Providing Effective Providing Effective Continuing Medical Continuing Medical

Education for PhysiciansEducation for Physicians

Suzanne Ziemnik, MEdSuzanne Ziemnik, MEdDirector, Division of CMEDirector, Division of CME

American Academy of PediatricsAmerican Academy of Pediatrics

““Continuing medical education is a distinct and definableContinuing medical education is a distinct and definableactivity that supports the professional development of activity that supports the professional development of physicians and leads to improved patient outcomes. It physicians and leads to improved patient outcomes. It encompasses all of the learning experiences that encompasses all of the learning experiences that physicians engage in with the conscious intent of regularly physicians engage in with the conscious intent of regularly and continually improving their performance of professional and continually improving their performance of professional duties and responsibilities. Essential to the continuum of duties and responsibilities. Essential to the continuum of medical education, CME shapes the growth and medical education, CME shapes the growth and development of physicians in their full range of duties and development of physicians in their full range of duties and responsibilities.” responsibilities.”

((Academic MedicineAcademic Medicine, 2000, 75:1167-1172), 2000, 75:1167-1172)

“In what is typically an intensive 2- or 3- day short course,(instructors lecture and lecture and lecture) fairly large groups of…professional 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

Does CME Work?Does CME Work?

Studies of the effectiveness of CME Studies of the effectiveness of CME measured against physician performancemeasured against physician performance

and health care outcomesand health care outcomes

EFFECTIVENESS OF INTERVENTIONSEFFECTIVENESS OF INTERVENTIONSby Type of Interventionby Type of Intervention

Number of interventionsdemonstratingpositive or negative/inconclusivechange

Positive outcomes

Negative/inconclusiveoutcomes

(presented by Dave Davis, MD to the Specialty Society SIG at the Alliance for CME Annual Conference January, 2000)

FindingsDidactic interventions fail to change physician performance or health Didactic interventions fail to change physician performance or health care outcomescare outcomes

Interactive CME is more effective in changing physician Interactive CME is more effective in changing physician performance or health care outcomeperformance or health care outcome

Sequenced CME interventions appear to have more impactSequenced CME interventions appear to have more impact

Addition of "enabling methods" which may facilitate adapting to Addition of "enabling methods" which may facilitate adapting to changes in the practice site are effectivechanges in the practice site are effective

Multiple or longitudinal interventions demonstrated positive Multiple or longitudinal interventions demonstrated positive outcomes on physician performance (and in some cases on health outcomes on physician performance (and in some cases on health care outcomes) as compared to single interventionscare outcomes) as compared to single interventions

No relationship between group size and positive outcomesNo relationship between group size and positive outcomes

Implications of the FindingsImplications of the Findings

Interventions to improve professional Interventions to improve professional performance are complexperformance are complex

There are no “magic bullets” to change practice There are no “magic bullets” to change practice in all circumstances and settings in all circumstances and settings (Oxman, 1995)(Oxman, 1995)

Multi-faceted interventions targeting different Multi-faceted interventions targeting different barriers to change are more likely to be effective barriers to change are more likely to be effective than single interventions than single interventions (Davis, 1995; Davis, 1999)(Davis, 1995; Davis, 1999)

Role and Value of Role and Value of Traditional CMETraditional CME

Reaffirming and/or increasing knowledgeReaffirming and/or increasing knowledge

Validating current practice behaviorValidating current practice behavior

Changing attitudesChanging attitudes

Providing multiple messagesProviding multiple messages

"Optimal CME is highly self-directed, with content, "Optimal CME is highly self-directed, with content, learning methods, and learning resources selectedlearning methods, and learning resources selectedspecifically for the purpose of improving thespecifically for the purpose of improving theknowledge, skills, and attitudes that physiciansknowledge, skills, and attitudes that physiciansrequire in their daily professional lives that lead torequire in their daily professional lives that lead toimproved patient outcomes.”improved patient outcomes.”

