by intuition alone; each practitioner's educational needs can be expected to vary as his practice varies. Our study involved the practices of approximately I20 physicians in the United States; it is complicated and I shall rever to only a part of it. In essence, it involves the collection of data on all the occasions on which a physician had contact with patients during four separate 24hour periods in a month. This data is collated, and from it we design a test related to this observed practice. The test results become one factor in the design of the physician's personalized educational program.* While the data related to individual practices is too large to present within this paper, it does support the thesis that individual practices vary. Two family practitioners with adjacent offices in the same building will serve vastly different needs of patients. Even in those areas of medicine (e.g., cardiovascular disease) where there are similarities, testing will often reveal a significant difference in the ability of physicians to recall factual knowledge instantly in these areas. *Sivertson, S. E., Meyer, I'. C., Hansen, R., and Schoenenberger, A.: Individual physician profile: Continuing education related to medical practice. J. Med. Edcuc. 48:1006-12, 1973.
Bull. N. Y. Acad. Med.
TOWARD A CONTINUUM
TOWARD
72 3
723
Our conclusion is that we may well be doing the practitioner a disservice if we intuitively plan a course, publicize it, take enrollments, determine his satisfaction with it, and send him home with a feeling of accomplishment. His time is too valuable and his responsibilities for the care of patients are too great for that approach. We are also attempting, in a rather informal manner, to determine the learning behavior of the physicians who participate. They are asked "Do you know how you learn best?" A small percentage can answer this directly. More frequently, the determination is made by a discussion of the physicians' performance in the preclinical and clinical years of medical school and by their current use of books and journals as opposed to audio-journals and attendance at conferences. Two thirds of them were identified as audio-visual learners or felt that they did not learn unless they were personally doing something. The implications for teaching media and methodology in continuing education are evident: attention must be given to providing educational content in the diverse forms by which individual physicians learn best. The cumulative data on the diseases and conditions seen by the 63 family practitioners involved in this study evoked many issues. One fifth of their contacts with patients as categorized in the International Classification of Diseases Adapted (ICDA) were in category i 8, Special Conditions and Examinations Without Illness. When physicians make their choices of continuing education on the basis of what is interesting or challenging to them, rather than on the needs of their patients, they infrequently show much enthusiasm for this area of medicine. Testing, however, frequently shows that physicians have marginal performance in this category, and the educational prescription for this often includes a revision of basic skills in physical diagnosis. But perhaps the real significance of this data lies in another direction. We must ask what degree of training and education is necessary for the delivery of some health services now being delivered by the physician and whether the high level of contacts with patients in this category might reflect an inappropriate use of physician manpower. In its expanded role, continuing education must determine in this instance where the educational task lies-in the traditional area of scientific medicine or in the nonscientific area of proper utilization of allied health personnel-to improve preventive medical care. Another interesting facet of study occurred in the test results. Some Vol. 51, No. 6, June 1975
724
T. C. MEYER T.
C.
MEYER
physicians scored higher on test questions in those areas of medicine where they have few contacts with patients and performed less well in areas which constituted major portions of their practice. This raises the question of whether continuing education-or for that matter medical schools-are producing physicians highly trained in areas where they see few patients, but less well trained to respond to the needs of the majority of patients. Our data on this is sketchy at present, but it is reinforced by the work of Keith Hodgkin, M.D., who is in general practice in a little town near Newcastle, England. Dr. Hodgkin's book Toward Earlier Diagnosis* tries to help physicians avoid some of the many heart searchings he suffered while struggling to modify his hospital-based training to fit the extensive needs of a general ambulatory practice. While highly supportive of the training he received, Dr. Hodgkin demonstrates from his own experience that hospital-based medical training may leave the graduate poorly prepared to meet his first private patient-a telephone operator with "dizzy spells in the busy spells"or his second patient, who has a casual history of a grey cloud in the visual field of his right eye. Dr. Hodgkin's illustration is graphic in that he documents his personal encounters with diseases as a student and intern and compares them with a year's experience in general practice. His data is broken down into categories of disease, e.g., he shows the number of malignant diseases he encountered in his training in the left-hand column and the cases of malignancy he encountered in one year of practice on the right. He documents an imbalance for malignant, mental, cardiovascular, respiratory, and other categories of disease. Dr. Hodgkin is a careful investigator in that his diagnoses in practice are verified by a five-year follow-up. Not every practitioner can be expected to devote the time and effort to a study of his training and practice that Dr. Hodgkin did. But it falls within the role of continuing education to assist physicians in carrying out some analysis of society's needs in relation to their own medical preparation. The problems facing the practitioner and his patient are not always in the area of scientific medicine, nor do they always lend themselves to educational solutions in the traditional meaning of the word. Nor can these solutions always be found in continu*Hodgkin,
R.: Toward Earlier Diagnosis.
