Davis, David A. MD; Prescott, John MD; Fordis, C. Michael Jr. MD; Greenberg, Stephen B. MD; Dewey, Charlene M. MD; Brigham, Timothy MDiv, PhD; Lieberman, Steve A. MD; Rockhold, Robin W. PhD; Lieff, Susan J. MD; Tenner, Thomas E. Jr. PhD
The clinical care gap, described by the Institute of Medicine (IOM) as the “quality chasm,” is one in which physicians' attainment of performance measures or treatment goals is less than desired.1 The gap reflects the difference between what best evidence indicates clinicians should do and what they actually do. Gaps in clinical care may result in inadequate adherence to cardiac care guidelines, poor attention to the diagnosis and treatment of mental health problems, and too little implementation of preventive measures.2 Some have characterized these gaps as misuse, underuse, and overuse.3 Causes of this gap are numerous, ranging from those in the larger health care environment (e.g., access to care), to those in the immediate care setting (e.g., team functioning), to those specific to the clinician (e.g., lack of knowledge). Another source of the gaps in quality care is the quality of, and presence of bias in, the evidence on which practicing physicians base clinical actions.
Failures in continuing medical education (CME) to communicate evidence to practicing physicians are not the sole cause of the gap. However, CME does bear responsibility for the education that supports the manner and delivery of clinical care in the United States. Itself the product of many forces, CME has grown into a large and costly enterprise, currently estimated at two billion dollars per year.4 A two-decades-old model5 of continuing education describes three routes by which physicians may maintain their competence: (1) engaging in formal continuing education by attending courses or conferences, (2) pursuing a competency-based approach in undertaking independent, self-directed learning activities, and (3) using a wide variety of informal learning opportunities in the course of normal practice, triggered by encounters with patients, colleagues, and/or experiences (i.e., the “performance model”).
Challenges exist in all three of these constructs. Chief among them is the assumption that the formal update model is sufficient for today's practicing physician. Possibly adequate in an earlier era characterized by a relatively stable body of knowledge and a simpler health care environment, this “conference model” is inadequate in the current period of a complicated health care delivery system and an ever-expanding body of knowledge. The relative inadequacy of didactic lectures to change clinical performance or health care outcomes also detracts from the effectiveness of this model.6 Further, clinicians' inability to fully assess their own learning needs7 mars the notion of self-directed learning, which has been a guiding principle of CME as it now exists. A recent report of the IOM, “Redesigning Continuing Education in the Health Professions,” articulates additional problems in current CME delivery and practice: its lack of linkage to the health care system, a weak scientific base, and dependence on commercial support.8 Improving CME requires bridging the clinical care gap and reforming U.S. health care delivery.
This article, the product of a discussion group convened to focus on the future of faculty development in academic medicine, attempts to address—and thus, possibly help to close—the clinical care gap by providing an analysis of the ways in which a revitalized model of CME, strongly supported by academic medicine, can effect a better health care delivery system. We envisaged four domains essential to this process: (1) the creation of an engaged clinician–learner, (2) a robust, unbiased, and accessible body of information based on best evidence, (3) a more effective CME delivery system, and (4) a health care, educational, and regulatory environment supportive of physicians' lifelong learning. Although the scope of this article excludes health system issues such as payment reform, it includes and emphasizes the accountability of the academic medical enterprise in preparing and supporting learners across the entire medical education continuum. In our vision of this process, faculty play prominent roles. Figure 1 outlines the major argument of this article: that faculty members can and should actively engage in all four of these domains—by facilitating and supporting the clinician–learner, by creating and “packaging” evidence, and by actively developing and testing educational delivery systems (across the continuum)—much as they actively invest in many domains of patient care.
Problems With the Current Construct of CME
The need for a better clinician–learner
Both undergraduate medical education (UME) and graduate medical education (GME) programs have been subject to calls for changes in the content, processes, and methods of preparing medical students and residents for practice.9 One frequent call is to more often include the teaching, testing, and incorporation of knowledge management skills.10 This call has provoked many medical educators to consider the inadequacy of traditional didactic teaching methods for imparting, during prepractice training, the concepts of lifelong learning. In their stead, or in addition to these traditional methods, our working group emphasizes workplace learning, which is based in the health care setting, uses data derived from actual performance to guide individual and group learning, and is supported by information technology applications such as computerized decision support systems. In a workplace learning-focused system, UME and GME educators must employ interprofessional strategies; that is, team members from a variety of health disciplines learn together in order not only to apply new knowledge and improve the quality of care but also to align curricula and teaching methods with practice realities such as informatics, clinical practice guidelines, and computerized decision-support systems. The call for training clinicians to be well prepared for practice has also prompted questions about the degree to which current educational systems for practicing health professionals (not just trainees) truly support the efforts of the clinician–learner. (Specialty societies and certifying boards, lending valuable educational support to practicing clinicians, may be exceptions.)
The competency of lifelong learning or knowledge management, highly important to CME, includes an appreciation and understanding of evidence-based medicine (EBM).11,12 EBM encourages learners to develop skills in formulating clinical questions, searching for and finding answers, applying critical appraisal techniques, and evaluating the impact of new knowledge. Further, the practice of EBM requires competence in numeracy (i.e., the ability to grasp and convey statistical concepts such as the number needed to treat and the difference between relative and absolute risk).
