Medical Education 1990, 24, 546-550

REPORT O F A CONFERENCE OF THE ASSOCIATION FOR THE STUDY OF MEDICAL EDUCATION HELD AT THE NATIONAL HEART AND LUNG INSTITUTE, LONDON ON 19 JANUARY 1990

Effective continuing medical education

K. M. PARRY

General Secretary, Association f o r the Study of Medical Education

Introduction

Introducing the conference, Sir Peter Froggatt referred to continuing medical education (CME) as the last great territory of medical education. I t was no longer acceptable that it was an optional or obscure territory, and the sentiment of the ‘lifelong student’ had to be expressed in terms of explicit, tangible commitments. It was a chal- lenge to all, and to all aspects of medical edu- cation, and should not be regarded as eligible for standard approaches to medical teaching by lectures and other forms of formal instruction. It must be based on a proper understanding ofhow adults learnt and how this related to the tasks that they undertook. It was astonishing that so many practising doctors did not appear to be aware of basic principles of pedagogy, and that there should be any doubt that continued learning was an obligatory part of professional life. In some countries steps had already been taken to impose sanctions on non-participants in approved activi- ties relating to continuing education, and there was increasing pressure to relate this to the quality of care that they provided. The key question was whether the medical profession was prepared to take the initiative, or whether steps would be taken by external agencies, which had been well illustrated by the emphasis given by the Government’s White Paper on the NHS, and its Working Papers on Medical Audit and on Edu- cation and Training. This reflected growing consumer pressure for greater accountability for professional services, and assurance on the qual- ity of what was provided.

Correspondence: Dr K. M. Parry, Scottish Council for Postgraduate Medical Education, 12 Queen Street, Edinburgh EH2 lJE, UK.

Continuing education as professional development in general practice

D r Marshall Marinker outlined the background to changes which had taken place in general practice education in recent years. Despite the many exciting developments in the teaching of medical students, and the impressive growth of voc- ational training, CME still seemed to be based on a tacit assumption that general practitioners needed to be ‘updated’ - principally by hospital specialists. The lunch-time lecture by consultants at the District Postgraduate Centre continued to dominate CME.

He quoted from a recent study by Alan Branthwaite and his colleagues. They found that general practitioners were concerned about their relatively low status in the profession, and in relation to patients; they felt insecure about the clinical decisions which they had to make; they felt isolated and lonely in their work, and frus- trated because of the pressures of time, limited resources, patient demand and what they experi- enced as the triviality of most of the complaints about which they were consulted.

Although there was now renewed interest in clinical standard setting, in medical audit and performance review, these activities were still by no means widespread. Dr Marinker said that the major reason for this was that excellence in clinical specialism was much more easily under- stood than excellence in medical generalism. Both specialists and general practitioners may therefore undervalue the tasks of the general practitioner. The job of the specialist was to reduce uncertainty, to explore possibility and to marginalize error. The job of the general prac- titioner was to accept uncertainty, to explore probability and to marginalize danger. He

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quoted Professor David Metcalfe, who had pointed out that, while the biotechnological role of the general practitioner remained fairly static, that of the specialist changed apace. In contrast, the social role of the hospital remained static while the role of general practice changed con- tinuously in relationship to the shifting patterns of our society.

D r Marinker set out three issues which he felt to be relatively new in CME. First the search for good standards of care in general practice. Much work still needed to be done in defining good standards. In the course of a series of workshops for consultants and general practitioners, organized by the MSD Foundation, new light was thrown on the creation of these standards. Younger general practitioners were increasingly aware that judgements about standards must be rooted in their own experience of practice, and not simply translated from textbooks which reflected the hospital experience.

Second, there was renewed interest in the need to understand the stress under which general practitioners worked so as to avoid unnecessary or damaging stress. Third, many younger prac- titioners were becoming interested in the idea of a career in general practice; this contrasted sharply with previous images of general practice which emphasized continuity, a lifetime spent in one practice, with no differentiation or change of task.

Continuing education was an enzyme for change. It merited closest attention in times of accelerating change.

Cont inuing education in specialist practice

Professor Michael Peckham focused on change in continuing education in the field of oncology. Ignorance could be dangerous; cancer may be under-treated or even over-treated, and ignor- ance was widespread. Highly technical staffwere now commonplace, and many advances were making old practices obsolete. Without con- tinuing education, doctors soon became out-of- date, and ethical issues too emphasized the importance of adaptation to reflect the quality of life. Continuing education should not be restric- ted to a narrow specialist view ofoncology, since interdisciplinary education now needed to be

addressed, affecting not only doctors, but other professions and the public at large.

Requirements included clinical update, coming to terms with rapid change, and science update, applying science to routine care. Pro- fessor Peckham described progress in continuing education in oncology in Europe, which served the public as well as doctors and other profes- sions who should be taught about good patient care.

Despite much being achieved by the European School ofOncology, there was still a great deal to be done. The provision was not comprehensive and help was needed in the development of quality control over clinical practice as a further inducement to participation, as it had been in the United States.

