Providing Effective Continuing Medical Education for Physicians

1
Providing Effective Continuing Medical Education
for Physicians

• Suzanne Ziemnik, MEd
• Director, Division of CME
• American Academy of Pediatrics

2

• Continuing medical education is a distinct and
  definable
• activity that supports the professional
  development of
• physicians and leads to improved patient
  outcomes. It
• encompasses all of the learning experiences that
• physicians engage in with the conscious intent of
  regularly
• and continually improving their performance of
  professional
• duties and responsibilities. Essential to the
  continuum of
• medical education, CME shapes the growth and
• development of physicians in their full range of
  duties and
• responsibilities.
• (Academic Medicine, 2000, 751167-1172)

3
In what is typically an intensive 2- or 3- day
short course, (instructors lecture and lecture
and lecture) fairly large groups ofprofessional
people who sit for long hours in an audiovisual
twilight, making never-to-be-read notes at rows
of narrow tables covered with green baize and
appointed with fat binders and sweating pitchers
of ice water. Philip Nowlen, 1988
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Does CME Work?

• Studies of the effectiveness of CME
• measured against physician performance
• and health care outcomes

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EFFECTIVENESS OF INTERVENTIONSby Type of
Intervention
Number of interventions demonstrating positive
or negative/ inconclusive change
(presented by Dave Davis, MD to the Specialty
Society SIG at the Alliance for CME Annual
Conference January, 2000)
6
Findings

• Didactic interventions fail to change physician
  performance or health care outcomes
• Interactive CME is more effective in changing
  physician performance or health care outcome
• Sequenced CME interventions appear to have more
  impact
• Addition of "enabling methods" which may
  facilitate adapting to changes in the practice
  site are effective
• Multiple or longitudinal interventions
  demonstrated positive outcomes on physician
  performance (and in some cases on health care
  outcomes) as compared to single interventions
• No relationship between group size and positive
  outcomes

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Implications of the Findings

• Interventions to improve professional performance
  are complex
• There are no magic bullets to change practice
  in all circumstances and settings (Oxman, 1995)
• Multi-faceted interventions targeting different
  barriers to change are more likely to be
  effective than single interventions (Davis, 1995
  Davis, 1999)

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Role and Value of Traditional CME

• Reaffirming and/or increasing knowledge
• Validating current practice behavior
• Changing attitudes
• Providing multiple messages

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• "Optimal CME is highly self-directed, with
  content,
• learning methods, and learning resources selected
• specifically for the purpose of improving the
• knowledge, skills, and attitudes that physicians
• require in their daily professional lives that
  lead to
• improved patient outcomes.
• (Academic Medicine, 2000, 75 1167-1172)

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Recommendations for Effective CME

• Highly self-directed
• Incorporates interactive learning formats
• Includes practice enabling and reinforcing
  strategies
• Accessible within physicians' practice or work
  settings
• Physicians recognize knowledge, skills and
  attitudes to maintain competence
• (AAMC Statement on Lifelong Professional
  Development
• and Maintenance of Competence, 2000)

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More Recommendations for Effective CME

• Accommodates the different styles of learning
  that will be seen within a community of learners
• Relates directly to the maintenance of competence
  of the practitioner
• Link to evidence-based medicine whenever possible
• Learner-centered
• Active rather than passive

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More Recommendations for Effective CME (contd)

• Link to improving physicians' practice behaviors
  and patient outcomes
• Based on individual's real needs (based on
  objective methods) and perceived needs
• Engaging
• Reinforcing
• Relevant to clinical practice
• Point-of-Care CME

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Eight Principles to Guide CME

• CME planning and program development should be
  based on needs assessment, including outcomes
  data.
• Goal of CME should include the development of
  skills necessary for lifelong learning, the
  exercise of clinical reasoning, an understanding
  of the decision making process, and specific
  content acquisition.
• Multiple goals of CME should be reinforced by the
  appropriate choice of learning methods
• Incorporation of new instructional technologies
  for CME should be based on their intrinsic
  strengths as learning tools after thorough
  evaluation

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Eight Principles to Guide CME (contd)

• Faculty development is important within CME and
  should include exposure to new learning methods
  (theory and application), enabling faculty to
  translate their content expertise into formats
  more appropriate to learners' needs.
• Educational activities should be supportive of
  and coordinated with the transition to
  evidence-based medicine.
• Professional and, whenever possible,
  interdisciplinary interaction should be given
  priority in CME programming.
• Outcomes-based measures of CME effectiveness and
  research should be introduced into the
  determinants of physicians' practice behaviors.
• 
  (Academic Medicine, Vol. 74, No 12/December 1999)

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Self-directed Learning

• "Physicians must understand and control their own
  learning experiences with access to professional
  activities that are appropriate for the practice
  environment."
• (Bennet, et al)
• "The efficiency and effectiveness of learning in
  the workplace is related to a physician's ability
  to select the right problems to solve, frame the
  problem in terms of a question or problem
  statement, successfully obtain and appraise the
  information retrieved, and develop a plan to
  integrate the learning into practice."
• (Campbell, et al)

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Recognition of Stages of the Learning Process

• Determining if the content of the CME program is
  relevant
• Using the CME event as one of several resources
  selected for learning
• Already implementing changes in practice and
  seeking assurance of doing the "right thing"

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Assessment of Outcomes in Continuing Education
LEVELS
1
2
3
4
Opinions, Perceptions, Attendance Data
Competence (knowledge, skills, attitudes) of
Health Professionals
Patient/Health Care Outcomes
Health Professional Performance
(Adapted from Dixon, J. Eval. the Health Prof.
1977 and presented by Davis to the Specialty
Society SIG at the Alliance for CME Annual
Conference, January, 2000)
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Barriers to Measuring the Effectiveness of Level
3 and Level 4 Educational Interventions