((Academic MedicineAcademic Medicine, 2000, 75: 1167-1172), 2000, 75: 1167-1172)

Recommendations for Effective CME

Highly self-directed Highly self-directed

Incorporates interactive learning formats Incorporates interactive learning formats

Includes practice enabling and reinforcing strategiesIncludes practice enabling and reinforcing strategies

Accessible within physicians' practice or work settingsAccessible within physicians' practice or work settings

Physicians recognize knowledge, skills and attitudes to Physicians recognize knowledge, skills and attitudes to maintain competencemaintain competence

(AAMC Statement on Lifelong Professional Development (AAMC Statement on Lifelong Professional Development and Maintenance of Competence, 2000)and Maintenance of Competence, 2000)

More Recommendations for Effective CME

Accommodates the different styles of learning that will be Accommodates the different styles of learning that will be seen within a community of learnersseen within a community of learners

Relates directly to the maintenance of competence of the Relates directly to the maintenance of competence of the practitioner practitioner

Link to evidence-based medicine whenever possibleLink to evidence-based medicine whenever possible

Learner-centeredLearner-centered

Active rather than passiveActive rather than passive

More Recommendations for Effective CME (cont’d)

Link to improving physicians' practice behaviors and Link to improving physicians' practice behaviors and patient outcomespatient outcomes

Based on individual's real needs (based on objective Based on individual's real needs (based on objective methods) and perceived needsmethods) and perceived needs

EngagingEngaging

ReinforcingReinforcing

Relevant to clinical practiceRelevant to clinical practice

Point-of-Care CMEPoint-of-Care CME

Eight Principles to Guide CME

CME planning and program development should be CME planning and program development should be based on needs assessment, including outcomes data.based on needs assessment, including outcomes data.

Goal of CME should include the development of skills Goal of CME should include the development of skills necessary for lifelong learning, the exercise of clinical necessary for lifelong learning, the exercise of clinical reasoning, an understanding of the decision making reasoning, an understanding of the decision making process, and specific content acquisition.process, and specific content acquisition.

Multiple goals of CME should be reinforced by the Multiple goals of CME should be reinforced by the appropriate choice of learning methodsappropriate choice of learning methods

Incorporation of new instructional technologies for CME Incorporation of new instructional technologies for CME should be based on their intrinsic strengths as learning should be based on their intrinsic strengths as learning tools after thorough evaluationtools after thorough evaluation

Eight Principles to Guide CME (cont’d)

Faculty development is important within CME and should Faculty development is important within CME and should include exposure to new learning methods (theory and include exposure to new learning methods (theory and application), enabling faculty to translate their content application), enabling faculty to translate their content expertise into formats more appropriate to learners' needs.expertise into formats more appropriate to learners' needs.

Educational activities should be supportive of and Educational activities should be supportive of and coordinated with the transition to evidence-based medicine. coordinated with the transition to evidence-based medicine.

Professional and, whenever possible, interdisciplinary Professional and, whenever possible, interdisciplinary interaction should be given priority in CME programming.interaction should be given priority in CME programming.

Outcomes-based measures of CME effectiveness and Outcomes-based measures of CME effectiveness and research should be introduced into the determinants of research should be introduced into the determinants of physicians' practice behaviors.physicians' practice behaviors.

((Academic MedicineAcademic Medicine, Vol. 74, No 12/December 1999), Vol. 74, No 12/December 1999)

Self-directed Learning

"Physicians must understand and control their own "Physicians must understand and control their own learning experiences with access to professional learning experiences with access to professional activities that are appropriate for the practice activities that are appropriate for the practice environment."environment."

(Bennet, et al)(Bennet, et al)

"The efficiency and effectiveness of learning in the "The efficiency and effectiveness of learning in the workplace is related to a physician's ability to select the workplace is related to a physician's ability to select the right problems to solve, frame the problem in terms of a right problems to solve, frame the problem in terms of a question or problem statement, successfully obtain and question or problem statement, successfully obtain and appraise the information retrieved, and develop a plan to appraise the information retrieved, and develop a plan to integrate the learning into practice."integrate the learning into practice."