Edinburgh and London, Livingston, 1966. Bull. N. Y. Acad. Med.
A CONTINUUM TOWARD TOWARD A
CONTINUUM
725
725
ing education; they often relate to earlier stages in the continuum of medical education. What then is the role of the medical school in the continuum of medical education? First, it must produce graduates who have the skills and concepts to minister logically to the needs of the ill while protecting the health of citizens before they become ill. This base is essential for an effective program in continuing education. Second, the medical school must prepare its graduates for the personalized form of learning that must be their way of life for the remaining 30 to 40 years that they will be in practice. Personalized learning depends upon the ability to perceive and document one's own learning needs and to recognize one's own optimal style of learning by which the indentified needs may be rectified. Premedical and medical schools should offer diverse pathways by which students may attain established levels of competence, namely, objectives. The function of the medical faculty is to i) identify these objectives for the students, 2) design, identify, and, if necessary, produce alternate pathways by which these objectives can be attained, 3) solve problems for the students, and 4) determine whether the students have attained these objectives. Theoretically, then, each student will be consciously aware of and comfortable with his own optimal style of learning by the time he obtains his M.D. The period of postgraduate education is one in which the individual learns how to set his own personal educational goals by utilizing both objective means such as evaluation of medical care and subjective aspirations and career goals. Thus, by the end of the period of formal training the physician should be able to prescribe both his learning needs and the form in which he requires them. The third role of the medical school is to make its resources constantly available to the physicians who wish to reincarnate themselves by whatever means they select and at a time convenient to them. Fourth, it must assist the physician in constantly redefining his role in the delivery of health care and in adjusting to changes which he initiates or which are thrust upon him by his patients or the society in which he practices. Finally, the medical school has a duty to educate the public in health. Members of the public should have at their disposal the skills of medical faculties to teach them how to use the health-care system Vol. 51, No. 6, June 1975
7 2. 6
T. C. MEYER T. C. MEYER
logically and systematically. In so doing the practicing physician can be simultaneously protected and motivated to spend his study time in a way which is appropriate to the population which he serves. In summary, I have tried to indicate the evolving role of continuing education as an interface between consumers, providers, and educators in the system of health care. To do this it must develop the means by which it can influence and be influenced by each segment it serves. Each must be given due service and respect and each must be made to understand the role and function of the other two. The continuum encompasses all of these facets; their importance remains paramount, whether the learner is a premedical, medical, postgraduate, or continuing student of medicine.
Bull. N. Y. Acad. Med.
TOWARD A CONTINUUM IN MEDICAL EDUCATION*
THOMAS C. MEYER, M.D. Chairman, Department of Continuing Medical Education University of Wisconsin Extension Associate Dean for Education University of Wisconsin Medical School Madison, Wis.
MMEDICAL education is concerned with the communication of knowledge, techniques, and attitudes and with teaching students the use of the scientific method of solving problems in the unique setting of the clinical encounter. This is a continuous process which begins with premedical training and ends with retirement or death. The continuum is divided, perhaps too sharply, into three phases: i) Premedical and medical education in the university, which usually lasts eight years. 2) The period of residency training, based in the teaching hospital, which varies from three to seven years, depending upon the residency requirements of the specialty board. 3) The phase of continuing education, the duration of which is variable-usually between 3o and 4o years. The form this phase takes is amorphous and multifaceted but it is critical indeed. In this domain lie the problems of ensuring the continuous flow of scientific information while attempting to change the attitudes of overburdened individuals toward their roles, responsibilities, and traditional functions in a demanding and critical society. I shall dwell for a moment on the traditional role of continuing medical education. During the second and third decades of this century medical schools industriously made available to their students a well-circumscribed, well-accepted body of knowledge, taught them a limited number of skills, and then evaluated the students' competence. The schools could, with pride, award their graduates the M.D. degree and allow them to practice medicine with some confidence that these *Presented as part of a Symposiwun on Continuing Medical Education held by the Committee on Medical Education of the New York Academy of Medicine October 10, 1974.