Technical deve lopments in cont inuing educat ion

Professor Ronald Harden stressed the speed of change in an age of technology. The develop- ment of individual and small-group learning methods was challenging and attractive, but by no means universally adopted. Educational changes were not in step with the advances in hardware technology, and he outlined a strategy for improvement.

Continuing education should be convenient in time and location to facilitate participation. The content should be relevant to the practice of the participants and include not just ‘facts’, but case studies. This included more than the clinical care of patients, and should extend to management education to facilitate the implementation of strategies for change. Programmes should be individualized, allowing for different approaches to education by each participant, making use of modern information technology to provide feed- back and alternative approaches to learning. Facilities for self-assessment should be included in each programme and key interest points should be incorporated to maintain the momentum of participation. The curriculum for continuing education should recognize the requirements, especially of general practitioners, for a systematic coverage of relevant material, not simply to maintain up-to-date knowledge but to adapt to social attitudes and the public’s expectations of medical care. This inevitably involved areas of

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speculation, since matters of uncertainty were an inevitable feature of modem practice.

If effective continuing education was to be developed, it should not be overwhelmed by new technology, although the benefits should be fully acknowledged. Account also had to be taken of the communication gap between doctors and patients, and here technology could have a powerful role. Educational technology should be recognized as well as technical developments.

The management of continuing medical education

Professor T o m Hayes stressed that the use of the word ‘management’ should not imply authorita- rianism. He developed ways and means of facil- itating CME for individuals and forgroups. For the former, motivation and opportunities were the key factors. This required recognizing individual needs, knowing how to respond to them, and possibly introducing an element of persuasion. The Government’s proposal for a new contract for general practitioners required a major thrust to develop programmes for individuals which were acceptable within the framework of the contract and met the perceived needs of each doctor. A wide variety of opportunities were readily available, but these needed to be person- alized, and different choices catered for. Compulsory commitment was becoming widely accepted. This should not be to force participa- tion, but to stimulate doctors to undertake their own continuing education. Experience in other countries had indicated that legislative compul- sion was counterproductive, and conflicted with principles of adult education. Opportunities for individualized continuing education included self-leaming programmes, informal methods (such as practice-based education), formal courses, meetings and other activities. A11 were valuable but their effectiveness was subject to speculation. Effective mechanisms had been developing at local levels, or for instance amongst young general practitioner groups, where responsiveness to their perceived needs had led to practice-based education. This should be extended to continuing education in the hospital service, which should be multidiscipli-

nary, both within the medical profession and across other professional barriers.

An open question was how to accredit con- th-uing education programmes and here help would be required, not just for general practice, but for other medical disciplines. Emphasis should be given to the relevance of the pro- grammes, and links established with ongoing performance review. Evaluation should be included in the future management of group continuing education. Planning would involve discovering the perceived needs of all doctors which could be undertaken by interviews, ques- tionnaires, group discussions and the seeking of opinions, although these did not always reflect real needs. Methods ofassessment should include monitoring and knowledge, skills and attitudes of practising doctors and dentists, and matching these with advances in medical science and medical care so as to identify the learning requirements both to advance knowledge and to overcome identified incompetencies. Budgeting was at present on a disturbingly ad hoc basis. National Health Service (NHS) staff contribut- ing to traditional courses were very modestly rewarded as compared to rewards in the private sector, and fixed costs, such as revenue expendi- ture on postgraduate centres, were inadequately met. Investment was needed in evaluation meth- ods, which would include not only measuring changes in knowledge, skills and attitudes, but in the satisfaction generated amongst participants.

Professor Hayes recommended that the workshop on the district organization of con- tinuing education should examine the edu- cational implications of medical audit, how multidisciplinary learning could be developed, and how postgraduate centres could become departments of education comparable to clinical departments of medicine or surgery.

The assessment of learning processes

Dr Colin Coles examined the effectiveness of continuing education, and to do this he reviewed the literature, examined different approaches, and proposed a set of criteria by which con- tinuing education could be evaluated.

Much ofthe literature, he said, including many research findings, largely described who was providing continuing education and why, but

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not how effective it was. A recurring theme was that continuing education programmes were largely teacher dominated. Moreover, research indicated that while knowledge could be improved, behaviour was not necessarily changed. Similarly, the outcome for care for patients did not seem to be greatly affected by continuing education.

Dr Coles described his experience with developing teaching courses for general practice trainers in Wessex. Participants were divided into groups, where in turn they showed video recordings of their own consultations. Another member of the group then ‘taught’ the person showing the video, and then the group discussed the teaching they had observed, giving feedback using a specially constructed protocol for encouraging reflection and self-assessment. This course emphasized that people learn best when helped to define their own problems, to ask the right questions and to accept responsibility for their own learning needs.

