The effort to build better CME

Why didactic lectures are out and interactive learning is in

From the November 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

By Deborah Gesensway

When Virginia's legislators wanted to make sure the state's physicians were competent to practice, the state board of medicine's first proposal seemed clear-cut: Require physicians to take continuing medical education (CME) courses. Virginia is one of the 15 or so states that does not currently require physicians to earn CME credits, and doing so seemed to be a step in the right direction.

At the same time, however, the state's licensing board was confronting mounting evidence that much of what traditionally passes for CME isn't very effective in building better doctors. The challenge: how to prove that physicians in Virginia were keeping up-to-date and do it in a way that reflected current thinking about CME.

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The result is Virginia's unusual mix of old-fashioned and newfangled CME requirements, which are expected to be approved this fall and instituted in 2000. If things go as planned, the state's physicians will have to keep a "learning portfolio" in which they track all kinds of CME activities like consults with peers, teaching and writing, not just traditional lectures and conferences. And to renew their license every two years, physicians will have to identify their educational goals in advance and then state whether they accomplished those goals at the end of the two-year period.

The quality improvement movement is making physicians realize that CME isn't simply a long day of lectures, but that education is a process that has to be taken seriously.

—Murray Kupelow, MD, executive director of the ACCME

Virginia's program demonstrates one of the approaches being used to reshape CME to meet the needs of today's health care providers and consumers. It also reflects a shift in thinking that has resulted from a decade's worth of research showing that traditional CME alone is rarely effective.

The latest study on the impact of CME, published in the Sept. 1 issue of The Journal of the American Medical Association, in fact, concluded that traditional, didactic CME plays "little or no role" in bringing about "change in physician behavior and patient outcomes." CME reformers increasingly argue that it is no longer good enough for doctors to spend a day of continuing education catching up with colleagues and making sure that their knowledge is up-to-date, a process that education experts call "verification."

As a result, educators are slowly creating new teaching tools like interactive clinical skills workshops and learning portfolios to better educate physicians. At the same time, they are sparking debate about whether traditional CME should be abandoned, and how much it can help some physicians.

New learning models

When it comes to teaching physicians, the key question on the minds of many educators is what will work best. "The issue for CME in the new century is how do we measure, educationally speaking, its impact?" said David B. Nash, FACP, associate dean and director of the office of health policy and clinical outcomes at Thomas Jefferson University Hospital in Philadelphia.

Canada's new program transforms CME into a process in which physicians raise a question, answer it and appraise the answer.

Others talk about measuring the success of physician education the same way that health service researchers try to measure clinical care: by looking at its effectiveness. "The quality improvement movement is making physicians realize that CME isn't simply a long day of lectures, but that education is a process that has to be taken seriously," said Murray Kopelow, MD, executive director of the Accreditation Council for Continuing Medical Education (ACCME), which accredits CME providers. Beginning in July 2000, the ACCME will roll out a new accreditation process called "System98" that will reward educators who can prove their CME courses actually change physician behavior.

Another much-talked about effort is the "maintenance of competence project," known as MOCOMP. This project, developed by the Royal College of Physicians and Surgeons of Canada, intends to make continuing education an ongoing process instead of an event that physicians participate in once or twice a year. Using special computer software called PCDiary, physicians track "items of learning," which the Royal College defines as "the acquisition and assimilation of new (or the revision of old) knowledge, skills or attitudes" that enhance physicians' ability to practice their specialty.

At the core of an "item of learning" is an answer to a clinical question in the form of a "pearl-of-wisdom" or a "take-home message" that the physician may have derived from a workshop or from reading about a topic. As part of the program, the doctor is expected to note what stimulated that particular learning exercise in the first place.

For example, a doctor might say that a question presented itself while he was treating a patient or listening to a CME grand rounds presentation. The physician enters that question into the computer, and the software prompts him to include information about the resources he used to answer the question. The software also asks the doctor to state whether he plans to change how he practices—or not, and why not—as a result of this educational exercise.

Physicians periodically e-mail parts of their diary to the Royal College, which returns a certificate of participation and a profile of all of their continuing education credits. Physicians can compare their CME activities with those of colleagues in their specialty. The specific "items of learning" are also compiled into a database that all participating doctors can access and use for their own continuing education, thereby contributing to another item of learning.

Under the MOCOMP program, what most doctors now consider CME—listening to a talk or reading an article—is transformed into a process of raising a question, answering it, appraising that answer and deciding what to do with the newly acquired knowledge, said John Parboosingh, MD, the Royal College's director of professional development.