Vol. 51, No. 6, June 1975
720
720
T. C. MEYER
graduates possessed enough scholarship to keep abreast of the small volume of literature which reported the snail's pace of advances in knowledge. Equally, the necessary skills changed but little, and the hazard of a physician or surgeon not acquiring new skills was comparatively unimportant to the patient in terms of the care he received. Continuing education had, therefore, the comfortable role of reinforcing, updating, and expanding the scientific base upon which practitioners delivered care to the sick. Programs of continuing education were based on the intuitive assessment of the need by teacher, programmer, or student, and evaluated by the satisfaction of those involved. In I920 and 1930 these were probably fairly accurate, relevant, and helpful methods. The discoveries of Paul Ehrlich, L. Landsteiner, Frederick G. Banting, C. H. Best, Edgar D. Adrian, and many others made profound changes in the microstructure of medical-school curricula, but had little impact on continuing education. The changes affecting clinical practice appeared relatively uncomplicated, even though the results were frequently dramatic. The infrequency with which these changes were introduced allowed for a gradual change in performance. Thus, continuing medical education was equal to its task, not because it was effectively planned and implemented, but primarily because the task was so limited. I need not document the profound changes in medical science since World War II. I shall only mention the well-known graph depicting, as a function of time, the exponential increase in the number of scientific papers, journals of original publications, review articles, and thematic monographs. Admittedly, a similar graph depicting the rate of discovery of significant remedies that should be implemented immediately would not show such a rapidly rising curve, but the impact on the continuum of medical education is substantial and all-encompassing. The first two phases of medical training have, to a great degree, made adjustments for this burgeoning of scientific knowledge. The student physician-at the premedical, medical school, or residency level -is kept informed of significant new developments by his peers, the journals, the medical faculty, and the medical library. Through a delineation of specialties and subspecialties, the structure of residency training has changed so that each physician need not attempt to absorb all the scientific knowledge available. Bull. N. Y. Acad. Med.
TOWARD A CONTINUUM
TOWARD
A
CONTINUUM
72I
721
This is not true in the field of continuing medical education. The traditional roles of reinforcing, updating, and expanding the scientific base upon which practitioners deliver care has become a much more diverse and demanding one. The problems for both the educator and the practitioner have become much more complex. Accomplishing this traditional role now brings continuing medical education face-to-face with the same issues challenging every other branch of education today: developing methods of identifying needs and priorities, establishing objectives, planning educational methodology, and evaluating the effectiveness of these methods in terms of behavioral change. In addition to the exacting educational role, I shall explore a new "nonscientific" role which is being thrust on continuing education. This new role seems to lie in two principal areas: effecting changes required within the setting of the medical practice and effecting changes required for the physician to function within the social structure in which medicine is practiced. The changes within the setting of the medical practice for which continuing education must prepare the physician include the following: i) The assessment of the quality of the care which is delivered. We have heard and will hear more of the evaluation of medical care in this conference and many of us are familiar with the wondrous new language of the Professional Standard Review Organizations (PSROS) -Patient Care Appraisal (PCA), Concurrent Admission Certification (CAC), Continued Stay Review (CSR), and many others. There remains the baffling problem of measuring the quality of ambulatory care. This has been attempted in Hawaii with some success. The application of the problem-oriented medical record has aided this process immensely in the offices in which it is used. 2) The change from intervention in times of crises to continuous, comprehensive care. Again, we are struggling with the results of increased knowledge and specialization while trying to preserve the comfortable human interchange which seems essential to the patient's feeling of well-being and trust in the physician. 3) The team approach. Higher levels of competence of allied health personnel-along with the physician's lack of time and of competence in specialized technical areas-dictate a change from benevolent autocracy to a team approach to the delivery of medical care, Vol. 51, No. 6, June 1975
7722 2
T. C. MEYER T.C EE