• Ability to demonstrate a causal relationship
  between the educational intervention and the
  observed effect
• Nature of specialty society CME targeted to a
  national audience
• Financial
• Time

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Core Competencies for CME Educators

• Guide physician learners as they continually
  assess their own ongoing learning needs, and
  identify opportunities and resources to meet
  those needs in order to enhance performance and
  promote lifelong learning skills
• Study the role of continuing professional
  development to enhance physicians' knowledge,
  performance, and health care outcomes
• Design a CME list of effective educational
  strategies that uses research findings about how
  physicians learn and enact changes in their
  professional behaviors, and that addresses the
  variety of learning styles and learning needs

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Core Competencies for CME Educators (contd)

• Cooperate with CME educators and others
  throughout the continuum of medical education to
  maximize the ability of CME to meet the varied
  learning needs of physicians and health care
  systems
• Ensure that systems for measuring improvement of
  physician performance link CME to health care
  outcomes
• Enhance the professional development of CME
  educators, including their understanding and use
  of theory and research to provide effective
  support for appropriate changes in physicians'
  knowledge, performance, and health care outcomes
• (Academic Medicine, 2000, 751167-1172)

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American Academy of PediatricsContinuing Medical
EducationMission Statement

• The continuing medical education program of the
  American
• Academy of Pediatrics seeks to develop, maintain
  and/or
• increase the knowledge, skills and professional
• performance of primary care pediatricians,
  pediatric
• medical subspecialists, pediatric surgical
  specialists, and
• other pediatric health professionals by providing
  them with
• the highest quality, most relevant and accessible
  
• education experiences possible. The ultimate
  goal of
• the overall CME program is for participants to
  better identify
• their personal educational needs and be able to
  design
• appropriate self-directed learning plans to meet
  those
• needs.
• Adopted May 15, 1998

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AAP CME Program

• Live CME Activities
• Directly Sponsored
• Jointly Sponsored
• Enduring Materials
• Internet CME
• Print CME
• Other Multimedia CME

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AAP Strategies for Educating Physicians

• Traditional models/approaches transitioning
  to interactive, learner-centered formats
• Innovations

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Innovations

• Pedialink AAP CME Home
• eQIPP (Education in Quality Improvement for
  Pediatric Practice)
• SuperCME

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PediaLink.org

• A powerful online learning
• system designed to
• assist pediatricians to
• direct, focus, and manage
• their CME/CPD.

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PediaLink.org

• One stop spot for point-of-practice information
  and professional development
• Tracks and provides feedback on the quality of
  the individual pediatricians learning cycle
• Highly individualized and dynamic tool for
  lifelong professional development

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eQIPP

• Interactive online educational system designed to
  help pediatric health care professionals to
• learn about quality improvement strategies
• collect and analyze practice data over time
• document improved quality of care

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eQIPP

• Incorporates interactive, topic-focused CME
• Content derived from evidence-based guidelines
  and best practices
• Self-assessment based on real time chart audit
  and feedback with opportunity for peer
  benchmarking

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eQIPP

• Features
• facilitated online discussions
• practice enablers, tools and templates
• reminder systems
• patient satisfaction surveys
• supporting resource materials

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SuperCME Features

• Actors perform "real life" cultural communication
  issues encountered in the office
• Heart Sounds Workshop featuring new
  state-of-the-art advanced digital heart sound
  system coupled with infrared transmission and
  digital projection
• "I'll Take Adolescent Health for a Thousand,
  Alex"
• E-mail networking to connect online with fellow
  attendees before and after SuperCME
• "Guaranteed your questions are addressed by the
  professor - When you register early!"

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The Future

• "With the realization that lifelong learning is
• more than attending conferences, the potential
• for greatly expanding effective CME has never
• been more encouraging."
• (Manning)

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The Future (contd)

• "The social attraction of colleagues and the
  desire
• to interact personally with medical experts will
• ensure the survival of live conferences.
• Teleconferencing will become more practical as
• costs decline through the use of the Internet.
• Medical journals, print or electronic, will
  remain the
• dominant source of new research and clinical
• information."
• (Manning)

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References

• Abrahamson S, et al Continuing medical education
  for life eight principles. Acad Med 1999 Dec
  74(12) 1288-94.
• Bennett, NL, Davis DA, et al Continuing Medical
  Education A New Vision of the Professional
  Development of Physicians. Academic Medicine
  (2000) 75 1167-1172.
• Davis DA, Fox RD The Physician as Learner
  Linking Research to Practice. Chicago American
  Medical Association, 1994, pp 3-10 245.
• Davis DA, Thomson MA, Oxman AD, et al Changing
  physician performance A systematic review of the
  effect of continuing medical education
  strategies. JAMA 1995 274 700-705.

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References (contd)

• Davis DA, Thomson MA, Freemantle N, et al Impact
  of formal continuing medical education Do
  conferences, workshops, rounds and other
  traditional continuing education activities
  change physicians behavior or health care
  outcomes? JAMA 1999 282867-874.
• Fox RD, Mazmanian PE, Putnam RW Changing and
  Learning in the Lives of Physicians. New York
  Praeger Publishers, 1989.
• Manning Phil R, DeBakey L Continuing Medical
  Education The Paradigm Is Changing. The Journal
  of Continuing Education in the Health
  Professions, 2001, Volume 21, pp 46-54.
• Oxman, AD, Thomason MA, Davis DA, et al No magic
  bullets A systematic review of 102 trials of
  interventions to improve professional practice.
  Can Med Assoc J 1995 15153.