(Campbell, et al)(Campbell, et al)

Recognition of Stages of the Learning Process

Determining if the content of the CME program is Determining if the content of the CME program is relevantrelevant

Using the CME event as one of several Using the CME event as one of several resources selected for learningresources selected for learning

Already implementing changes in practice and Already implementing changes in practice and seeking assurance of doing the "right thing"seeking assurance of doing the "right thing"

Assessment of Outcomesin Continuing Education

(Adapted from Dixon, J. Eval. & the Health Prof. 1977and presented by Davis to the Specialty Society SIG at

the Alliance for CME Annual Conference, January, 2000)

LEVELS

1 2 3 4

Opinions,Perceptions,

Attendance Data

Competence

(knowledge, skills,

attitudes) of Health

Professionals

Health Professional

Performance

Patient/Health

Care Outcomes

Barriers to Measuring the Effectiveness Barriers to Measuring the Effectiveness of Level 3 and Level 4 of Level 3 and Level 4

Educational InterventionsEducational Interventions

Ability to demonstrate a causal relationship between the Ability to demonstrate a causal relationship between the educational intervention and the observed effecteducational intervention and the observed effect

Nature of specialty society CME targeted to a national Nature of specialty society CME targeted to a national audienceaudience

FinancialFinancial

TimeTime

Core Competencies for CME Educators

Guide physician learners as they continually assess their Guide physician learners as they continually assess their own ongoing learning needs, and identify opportunities and own ongoing learning needs, and identify opportunities and resources to meet those needs in order to enhance resources to meet those needs in order to enhance performance and promote lifelong learning skillsperformance and promote lifelong learning skills

Study the role of continuing professional development to Study the role of continuing professional development to enhance physicians' knowledge, performance, and health enhance physicians' knowledge, performance, and health care outcomescare outcomes

Design a CME list of effective educational strategies that Design a CME list of effective educational strategies that uses research findings about how physicians learn and uses research findings about how physicians learn and enact changes in their professional behaviors, and that enact changes in their professional behaviors, and that addresses the variety of learning styles and learning needsaddresses the variety of learning styles and learning needs

Core Competencies for CME Educators (cont’d)

Cooperate with CME educators and others throughout the Cooperate with CME educators and others throughout the continuum of medical education to maximize the ability of continuum of medical education to maximize the ability of CME to meet the varied learning needs of physicians and CME to meet the varied learning needs of physicians and health care systemshealth care systems

Ensure that systems for measuring improvement of Ensure that systems for measuring improvement of physician performance link CME to health care outcomesphysician performance link CME to health care outcomes

Enhance the professional development of CME Enhance the professional development of CME educators, including their understanding and use of theory educators, including their understanding and use of theory and research to provide effective support for appropriate and research to provide effective support for appropriate changes in physicians' knowledge, performance, and changes in physicians' knowledge, performance, and health care outcomeshealth care outcomes

(Academic Medicine(Academic Medicine, 2000, 75:1167-1172), 2000, 75:1167-1172)

American Academy of PediatricsAmerican Academy of PediatricsContinuing Medical EducationContinuing Medical Education

Mission StatementMission Statement

The continuing medical education program of the AmericanThe continuing medical education program of the AmericanAcademy of Pediatrics seeks to Academy of Pediatrics seeks to develop, maintain and/ordevelop, maintain and/orincrease the knowledge, skills and professionalincrease the knowledge, skills and professionalperformanceperformance of primary care pediatricians, pediatric of primary care pediatricians, pediatricmedical subspecialists, pediatric surgical specialists, andmedical subspecialists, pediatric surgical specialists, andother pediatric health professionals by providing them withother pediatric health professionals by providing them withthe highest quality, most relevant and the highest quality, most relevant and accessibleaccessible education experienceseducation experiences possible…. The ultimate goal of possible…. The ultimate goal of the overall CME program is for participants to better identifythe overall CME program is for participants to better identifytheir personal educational needs and be able to their personal educational needs and be able to designdesignappropriate self-directed learning plansappropriate self-directed learning plans to meet those to meet thoseneeds. needs.