Learning portfolio programs like MOCOMP, which are still in their infancy, appear to be a good way to "focus on how you address a learning need rather than documenting episodes of participation at singular activities," explained Barbara Barnes, FACP, associate dean for continuing medical education at the University of Pittsburgh School of Medicine and vice president of the Society for Academic CME.

The idea of learning portfolios is leading some researchers to recommend that the existing "credit" system be scrapped. An alternative, they say, is to follow MOCOMP's lead and allow doctors to assign variable amounts of credit to their own CME activities, depending on how interactive the course was, how influential the discussion was or how relevant the reading was. With this system, doctors can claim two hours of credit for every hour taken, as long as the CME resulted in real learning.

Clinical skills courses

Learning portfolios aren't the only new development in the modernization of CME. A new ACP-ASIM effort, for instance, is developing small group workshops, or clinical skills courses, that focus on teaching procedural, communication and physical examination skills. Clinical skills courses differ from other types of CME, such as postgraduate courses or Annual Session scientific program courses, in that they are not simply lectures aimed at imparting "content" to listeners. Instead, doctors at these workshops watch a skill being demonstrated, practice it themselves and receive individual feedback from the faculty.

This summer, David S. Hanekom, ACP-ASIM Associate, an internist in Fargo, N.D., traveled halfway across the country for continuing education to fill in what he considered a serious gap in his knowledge: doing a competent pelvic exam on female patients. In two days of workshops in Philadelphia led by women's health experts and standardized patients, Dr. Hanekom said he accomplished his goal of changing how he practices.

Since returning from the clinical skills workshop, Dr. Hanekom said, he is able to tell patients that he is trying to feel their ovaries and describe what they will feel. "They will tell me that they're getting that feeling, and I know that what I'm feeling is the ovary," he said. "I would never have done that before. In which book do you learn that?"

The College's workshops are bolstered by a lecture component. "There is always content, but the content part is not stressed as much as a psychomotor skill or a communication skill," explained Patrick Alguire, FACP, ACP-ASIM's Director of Education and Career Development. "The courses are hands-on and focused on skills that participants can conceivably use in their office the next day."

Since the program was introduced in 1994, the College has held clinical skills programs on skin biopsy and cryosurgery, arthrocentesis and joint injection, musculoskeletal examination, pelvic and breast examination, ENT examination, opthalmology examination, heart murmur, counseling for behavioral change and discussing end-of-life choices. (Clinical skills courses are offered at Annual Session and at some of the College's chapter meetings. For more information, call Linda Casey at 800-523-1546, ext. 2573.)

A place for the 'old' way?

Despite such enthusiasm for new forms of CME, some doctors are less than thrilled. "People want to go to the CME they are used to, to sit and be critical of the coffee at the end and mix vacation with CME," said Dr. Parboosingh from the Royal College. "We know what's popular, but we also know what's effective."

In Canada, doctors using Canada's MOCOMP have given it rave reviews, yet only 1,000 physicians over four years have participated in the program, Dr. Parboosingh said. Part of the problem is that doctors like the ease and familiarity of returning to what they knew as "school," and CME departments have found a formula that makes enough money to perpetuate itself. Bringing 200 physicians in to listen to a lecture is cheaper than running an interactive workshop for 20 people. That's why most CME still comes packaged as talking heads with slides droning in dark lecture rooms or as columns of type in printed journals. Even consumers, who say they want to be sure that their physicians are up to snuff, still tend to equate education with formal lectures and tests, not self-directed learning.

Educators point out, moreover, that not all continuing education as it now exists is a waste of time. Herbert S. Waxman, FACP, the College's Senior Vice President for Education, said that it has been well documented that listening to lectures does work when the goal is to help people pass exams. And with most internists now facing recertification, there continues to be a need for that kind of CME.

Although Susan R. Dresdner, ACP-ASIM Member, said she typically opts for small group, interactive workshop types of CME, she may make an exception. "The next time I have to recertify I'm sure I'm going to take a board review course," said Dr. Dresdner, general internist and assistant professor of medicine at New York's Albert Einstein College of Medicine.

Bruce J. Bellande, executive director of the Alliance for Continuing Medical Education, the specialty society for providers of CME, also said the "verification experience" of a physician going to a CME course to find out if he knows what he should know is sometimes unfairly discounted in this flurry of attention to the new models of learning. Doctors continue to flock to traditional CME, he noted, and not just because they need the credits to maintain their license or hospital privileges. "They are saying it's worth my time for a day or two or a lecture or two to go and make sure that nothing has changed so significantly that I would need to change my practice pattern," he said. "They are auditing their own knowledge."

Nonetheless, said Dr. Kopelow of the ACCME, "It's not good enough for CME to be a social outing. The education has to really matter. It has to really have impact. People are holding us accountable for that. The public wants to be assured of the competence of doctors."

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