Bennett, Nancy L. PhD; Davis, Dave A. MD; Easterling, William E. Jr. MD; Friedmann, Paul MD; Green, Joseph S. PhD; Koeppen, Bruce M. MD, PhD; Mazmanian, Paul E. PhD; Waxman, Herbert S. MD
The professional development of physicians is a lifelong commitment that builds on formal and informal opportunities to learn emerging science, apply innovations in clinical settings, and expand understandings of caring for patients. One essential element in that commitment has been continuing medical education (CME), the final part of the education continuum. Although CME has a long history in supporting physicians as lifelong learners, it has become increasingly important and focused during the past ten to 15 years as a result of the impact of changing educational, social, and political forces on medical practice. In this article, we describe our vision of how we in academic medicine can support continuing medical education to respond to the changed and changing health care environment, and suggest new directions for individuals and institutions involved with continued learning.
SOURCES OF UNDERSTANDING HOW PHYSICIANS LEARN
The practice of medicine has changed dramatically in the past decade because of forces demanding a new way to envisage health care. These include rapid advances in biomedical knowledge and its application to the practice of medicine; changing expectations of physicians as effective communicators and team members; enhanced awareness of the role of physicians in disease prevention; incorporation of evidence-based medicine, accountability, and financial incentives into daily medical practice; changing work environments as more care moves to ambulatory settings; and the use of CME as evidence of competence for medical practice when granting medical re-licensure, hospital privileges, specialty recertification, professional society membership, and recognition for selected other professional activities.
To assist physicians as they respond to these forces, we, as educators in the field of CME, have been building an understanding of how physicians learn by drawing on a wide variety of ideas. Several types of literature have been important in the growth of our thinking in the field and have contributed to the ways we conceptualize and address how, why, and when physicians learn. Below are listed some of the important areas of literature that have been valuable sources.
▪ Learning and adult development. The adult learning literature provides a framework to think about how and when adults learn, and how learning is best facilitated. Work in the field adds to our understanding of the forces that motivate learners, translating experience into a knowledge base to maintain competence, linking stages of professional development with practice changes, and identifying learner responsibilities. Also, theories of how adults process information, best ways to provide and evaluate learning, and measurement of outcomes contribute to a more complex approach.
▪ Problem-based/practice-based learning. Research and experience in medical education at the undergraduate and graduate levels adds to the thinking about continuing professional development with ideas about physicians' developmental learning processes and their translation to a self-directed learning system modeled on problem-based learning. Contributions include new approaches to learning that mirror the problems physicians face and the decisions they make in their own practices, adaptations of traditional teaching and learning methods for synergy between the learner and the content, and new forms of assessment.
▪ Continuing professional education (CPE). Society recognizes professionals and assigns them roles. Some of the questions that emerge relate to recognizing how professionals develop, measuring performance and competence in physicians' practices, designing a self-directed curriculum for professional growth, supporting faculty as they expand their teaching skills, and inventively formulating learning activities. The impact of cultural change on professional practice, and the emergence of new kinds of professionals contribute to our thinking about CME.
▪ Change. Assuming that the purpose of learning is to change necessitates understanding what is known about how individuals and organizations go about making changes. The impact of change on professional practice, factors that encourage or discourage change, defining who makes changes, and ways to think about the range of approaches to new practices are essential areas for us to address as part of professional development. Creating learning organizations and managing ongoing change within an organization are central themes in continuously improving health care.
▪ Organizational development and behavior. As medical practice changes shape with more emphasis on the employers of physicians and of other health care professionals, there is a greater need to understand the ways that organizations form and re-form, and how organizational systems work. Physicians as employees, work in new kinds of teams, and definitions of organizational goals for the health of the public all raise questions about what physicians must learn to effectively provide care. Balancing organizational goals with individual physicians' goals for patients demands an understanding of the complex roles of organizations.
▪ Health services research. Research from many components of the health care system provides a more sophisticated view of the doctor—patient relationship as part of care, the need for better understanding of physicians' concerns and creative solutions to questions of care when science cannot provide definitive responses, outcomes measures, and the role of the institution in responding to and being part of providing care.
ROLE OF THE AAMC IN FOSTERING CME
The Association of American Medical Colleges (AAMC) states that its mission is to improve the health of the public by enhancing the effectiveness of academic medicine. The AAMC pursues its mission in part by assisting academic medicine's institutions, organizations, and individuals in carrying out their responsibilities for educating physicians and biomedical scientists.