Drawing on this experience and the current literature concerning the way people learn most effectively, Dr Coles proposed a model for evaluating continuing education which addressed three broad questions:

(1) Did the learning programme provide an appropriate context for learning, i.e. did it find out what the learner’s needs were, where the learner was, and did it get learners to ask the right questions, and to reflect on their own experience?

(2) Was the necessary information being pro- vided which was relevant to the needs of the participants taking part, and was it appropriately packaged?

(3) Were there built-in opportunities for people to handle appropriately the information given? Did this enable partici- pants to make the right ‘connections’, to elaborate their knowledge and to enable them to solve problems. Moreover, was the process enjoyable?

Concluding, Dr Coles posed three questions to the workshops:

- how well did his suggested model account for success in continuing education, and provide a useful set of criteria for its evaluation?

- how well could the model be used to develop continuing education pro- grammes?

- what research was necessary to study the effectiveness of continuing education pro- grammes, who should undertake it and from where and how could funding be acquired?

Discussion

The Chairman asked the participants to put forward specific recommendations. The three workshops were linked, bringing together the aims of CME, its processes and its effective management. In discussion, the need for a coher- ent pattern of CME was stressed. There were hazards ahead if the profession did not itself take initiatives, overcoming health service managers’ attempts to make use of the potential that they saw for CME as a means ofcontrol. Research had indicated that many CME activities did not necessarily improve clinical performance, but in part this was due to inappropriate data used for the evaluations. The emphasis was on perform- ance in practice and its relationship to know- ledge; this was not enough, and did not account for personal development and the stimulaton of intellectual curiosity. The time doctors could devote to CME was limited, and they had to make choices from a wide variety of activities that were available. Many of the learning pro- cesses were not in a formal setting, but ‘in daily practice, and doctors needed help to make that a learning process.

The need for change in CME had long been recognized, and the reasons for the apparent inertia were examined. Doctors seemed to be prisoners within their past learning experiences. GPs appeared to have been more adventurous in exploring their own development and fashioning altered behaviour, as compared with other specialties which seemed to be dominated by an overload of information without the inclination or insight to look at their attitudes to practice. CME could be regarded as a means of elevating standards of practice, or an assurance of mini- mum standards; the danger was that ‘standards’ were not immutable and could be readily misin- terpreted if not seen in the right context and conditioned by misconceptions.

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The workshops contained proposals which inevitably raised resource issues, e. g. the need for CME facilitators, but they did not grow on trees. A regional training strategy could achieve appro- priate training for them but an initiative had to be taken. Whether this was best at district, regional or national level was discussed. The GMC’s Education Committee had stressed the import- ance of ‘training the trainers’ but this cost time and money. The advantage of a regional initiat- ive would be that the Regional Health Authori- ties presently held consultants’ contracts and had direct links with Universities which could signi- ficantly influence the quality of the education provided. Political support would also be neces- sary, particularly at the present time with major changes taking place in the NHS.

It was agreed that the next stage should be for the Association to pull together the themes on CME identified by the workshops, and to make a major thrust in the clarification of what was meant by the quality of care in a changing environment.

Commentary

The Conference acknowledged that, to ensure the maintenance of good quality of clinical practice as the medical profession had reasonable cause to claim, continuing education of all prac- titioners should today be an actively planned and effectively managed process. The purpose was both to enhance the quality of care provided and the discipline of medicine. This should be achieved by defining and redefining its values, competencies and the definitions of quality through the critical appraisal ofpractice in action, together with the application of both qualitative and quantitative medical audit. This process should be self-motivated and self-directed, which should be universally acknowledged as an essential and desirable part of professional practice.

To achieve these aims individual doctors should be given support to enable them to

identify their educational needs through various forms of self-assessment so as to make their continued learning an essential part of medical pracilce. Peer group collaboration was an impor- tant part of continued learning, and this needed to be extended to interdisciplinary groups so as to identify common professional competencies. To facilitate these proposals facilitators should be appointed to develop the functions of learning groups, to encourage individuals to study their special interests in depth, and to identify aspects of continuing education into which research should be undertaken. This applied in particular to how individuals adapted to and participated in change as a consequence of continuing edu- cation.

An organizational framework was proposed. Continuing education should be provided on a multidisciplinary basis, catering for different interests, by district medical education com- mittees, which should carry sufficient authority and be managed by identified and salaried tutors with administrative staff. Continuing education should be probided where there was an adequate source of advice and resources available to enable participants to exercise their own responsibility to meet their own needs. Specialty interests should be catered for, together with interdiscipli- nary education, and medical audit should be seen to be an essential part ofcontinuing education as a means of identifying needs. The true costs of continuing education had as yet not been ad- equately identified; individuals valued what they themselves paid for, and they should be expected to contribute personally to their continuing education, although the management of a rev- enue budget was necessary so as to ensure income generation and the encouragement of compe- tition.

It is proposed that the Association should publish an outline structure for the provision of continuing education, identifying resource requirements in development areas, and invite detailed comments from all its Corporate and Individual members.