Adopted May 15, 1998Adopted May 15, 1998

AAP CME Program

Live CME ActivitiesLive CME Activities– Directly SponsoredDirectly Sponsored– Jointly SponsoredJointly Sponsored

Enduring MaterialsEnduring Materials– Internet CMEInternet CME– Print CMEPrint CME– Other Multimedia CMEOther Multimedia CME

AAP Strategies for AAP Strategies for Educating PhysiciansEducating Physicians

““Traditional” models/approaches transitioning Traditional” models/approaches transitioning to interactive, learner-centered formatsto interactive, learner-centered formats

InnovationsInnovations

InnovationsInnovations

Pedialink: AAP CME HomePedialink: AAP CME Home

eeQIPP (Education in Quality QIPP (Education in Quality Improvement for Pediatric Practice)Improvement for Pediatric Practice)

SuperCMESuperCME

PediaPediaLink.orgLink.org™™

A powerful online learningA powerful online learningsystem designed tosystem designed toassist pediatricians toassist pediatricians todirect, focus, and managedirect, focus, and managetheir CME/CPD.their CME/CPD.

PediaPediaLink.orgLink.org™™

One stop spot for point-of-practice information One stop spot for point-of-practice information and professional developmentand professional development

Tracks and provides feedback on the quality of Tracks and provides feedback on the quality of the individual pediatrician’s learning cyclethe individual pediatrician’s learning cycle

Highly individualized and dynamic tool for Highly individualized and dynamic tool for lifelong professional developmentlifelong professional development

eeQIPPQIPP

Interactive online educational system Interactive online educational system designed to help pediatric health care designed to help pediatric health care professionals to:professionals to:

– learn about quality improvement strategieslearn about quality improvement strategies

– collect and analyze practice data over timecollect and analyze practice data over time

– document improved quality of caredocument improved quality of care

eeQIPPQIPP

Incorporates interactive, topic-focused CMEIncorporates interactive, topic-focused CME

Content derived from evidence-based guidelines Content derived from evidence-based guidelines and best practicesand best practices

Self-assessment based on real time chart audit Self-assessment based on real time chart audit and feedback with opportunity for peer and feedback with opportunity for peer benchmarkingbenchmarking

eeQIPPQIPP

FeaturesFeatures– facilitated online discussionsfacilitated online discussions

– practice enablers, tools and templatespractice enablers, tools and templates

– reminder systemsreminder systems

– patient satisfaction surveyspatient satisfaction surveys

– supporting resource materialssupporting resource materials

SuperCME Features

Actors perform "real life" cultural communication issues Actors perform "real life" cultural communication issues encountered in the officeencountered in the office

Heart Sounds Workshop featuring new state-of-the-art Heart Sounds Workshop featuring new state-of-the-art advanced digital heart sound system coupled with infrared advanced digital heart sound system coupled with infrared transmission and digital projectiontransmission and digital projection

"I'll Take Adolescent Health for a Thousand, Alex" "I'll Take Adolescent Health for a Thousand, Alex"

E-mail networking to connect online with fellow attendees E-mail networking to connect online with fellow attendees before and after SuperCMEbefore and after SuperCME

"Guaranteed your questions are addressed by the professor "Guaranteed your questions are addressed by the professor - When you register early!"- When you register early!"

The Future

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

(Manning)(Manning)

The Future The Future (cont’d)(cont’d)

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

(Manning)(Manning)

ReferencesReferences

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.

References References (cont’d)(cont’d)

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; 282:867-874.

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; 15:153.