In the association's 1995 strategic plan, Taking Charge of the Future, the AAMC established the strategic commitment of “stimulating changes in medical education to create a better alignment of educational content and goals with evolving societal needs, practice patterns, and scientific developments.” The AAMC recognizes that CME represents an essential component of the continuum of medical education and is therefore one area of the AAMC's commitment to the professional development of physicians. In 2000, the AAMC Executive Council approved a statement, “Lifelong Professional Development and Maintenance of Competence,” that outlines a mechanism intended to assure the public that doctors are remaining competent throughout their careers.
Given this commitment to medical education, including CME, it is clear to us that the AAMC has an important role in helping CME enhance its effectiveness for the professional development of physicians. We have written this article to define our ideas about the actions required to support a new view of CME. Our hope is that this definition and view will help the AAMC in its efforts to carry out its strategic commitment in the area of CME with its institutional and organizational members, and members of the medical education community.
A VISION FOR CME
Our work in creating the new view of CME presented in this article was facilitated by the AAMC when we were invited in 1998–99 to meet, as the members of the AAMC's Continuing Medical Education Advisory Group, to develop an understanding of a new system for CME. Our group built on excellent materials and discussions already developed by the Society for Academic Continuing Medical Education (SACME), the Alliance for Continuing Medical Education (ACME), and the American Medical Association (AMA), as well as a previous advisory group at the AAMC. We considered the role of CME in the continuum of medical education; appropriate settings for CME; barriers and bridges to the continuum seen by learners, teachers and institutions; and models that better realize the role of CME in the continuum of medical education.
The Nature and Values of CME
Continuing medical education is a distinct and definable activity that supports the professional development of physicians and leads to improved patient outcomes. It encompasses all of the learning experiences that physicians engage in with the conscious intent of regularly and continually improving their performance of professional duties and responsibilities. Essential to the continuum of medical education, CME shapes the growth and development of physicians in their full range of duties and responsibilities.
We intend for the values conveyed in our vision of CME stated in this article to define ethical and effective CME for physician-learners as well as those who implement and study continuing medical education. Our vision of CME emphasizes the continuous development of the learner within his or her own setting. Some standards for behavior begin in medical school, but we assume that
▪ physicians build and refine their understanding of ways to care for patients and contribute to the health system throughout a career in medicine,
▪ physicians take on new responsibilities that demand new learning, and
▪ physicians direct their own learning.
Optimal CME is highly self-directed, with content, learning methods, and learning resources selected specifically for the purpose of improving the knowledge, skills, and attitudes that physicians require in their daily professional lives that lead to improved patient outcomes. In this context, the selection and design of the most relevant CME is based on data from each physician's present professional responsibilities and performance. One source to define specific content criteria to maintain competence in a variety of specialties comes from new efforts of professional societies. Evaluating CME in the context of performance improvement is a logical and essential element in the cycle of learning. To ensure consistency in meeting standards, we believe that accreditation of medical school, teaching hospital, and professional society CME units must take into account optimal criteria for the provision of CME as defined in this article. Changes occurring in the field of CME demand new structures that direct thinking about the role of learning in each physician's professional development. Effective health care requires continuous learning. New bridges must be built to better link the components of the health care system so that a unified and integrated system of continued learning will support improved patient care.
The organizations and structures of medical school, teaching hospital, and professional society CME units vary, with individuals occupying diverse roles and having titles such as dean, director, educator, evaluator, and planner. For simplicity, the term we have chosen for this document to describe those with responsibility and authority for supporting CME efforts is CME educator. In order to support physicians, CME educators must know and be able to use the literature, must derive practical and effective results that create or improve learning systems, and must continue their own professional development to support continued improvement.
DEFINING THE ACTION STEPS TO ENACT A NEW VISION OF CME
It is our vision that CME will effectively assist physicians in the generation, translation, diffusion, critical appraisal, and utilization of new knowledge that contributes to high-quality, compassionate, cost-sensitive care for patients. To carry out these responsibilities requires a structure of specific action steps taken by all in the field of CME. We believe that a collaborative approach will better advance what doctors know and how they practice medicine and will result in better health care. In addition to the physician learner, a number of entities will play roles in the transformation of CME. All members of the CME community are invited to collaborate. Our vision focuses on academic CME as defined by the AAMC, its member institutions and organizations—including medical schools, teaching hospitals, academic medical centers, and professional societies.
