A Look at Curriculum in Continuing Professional Education: a Case Study from Medicine

A look at curriculum in continuing professional education

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A look at curriculum in continuing professional education: a case study from medicine

Sonia J. S. Crandall and Lloyd Korhonen, University of Oklahoma

Abstract

This study attempted to identify various aspects of the practice of Continuing Medical Education (CME) that are reflected in patient care. Five physicians agreed to participate in a six-month case study assessing whether a CME programme addressing cardiac arrhythmias had any effects upon their practice and patient care. Case study data suggested that CME curriculum could potentially effect physician performance and patient care.

History and description of CME in the United States

Continuing Medical Education (CME) has a relatively long history dating back to the early 1900s. Prior to 1910, and certainly until after World War II, CME was reparative and remedial in nature, concentrating primarily on correcting physician deficiency[1]. Abrahamson[2] provides a brief history of CME. The first CME effort, prior to 1910, the Blackburn Plan, consisted of weekly one-hour sessions covering basic sciences and treatment techniques. The first outreach efforts of CME to service physicians practising in locations not served by medical schools was the North Carolina Extension Plan established in 1916. The University of Michigan established ‘the first permanent, budgeted, administrative unit (for CME) within a school of medicine’[3] prior to 1930. By 1930 the concept of regionalisation had evolved. At that time three regional centres were established at Michigan, Albany, and Tufts (medical schools). Their mission ‘was to provide a co-ordinated continuing medical education programme for the units in its [each] ‘region’’[4]. Units were defined as medical centres identified with medical schools, regional hospitals greater than 100 beds, small community hospitals, and ambulatory care facilities. The University of Minnesota established the first centre for CME in 1936.

As the network for providing CME grew, so did the number of course offerings. Ten years after establishment of Minnesota’s centre, 47 ‘schools’ offered 491 courses. During the next 20 year period providers shifted from ‘schools’ to ‘sponsors’ of CME. In 1966, 252 sponsors offered 1600 courses; in 1976, 554 sponsors offered 5000 courses; in 1984, 1000 sponsors offered 9000 courses[5]. The trend is obvious, more sponsors and more courses.

Just as CME offerings and sponsors have evolved since their inception, so too have methods by which CME has been evaluated. The evolution of evaluation methods occurred in six phases. Initially, the success of a programme was measured by the number of physicians attending. The second level of measurement was to determine participant satisfaction, i.e. ‘happiness index’. The third level was the first attempt to assess programme effectiveness by determining if a change in knowledge had occurred through the use of pre-post testing. The fourth and fifth levels were to determine if a gain in competency, or a change in performance had occurred. Finally, if there were changes in performance, did patients benefit? Thus, patient outcomes represents the highest and final level by which to assess programme effectiveness[6].

Since 1910, CME has been fraught with policy issues and power conflicts regarding the content, accountability, availability of delivery systems, and accreditation of delivery systems[7]. The contemporary issue of primary concern is, what impact does CME have on professional practice? The purpose of this paper is to discuss CME curricula and propose recommendations for policy and curricular changes necessary to meet physicians’ CME needs in the 1990s. Results of a case study assessing physicians performance in relation to participating in a CME conference will provide supporting evidence for addressing the proposed recommendations.

CME research

The role of Continuing Medical Education (CME) is ‘to enable practising physicians to achieve and maintain the knowledge, skills, and attitudes they need to carry out their patient care responsibilities at an optimum level of competence’[8]. Does CME do that? How does CME curriculum effect physicians’ professional lives?

CME curricula still are being criticised. Many writers in the field suggest that CME has not improved significantly in the past 80 years in spite of phenomenal growth in availability and accessibility of programmes[9]. CME curricula still are dominated by didacticism, content oriented, provider driven, seldom related to individual physician practice needs, and basically unsuccessful in changing physician behaviour[10].

CME research has not provided conclusive empirical evidence that CME is effective when one examines the outcome of continuing education on physician performance and patient health. In all fairness to the body of research that exists, it is difficult, if not sometimes an insurmountable task, to establish empirically that CME is a direct cause of changes in physician performance and patient health. It clearly is evident to CME providers and medical practitioners that patient outcomes are multifarious and difficult to trace to a single source of influence on physician performance.

There are three distinct problems CME researchers encounter when evaluating CME effectiveness: l) determining if desired changes in physician behaviour occurred, 2) determining if patients improved as a result of changes in physician behaviour, and 3) demonstrating whether the CME intervention caused those changes.

