Recently I drove to Flagstaff, Arizona, to enjoy the cool mountain air and to attend a continuing medical education (CME) seminar sponsored by the Arizona State Association of Physician Assistants. I didn’t particularly need any CME credits, since I had previously attained the requisite number of hours to maintain my license and certification. I must admit the real reason for my trip was the opportunity to rub shoulders with old friends and new leaders in my profession.
At the conclusion of this well-planned and well-implemented CME event, I completed a short survey. I was asked the usual questions regarding my decision to attend this seminar: location, acquisition of CME credits, an opportunity to network, etc. The next question related to whether the lectures I attended would change the way I practice—a question that was difficult for me to answer, although I knew what the politically correct answer would be.
The American Medical Association presently defines CME as “educational activities that serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships a physician uses to provide services for patients, the public, or the profession.”1 I am sure that the national PA and NP associations have similar definitions.
CME, or continuing education (CE), has been widely discussed and criticized for decades. Much of the discussion centers on the contention that listening to lectures that review or introduce new medical information is sufficient to change clinician performance. Regulatory boards and certification bodies continue to require clinicians to complete a certain number of formal hours of education each year to retain licensure or certification. In fact, almost every professional association provides CME/CE; it is often an important part of the organization’s revenue. Many national associations continue to sponsor large educational opportunities each year.
Most continuing education for clinicians is aimed at improving performance and/or optimizing patient outcomes. These efforts are patterned after undergraduate medical education and consist of variable formats, from large-group presentations to interactive small-group discussions and even individual one-on-one sessions. In recent times, formal CME/CEs have become available via the Internet with written and/or video/audio lectures, including posttests. With the advent of the Blackberry® and the iPhone®, clinicians can now receive formal offerings through these devices as well.
Despite the variety of available CME/CE offerings, questions remain about what effect they have on clinicians’ performance in current practice. The Agency for Healthcare Research and Quality concluded, “Despite the low quality of the evidence, CME appears to be effective at the acquisition and retention of knowledge, attitudes, skills, behaviors, and clinical outcomes.” But is this true?
Research has shown that clinicians continue to misuse therapeutic and diagnostic interventions in practice.2 The Johns Hopkins University Evidence-Based Practice Center prepared a report that suggested more research is needed to determine what types of media, techniques, and exposures are most associated with improved outcomes.3 After reading these and other studies, I think there is actually quite a bit of doubt as to whether CME/CE has any measurable effect.
So how do we close the educational gap between evidence and practice? Is formal CME/CE effective? If so, what is the best method for changing clinician performance to effect positive health care outcomes—and to meet the growing need for specialty-specific CME/CE?
In the last decade, there has been research documenting the utility of simulation technology for clinician education. Simulation, however, has not been widely endorsed or used for CME/CE. Anecdotal evidence suggests that it is effective, especially for psychomotor and communication skills, but evidence remains scant.4 Even so, we know that clinicians learn better if they are educated in the context of where they practice.
There has also, in recent years, been ongoing discussion regarding deliberate practice, which is defined as an educational variable associated with delivery of strong and consistent educational objectives as part of a mastery-learning model. This process is quite demanding, since it is deliberately grounded in information processing and behavioral theories of skill acquisition and maintenance.5 The end point of deliberate practice in a CME mastery-learning context is to require constant improvement of skill and knowledge in clinical practice rather than maintenance at a minimal level.
Based on this information and personal experience, I have several suggestions to make CME/CE more effective. Clinicians should:
• Be highly motivated, with good concentration.
• Be engaged in a process that is based on well-defined educational learning objectives.
• Be challenged with an appropriate level of difficulty.
• Be focused on material that promotes repetitive practice.
• Be evaluated through rigorous, precise measurements of outcomes.
• Receive informative feedback from valid educational sources (eg, simulators, instructors, or educational instruments).
• Be encouraged to reach a mastery standard.
• Have an opportunity for advancement to other, higher-level tasks.
There is one other component that requires mention whenever current CME/CE practices are considered. We cannot underestimate the importance of camaraderie and networking at CME/CE functions and the importance of opportunities for clinicians to just “get away.” I’d love to hear from you regarding CME/CE events that you have attended that met or exceeded your expectations and what made them worthwhile. You can reach me at PAeditor@qhc.com.
1. American Medical Association. Restoring Integrity to Continuing Medical Education [House of Delegates Policy #300.988].
2. Chassin MR, Galvin RW; Institute of Medicine National Roundtable on Health Care Quality. The urgent need to improve health care quality. JAMA. 1998;280(11):1000-1005.
3. Marinopoulos SS, Dorman T, Ratanawongsa N; Johns Hopkins University Evidence-based Practice Center. Effectiveness of continuing medical education (AHRQ Contract No. 290-02-0018). www.ahrq.gov/downloads/pub/evidence/pdf/cme/cme.pdf. Accessed October 15, 2009.