with the physician serving as supervisor and consultant in many aspects of care to insure that the correct quality and quantity is received by the patient. While the eventual solution may lie earlier in the continuum of education, there is currently little opportunity for the physician to develop these managerial skills during his formal training. These are difficult, often traumatic, adjustments for the physician to make. If he is to receive assistance in making these changes, it appears that it must come initially through the vehicle of continuing education. I shall return now to the expanded role of continuing education in carrying out its traditional tasks and also continue to develop the thesis that it has new nonscientific responsibilities. At the University of Wisconsin we have taken the first step in attempting to devise a method by which the physician can identify his individual educational needs in terms of the health care he is called on to deliver. We started with the hypothesis that no two practices are alike in that the background, fund of knowledge, and experience of every physician differs from that of his colleagues. Therefore, it is no longer comfortable to plan programs of continuing education by intuition alone; each practitioner's educational needs can be expected to vary as his practice varies. Our study involved the practices of approximately I20 physicians in the United States; it is complicated and I shall rever to only a part of it. In essence, it involves the collection of data on all the occasions on which a physician had contact with patients during four separate 24hour periods in a month. This data is collated, and from it we design a test related to this observed practice. The test results become one factor in the design of the physician's personalized educational program.* While the data related to individual practices is too large to present within this paper, it does support the thesis that individual practices vary. Two family practitioners with adjacent offices in the same building will serve vastly different needs of patients. Even in those areas of medicine (e.g., cardiovascular disease) where there are similarities, testing will often reveal a significant difference in the ability of physicians to recall factual knowledge instantly in these areas. *Sivertson, S. E., Meyer, I'. C., Hansen, R., and Schoenenberger, A.: Individual physician profile: Continuing education related to medical practice. J. Med. Edcuc. 48:1006-12, 1973.
Bull. N. Y. Acad. Med.
TOWARD A CONTINUUM
TOWARD
72 3
723
Our conclusion is that we may well be doing the practitioner a disservice if we intuitively plan a course, publicize it, take enrollments, determine his satisfaction with it, and send him home with a feeling of accomplishment. His time is too valuable and his responsibilities for the care of patients are too great for that approach. We are also attempting, in a rather informal manner, to determine the learning behavior of the physicians who participate. They are asked "Do you know how you learn best?" A small percentage can answer this directly. More frequently, the determination is made by a discussion of the physicians' performance in the preclinical and clinical years of medical school and by their current use of books and journals as opposed to audio-journals and attendance at conferences. Two thirds of them were identified as audio-visual learners or felt that they did not learn unless they were personally doing something. The implications for teaching media and methodology in continuing education are evident: attention must be given to providing educational content in the diverse forms by which individual physicians learn best. The cumulative data on the diseases and conditions seen by the 63 family practitioners involved in this study evoked many issues. One fifth of their contacts with patients as categorized in the International Classification of Diseases Adapted (ICDA) were in category i 8, Special Conditions and Examinations Without Illness. When physicians make their choices of continuing education on the basis of what is interesting or challenging to them, rather than on the needs of their patients, they infrequently show much enthusiasm for this area of medicine. Testing, however, frequently shows that physicians have marginal performance in this category, and the educational prescription for this often includes a revision of basic skills in physical diagnosis. But perhaps the real significance of this data lies in another direction. We must ask what degree of training and education is necessary for the delivery of some health services now being delivered by the physician and whether the high level of contacts with patients in this category might reflect an inappropriate use of physician manpower. In its expanded role, continuing education must determine in this instance where the educational task lies-in the traditional area of scientific medicine or in the nonscientific area of proper utilization of allied health personnel-to improve preventive medical care. Another interesting facet of study occurred in the test results. Some Vol. 51, No. 6, June 1975
724
T. C. MEYER T.
C.