Method

A study of physicians’ performance in relation to participating in a CME programme attempted to identify various aspects of the practice of continuing medical education that are reflected in patient care. The focus of the study was physicians involved in cardiac arrhythmia practice in a variety of settings. This study was qualitative in nature, employing the case study method as the primary means of data collection. There were three facets to this methodology that made the study unique:

1. Survey data were obtained pre and post conference that focused upon the area of practice being studied, i.e. cardiac arrhythmias. Survey data provided demographic information about the participants and attitudinal information about the topic of the CME programme.

2. Five physicians volunteered to have their practice monitored over a six-month period to assess whether the conference had any effects upon their practice and patient care. This was an important consideration since there are many potential hazards that are involved in documenting physician practice.

3. The five physicians were interviewed after the six month period to assess their behaviours and to evaluate the effects of this kind of CME intervention on their practice.

Case study research methodology demands dedication on the part of both researcher and subject. The benefits of this kind of interaction are, however, invaluable. It allows the researcher the opportunity to evaluate educational input against professional practice (output).

Results and recommendations

Results of the case study imply that physicians rely heavily on CME for new information. New information allows physicians to effect desired changes in their practice that indeed have an impact on patient care. The particular CME intervention of this study did bring about changes in physician performance. Study physicians incorporated new diagnostic and treatment methodologies that their practice environments allowed, and as needed by individual patients.

From the physician responses it seems clear that CME is best enacted in an interactive setting where physicians can work ‘hands-on’ with the methods or practices. For example, study participants stated:

I think it might be helpful to have some of the arrhythmias, maybe heart sounds recorded, or have teaching stethoscopes, ... along with rhythm strips.

What would probably be more helpful is ... have a little less, somewhat less, didactic presentation and a little bit more working in groups on problems and see whether you can apply the material, so a little bit more tutorial, quiz, problem-solving, utilising the material, rather than more passive listening.[11]

It is evident that the isolation of some practitioners makes the use of interactive networks an attractive alternative to the traditional delivery system of CME programmes. This is especially true in rural areas where there are few medical personnel who concentrate in one medical speciality area.

The most things that are beneficial for us is, quite honestly we’re out in the ‘boonies’ to some extent and we’re not as readily available to CME, we need good course summary type of things, update type programmes, intensive type things that deal with new updates in multiphase type of things.[12]

It is clear that practising physicians rely heavily upon printed material of any kind, such as professional journals and pharmaceutical literature. Handouts at CME programmes are very important because physicians want something they can refer back to at a later date. An examination of what is available in order to decide what materials would best support or supplant current written material would be important.

I wish more conferences would send the syllabus out ahead of time. Those that want to and can manage to do it, go through the syllabus material ... What I like to be able to have is something to take away, that I can either go over later, or share with somebody ... so, I think conferences where there is some handout material that can be reviewed later or shared with others are more worthwhile.[13]

The need for and the involvement of doctors in conference planning is evident. The problems of providing up-to-date information and interaction demands an understanding of the practice environment in medicine. This study provided information that enforces the idea that many doctors practice in isolation. This isolation sometimes leads to feelings of inadequacy in practice that are not generally expressed. Many of these perceptions are inaccurate but in order to deliver instruction we must assess these perceptions and take them into account when designing educational programmes.

This study re-enforces the observation that some physicians practice in closed environments with little if any intervention to effect their practice. This environment may be detrimental to both the practice of medicine and their professional attitudes. It is often difficult for them to obtain information and to admit they lack information that might improve patient care.

My capability, I can do everything, lots of things. But here, the equipment is very restricted. There are lots of things I did practice, but here, I cannot do that because we don’t have any equipment .... we get few instruments .... I bring my instruments from private practice here to do it [minor surgery] .... There is no medical budget .... You see here is a medical practice with constraints, I don’t have the freedom to do what I want.[14]

Summary and conclusions

Many physicians assert that CME provides the mechanism by which they remain current in their chosen specialities. There is evidence to suggest that physicians are committed to keeping abreast of new developments, are interested in mastering new knowledge and skills, and are interested in providing their patients with the best care possible[15]. Because physicians value their CME experiences, CME providers clearly should be addressing programme improvement and curricular issues that relate to individual physicians’ needs rather than what some committee determines their needs to be.