Actions must take place at the national, local, and individual levels. In consideration of this, we have identified the entities most likely to play lead roles in enacting specific elements necessary for the new vision of CME. This is not intended to exclude or preclude other groups or individuals from joining in to provide significant and innovative contributions. We wrote this article as an invitation to all in the CME community. Below we list the structures of specific action steps and suggestions to begin them.
We recommend that the AAMC play an important role in supporting and facilitating the process to create structures to assure that continuing professional development is an integral and effective part of a physician's work life. Our vision of academic CME is based on having the AAMC follow this recommendation. While each institution may support and enact a new vision of CME, the AAMC should be instrumental in supporting activities to
▪ initiate collaboration among appropriate groups to produce a new vision of CME,
▪ facilitate new partnerships among CME educators to understand and effectively use a new vision of CME, and
▪ create discussions that support new organizational assessment mechanisms to measure the ability of medical schools, teaching hospitals, and academic societies to implement the vision of CME.
Enacting the vision includes the following action steps.
1. We must conduct research to understand how and why physicians learn. Systematic research is essential to allow us to generate and apply new knowledge about continuing professional development toward understanding how physicians learn, select best practices, change their behaviors, and effect improved patient outcomes. Academic units within medical schools, health care centers, and professional societies provide a base for the generation of new knowledge and its application. We recommend that each institutional and organizational member of the AAMC
▪ ensure that every academic CME unit is linked with a program for research in medical education and/or research in health care delivery and quality improvement,
▪ involve a CME presence in organizational activities intended to ensure that physicians implement new medical knowledge and clinical practices,
▪ facilitate interactions of CME organizations to generate and disseminate new knowledge about CME and translate available information into practice,
▪ advance activities leading to consensus on effective new learning methods and address mechanisms to enhance their utilization in CME, and
▪ advocate the funding of research in CME.
2. We must promote professional activities for physicians to systematically learn from their clinical experience. To be effective in their responsibility for constructing meaning, physicians must understand and control their own learning experiences with access to professional activities that are appropriate for the practice environment. Academic units within medical schools, health care centers, and professional societies provide a portion of the learning activities available to physicians. We recommend that each institutional and organizational member of the AAMC
▪ identify examples of mechanisms that enhance the ways physicians use their practice environments to continuously learn from personal experience and
▪ develop and explore the reliability, validity, and effectiveness of self-directed learning measures.
3. CME units must provide appropriate resources for physicians to expand their learning skills. The development of physicians' knowledge, skills, and attitudes to adapt in the changing health care environment, emphasizing new thinking about measuring personal performance, is essential. Academic units within medical schools, health care centers, and professional societies are leaders in supporting the professional development of physicians. We recommend that each institutional and organizational member of the AAMC
▪ identify and disseminate sources for data, information, and resources among components of the health care system that assess problems, and develop corrective activities (e.g., health services research, public health department reports, community needs assessments, continuous quality improvement systems, private-practice-group self-study), and
▪ develop and provide expanded opportunities for physicians to be linked to information and data sources facilitating new learning options that include more opportunities for self-assessment.
4. We must provide the highest-quality educational activities and services. Fundamental to this vision is creating activities that are consistent with the criteria for optimal CME. Academic units within medical schools, health care centers, and professional societies are central to the provision of learning activities. We recommend that each institutional and organizational member of the AAMC
▪ develop an ongoing process to link health care data sources with an educational system to address the gaps between optimal and actual physician performance,
▪ encourage teaching organizations and individuals to communicate their views of important health issues with educational systems to support physicians where they work, including the translation of research findings for clinical applications,
▪ collaborate with the AAMC, medical schools, teaching hospitals, and professional societies to identify and overcome barriers to achieving the most useful and relevant learning, and develop skills to utilize sources of information and information technologies in effective ways in medical education,
▪ propose ways to develop, implement, and evaluate standards for technology utilization, and
▪ encourage the AAMC to continue a forum for work with the medical schools, teaching hospitals, professional societies, accrediting bodies, and other professional groups to evaluate effective accreditation standards in support of the CME vision and academic mission of medical schools. The Liaison Committee on Medical Education (LCME), the Accreditation Council for Graduate Medical Education (ACGME), and the Accreditation Council for Continuing Medical Education (ACCME) are the accrediting bodies of the educational continuum. Member organizations of the ACCME include the American Board of Medical Specialties, the American Hospital Association, the American Medical Association, the Association for Hospital Medical Education, the Council of Medical Specialty Societies, and the Federation of State Medical Boards.
