Sunday, September 03, 2006

Musings on continuing medical education

I’ve just returned home from a CME course, combined with a little vacation. It was one of those traditional CME activities centering on didactic presentations and workshops, held at a nice relaxing location. It was co-sponsored by a major professional organization and received financial support from several drug and device companies.

In my 28 year obsession with career learning I’ve availed myself of multiple methods---didactic, case based and Internet based to name a few. I’ve also become convinced that individual doctors have differing learning styles. I find that the different learning methods offer multiple dimensions, serving my educational needs in different and uniquely important ways.

Learning at the point of care about a specific clinical question (e.g., foreground reading) often directly impacts clinical decision making and sharpens my focus on diagnosis and treatment. Equally important is background learning, focusing on more general clinical features, treatment principles and pathophysiology. Background learning may employ textbooks, narrative reviews and didactic presentations. Although such learning has little immediate impact on my prescribing behavior it strengthens my conceptual framework for understanding medicine.

These two examples may represent opposite poles of a spectrum of learning styles. Both are essential. Without foreground learning we miss the best and most current evidence applicable to patient care. Without background learning we lose the underpinnings of medicine and resort to formulaic practice based on rote memorization and slavish adherence to algorithms. (See How and why do doctors read?).

For me the traditional didactic meeting offers a unique educational experience. The occasional retreat to a relaxed setting in a remote location, away from the time pressures and constant interruptions of the “point of care” helps me to maintain a receptive and enthusiastic frame of mind. Without these getaways I would miss an important aspect of lifelong learning.

Lately I’ve been troubled. In recent years these meetings have struggled for attendance and sponsorship. They’ve come under attack by naysayers from various camps. Some are unhappy with pharmaceutical company sponsorship. Others, like thought police, believe they know what type of continuing educational activity is best for me.

This salvo comes from a Medscape General Medicine video editorial by Dr. Jordan Cohen, president of the Association of American Medical Colleges. Dr. Cohen, describing “A New Vision for Continuing Medical Education”, wants to overhaul our CME system and thinks the didactic format should be used “only for appropriate issues, such as a basic science breakthrough.” Then there’s this astounding statement: “Research shows that the lecture-based format of CME does not change physician behavior or, more important, change the health outcomes for patients.” What’s the level of evidence for that claim? Moreover, the whole premise is wrong. A litmus test for CME that requires activity A to be measurably associated with behavior B is faulty because it ignores important intangibles. Under such a standard there would be no place for activities that teach pathophysiology, clinical diagnostic skills, general principles of evidence based medicine, or ethics. All are useful educational endeavors to be sure, but would change physician “behavior” mainly in intangible, and not readily measurable, ways.

Then there’s this curious statement (italics mine): “The vast majority of CME should employ self-directed, interactive, and relevant learning experiences that enable physicians to acquire the knowledge and skills necessary to exceed minimum expectations.” Well, that’s some vision. What if some doctors want to strive for excellence? If this is the latest theory on “outcome based” education applied to CME I’m underwhelmed.

As I’m often fond of doing I’ll invoke the memory of one of my favorite medical school mentors, Thomas Brittingham. His letter to third year students embarking on their Medicine clerkship concluded with “….for each one of us the primary teaching responsibility now and for the rest of his life lies within himself.”

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