Most physicians obtain CME credit through formalised structured CME programmes sponsored by accredited providers. In 1984 there were 1000 providers of CME[16]. The annual cost of CME has been estimated to be $3 billion[17]. Physicians expect CME to provide them with new knowledge, review, and updates in their specialities and expect the content to be understandable, usable, and practice related[18].

I expect to learn something [from CME].

I expect the contents to be made simple, or at least made understandable, or if not understandable, to me, at least highlight it in such a way that I can use something of it to detect problems and know where to refer people. I don’t expect that I’m going to understand everything, or that I’m going to be able to do everything I hear about.[19]

I think one of the overriding ones [needs] is keeping aware of what’s available in terms of either diagnosing a problem or treatment and trying to utilise what we’re able to do and refer people to those who can make a more definitive diagnosis and treatment .... I don’t necessarily use everything that I go to CME for in the sense that I can do what they’re talking about, but at least I know about it and then when a problem comes up I have some idea of what could be done and where to send a person.

I expect to find something new .... I expect to learn something different from what I already know. [20]

When one considers the individual annual cost of CME, the time physicians invest attending CME programmes, and their expectations, it is disturbing that so little evidence exists that supports whether the fundamental purpose of CME, that is, providing a mechanism for physicians to practice competently, has been achieved.

Houle[21] describes three modes of learning for professionals, that is, inquiry, instruction, and performance. Physicians decide to attend specific CME programmes based on their interests and needs for information. They use the mode of inquiry to ‘identify and explore’ which CME offerings will most closely meet their practice needs and fulfil their expectations. They may also use inquiry ‘to question established dogma and bring their experience to bear on the shaping of new principles and policies’[22]. Information is received primarily through the mode of instruction, most commonly in the form of instruction-by-others. Because this form is most common and most familiar to physicians, CME curriculum can play a significant role in bringing about desired changes in physician performance and patient health as it relates to physician performance. However, this role can be effected only if curriculum is of high quality and directly related to individual physician practice needs[23]. Thus, the content of the curriculum must be relevant to the individual.

What was most helpful was the fact that they presented me some new information that had a bearing on my practice.[24]

Reproduced from 1989 Conference Proceedings, pp. 173-179  SCUTREA 1997

[1] O’Reilly, P., Tifft, C. P., & DeLena, C. (1982) Continuing medical education: 1960s to the present. InJournal of Medical Education, 57 (11), 819-826. Richards, R. K. (1978) Continuing medical education. New Haven, Connecticut: Yale University Press. Stern, T. L. (1976) Continuing medical education in America. In Journal of Family Practice, 3 (3), 297-300.

[2] Abrahamson, S. (1984). Research in continuing medical education. In MOBIUS, 4 (4), 11-19.

[3] ibid. p. 12

[4] ibid.

[5] ibid.

[6] ibid.

[7] Richards, R. K. (1978) op. cit.

[8] Felch, W. C. (1987) Continuing medical education in the United States: an enterprise in transition. In Journal of the American Medical Association, 258 (10), 1356.

[9] Abrahamson, (1984) op. cit; Felch, (1987) op. cit. Miller, G. E. (1987). Continuing education: what it is and what it is not. In Journal of the American Medical Association, 258 (10), 1352-1354.

[10] Abrahamson, (1984) op. cit.; Miller, G. E. (1987) op. cit.; Stein, L. S. (1981) The effectiveness of continuing medical education: eight research reports. In Journal of Medical Education, 52 (2), 103-110

[11] Fieldnotes, January, 1989

[12] ibid.

[13] ibid.

[14] ibid.

[15] Crandall, S. J. (1989) A case study of physician performance in relation to participation in a continuing medical education programme. Unpublished doctoral dissertation. University of Oklahoma, Norman, Oklahoma.

[16] Abrahamson, S. (1984) op. cit.

[17] Tupper, R. L. (1984) CME in Michigan is growing up. In Michigan Medicine. May, 224-231

[18] Crandall, S. J. (1989) op. cit.

[19] Fieldnotes, January 1989

[20] ibid.

[21] Houle, C. O. (1980) Continuing learning in the professions. San Francisco: Jossey-Bass Inc

[22] ibid. p. 249

[23] Manning, P. R., Lee, P. V., Denson, T. A., and Gilman, N. J. (1980) Determining educational needs in the physician’s office. In Journal of the American Medical Association, 244 (10), 1112-1115.

[24] Fieldnotes, January 1989