MEYER
physicians scored higher on test questions in those areas of medicine where they have few contacts with patients and performed less well in areas which constituted major portions of their practice. This raises the question of whether continuing education-or for that matter medical schools-are producing physicians highly trained in areas where they see few patients, but less well trained to respond to the needs of the majority of patients. Our data on this is sketchy at present, but it is reinforced by the work of Keith Hodgkin, M.D., who is in general practice in a little town near Newcastle, England. Dr. Hodgkin's book Toward Earlier Diagnosis* tries to help physicians avoid some of the many heart searchings he suffered while struggling to modify his hospital-based training to fit the extensive needs of a general ambulatory practice. While highly supportive of the training he received, Dr. Hodgkin demonstrates from his own experience that hospital-based medical training may leave the graduate poorly prepared to meet his first private patient-a telephone operator with "dizzy spells in the busy spells"or his second patient, who has a casual history of a grey cloud in the visual field of his right eye. Dr. Hodgkin's illustration is graphic in that he documents his personal encounters with diseases as a student and intern and compares them with a year's experience in general practice. His data is broken down into categories of disease, e.g., he shows the number of malignant diseases he encountered in his training in the left-hand column and the cases of malignancy he encountered in one year of practice on the right. He documents an imbalance for malignant, mental, cardiovascular, respiratory, and other categories of disease. Dr. Hodgkin is a careful investigator in that his diagnoses in practice are verified by a five-year follow-up. Not every practitioner can be expected to devote the time and effort to a study of his training and practice that Dr. Hodgkin did. But it falls within the role of continuing education to assist physicians in carrying out some analysis of society's needs in relation to their own medical preparation. The problems facing the practitioner and his patient are not always in the area of scientific medicine, nor do they always lend themselves to educational solutions in the traditional meaning of the word. Nor can these solutions always be found in continu*Hodgkin,
R.: Toward Earlier Diagnosis.
Edinburgh and London, Livingston, 1966. Bull. N. Y. Acad. Med.
A CONTINUUM TOWARD TOWARD A
CONTINUUM
725
725
ing education; they often relate to earlier stages in the continuum of medical education. What then is the role of the medical school in the continuum of medical education? First, it must produce graduates who have the skills and concepts to minister logically to the needs of the ill while protecting the health of citizens before they become ill. This base is essential for an effective program in continuing education. Second, the medical school must prepare its graduates for the personalized form of learning that must be their way of life for the remaining 30 to 40 years that they will be in practice. Personalized learning depends upon the ability to perceive and document one's own learning needs and to recognize one's own optimal style of learning by which the indentified needs may be rectified. Premedical and medical schools should offer diverse pathways by which students may attain established levels of competence, namely, objectives. The function of the medical faculty is to i) identify these objectives for the students, 2) design, identify, and, if necessary, produce alternate pathways by which these objectives can be attained, 3) solve problems for the students, and 4) determine whether the students have attained these objectives. Theoretically, then, each student will be consciously aware of and comfortable with his own optimal style of learning by the time he obtains his M.D. The period of postgraduate education is one in which the individual learns how to set his own personal educational goals by utilizing both objective means such as evaluation of medical care and subjective aspirations and career goals. Thus, by the end of the period of formal training the physician should be able to prescribe both his learning needs and the form in which he requires them. The third role of the medical school is to make its resources constantly available to the physicians who wish to reincarnate themselves by whatever means they select and at a time convenient to them. Fourth, it must assist the physician in constantly redefining his role in the delivery of health care and in adjusting to changes which he initiates or which are thrust upon him by his patients or the society in which he practices. Finally, the medical school has a duty to educate the public in health. Members of the public should have at their disposal the skills of medical faculties to teach them how to use the health-care system Vol. 51, No. 6, June 1975
7 2. 6
T. C. MEYER T. C. MEYER
logically and systematically. In so doing the practicing physician can be simultaneously protected and motivated to spend his study time in a way which is appropriate to the population which he serves. In summary, I have tried to indicate the evolving role of continuing education as an interface between consumers, providers, and educators in the system of health care. To do this it must develop the means by which it can influence and be influenced by each segment it serves. Each must be given due service and respect and each must be made to understand the role and function of the other two. The continuum encompasses all of these facets; their importance remains paramount, whether the learner is a premedical, medical, postgraduate, or continuing student of medicine.
Bull. N. Y. Acad. Med.