5. We must establish a meaningful educational relationship among all parts of the educational continuum. Work between and among organizations responsible for undergraduate medical school education (MSE), graduate medical education (GME), and continuing medical education (CME) will yield a more cohesive system. Academic units within medical schools provide a continuum of learning. We recommend that each medical school and other interested institutional and organizational members of the AAMC
▪ support the inclusion of CME professionals on committees charged with oversight of MSE and GME (and vice versa) in medical schools, teaching hospitals, and professional societies,
▪ elaborate the educational principles that are critical across the continuum of MSE, GME, and CME,
▪ recommend that regional and national MSE and GME committees include CME representation (and vice versa),
▪ assist in facilitating faculty development to achieve educational effectiveness for all components of teaching, including needs assessment and issues specific to CME, and
▪ provide deans, CEOs, and other educational leaders with a mechanism to increase the depth of their understanding of the role of CME in their institutions and the major issues in the field of CME.
6. We must collaborate to develop and implement new systems to measure learning. CME outcomes assessment, measures to validate educational effectiveness, and efforts to promote educational evaluation research will expand our thinking. Academic units within medical schools, health care centers, and professional societies are central to the provision of learning activities and are committed to the quality of learning, including appropriate outcomes measures. We recommend that each institutional and organizational member of the AAMC
▪ develop resources using available and new information to define outcomes and assess them,
▪ develop an inventory of evaluation resources and tools that can be used in CME efforts, and
▪ encourage development and testing of new assessment tools, with training to use them.
7. CME educators must maintain their competence. Those who plan and study efforts that influence the continuing professional development of physicians must be encouraged to maintain lifelong learning and training. Academic units within medical schools, health care centers, and professional societies provide a core of expertise about the professional development of physicians. The continued development of the base of expertise is essential to moving forward with a new mission. We recommend that each institutional and organizational member of the AAMC
▪ develop an ongoing leadership initiative for CME, and
▪ foster the development of skills for professionals in the field of CME to assure the competencies required to generate, translate, and put into practice new knowledge, skills, and attitudes resulting from research and other work that reflect the vision we have articulated here.
CORE COMPETENCIES FOR CME EDUCATORS
We have defined six core competencies (listed below) that we believe CME educators need to begin to translate the elements of the new vision of CME into practice. These competencies are intended to provide our picture of a new CME system that assumes the CME educators are those individuals who take leadership roles in defining, designing, and implementing learning programs and systems. The purpose of programs and systems in CME is to foster learning opportunities that are relevant and appropriate for the continuing professional development of physicians. To develop such opportunities, we envision that CME educators must be able to
1. guide physician learners as they continually assess their own ongoing learning needs, and, with them, identify opportunities and resources to meet those needs in order to enhance performance and promote lifelong learning skills,
2. study the role of continuing professional development to enhance physicians' knowledge, performance, and health care outcomes,
3. design a CME list of effective educational strategies that uses research findings about how physicians learn and enact changes in their professional behaviors, and that addresses the variety of learning styles and learning needs. These strategies include established formats as well as evolving formats that incorporate new technical capabilities for synchronous and asynchronous learning,
4. cooperate with CME educators and others throughout the continuum of medical education to maximize the ability of CME to meet the varied learning needs of physicians and health care systems,
5. ensure that systems for measuring improvement of physician performance link CME to health care outcomes. Critical to that effort will be to disseminate information about new health care practices and links with patient and public education, and
6. enhance the professional development of CME educators, including their understanding and use of theory and research to provide effective support for appropriate changes in physicians' knowledge, performance, and health care outcomes.
We have proposed our vision of CME in terms of definitions and action steps so that those in the field of CME may begin to detail and implement the changes that must take place to move our ideas about CME into a new arena. Collaboration among the appropriate academic groups, professional societies, and health care institutions is essential to refine the best thinking in the field and to create learning systems for the professional development of physicians. We welcome comments from readers as we continue to refine our vision of CME and suggest further ways to implement it.