The need for better evidence: More robust, more useful, more accessible
A further consideration in CME is the nature of the evidence or knowledge transmitted. What forms of knowledge exist? Which of these forms are most readily available? To what extent is knowledge subject to bias? Are academic medicine faculty trained to understand the variability of diverse knowledge products and to grasp issues relevant to their validity?
The forms of knowledge.
Some of the many challenges in the production and use of available clinical evidence are the sheer volume of literature, its varying quality, and its many formats. Although knowledge exists in many forms (e.g., tacit versus explicit, propositional versus procedural), our working group limited our discussion to the concept of “evidence-based knowledge.” This construct encompasses a large number of clinical experiences and individual studies that clinicians read, digest, and internalize, thus forming a foundation on which they make most clinical decisions. Evidence-based knowledge also arises from a smaller number of systematic reviews that are based on comparable studies of robust randomized controlled trials, either with or without observational studies. Further, well-designed clinical practice guidelines provide thorough reviews of evidence that is linked explicitly to the strength of recommendations for which all stakeholders (care providers as well as patients, for example) have provided input.13 Tools (e.g., patient education materials, quality measures, and reminders for practicing physicians) that enable the integration and expression of this knowledge are, however, often lacking.12
The possibility of bias.
Many consider the question of bias induced by commercially supported CME to be a major issue in U.S. medicine.14 In response, the Accreditation Council for Continuing Medical Education has required faculty members to disclose conflicts of interest and has required CME planners both to ensure valid content and to manage possible conflicts.15 Nonetheless, problems persist both in the presentation of new information in traditional CME formats (such as lectures) and in the process by which clinician–learners actively detect potential bias. Is the given disclosure sufficient? Would a different application of critical appraisal (such as clearly quantifying risks, benefits, and side effects and/or identifying study limitations) by teachers and learners lead to better, more appropriate health care? Would better-designed studies such as head-to-head trials of alternative interventions provide better evidence?
An ineffective CME delivery system?
The third component of a new model for CME involves changes to the educational “delivery system”—that is, the media and methods used to communicate information. Most health professionals and educators think of education in terms of a formal transmission of a predetermined body of knowledge—for example, the traditional, teacher-centered approach inherent in lectures and in printed materials and their computer-mediated counterparts. Although the teacher-centered approach may be useful in communicating some new information, educators have raised concerns about the impact of formal, didactic, noninteractive, classroom-style continuing education (the most common form of CME) on actual practice performance and patient health outcomes.6 However, this traditional method of delivery remains the primary mode of most formal CME efforts, a product of its relatively low cost, the comfort of both the CME presenter and participant, and a CME credit system that recognizes and rewards such participation.
A dysfunctional health care and regulatory CME environment
For the most part, the regulatory environment related to CME continues to reflect the belief that attending formal educational activities ensures physician competence. The medical boards and medical practice acts of most states—as well as the current, major interpretation of the Physician Recognition Award of the American Medical Association (AMA)16—strongly support the update model. These organizations and institutions maintain their support of traditional CME despite emerging changes that focus on performance, including new guidelines by medical specialty boards17 and changes within the framework of the AMA's Physician Recognition Award itself (specifically, the model for performance improvement CME has changed16).
The premise of the current, extensive organizational structure—that is, that CME participation leads to better patient outcomes—is based on the twin, somewhat doubtful assumptions that (1) physicians are able to self-diagnose and meet their learning needs, and (2) participation in formal CME automatically leads to increased professional competence. CME as it now stands—that is, not practice-based—does not include the expectation that physicians will effect improvements in their practices or in the clinical care of patients. Thus, many physicians may perceive CME credit as simply a necessary requirement tied to licensure and certification, strangely unrelated to clinical practice or excellence.
The Academic Medicine Imperative
Physician educators and the academic medical enterprise: Gaps and challenges
Achieving progress in any of the four domains—readying learners, improving the evidence-based knowledge, enhancing the knowledge delivery system, and aligning the health care delivery environment—requires a dedicated and well-prepared faculty who can demonstrate competency not only in teaching EBM (including knowledge of the forms and levels of evidence, mastery of practice-based education principles, and an understanding of learning technologies) but also in the development, application, and testing of competency assessment methods that support lifelong learning and knowledge management skills. Progress also depends on each academic health center's capacities to embrace the continuum of medical education and to provide educational support for the clinician in practice. This shift in responsibility calls for the development of a faculty development process to achieve a better lifelong learner and possibly a better, “learning-centered,” health care system.18
A century ago, Flexner19 called for a reform in medical education, which led to the medical school of today, a university-based educational entity with a scientifically driven knowledge base. We argue for an extension of that construct to produce a seamless model of medical education from admission to retirement, integrating best evidence into clinical practice and preparing, assessing, and supporting the learner–clinician throughout his or her career. We argue, using the rubrics of the content, processes, and context of learning, for changes within the CME framework that require the full engagement of faculty and the academic medical enterprise.
The content of learning
The core of medical education—from learning basic anatomy during UME to applying new gene therapy techniques in a CME venue—is knowledge. Several basic principles (e.g., the appropriateness of study design and sample, the applicability to patient populations, risk/benefit profiles, congruence with the understanding of basic pathophysiology) are inherent in the development of this knowledge; however, faculty do not always completely appreciate these principles. To be able to prepare and support learners across the continuum, faculty members need a more complete understanding of the principles, practice, and teaching of EBM, and they must recognize the potential for bias in clinical medicine.11 Additionally, faculty members should engage more vigorously in the process of creating knowledge products, such as guidelines or accompanying patient educational materials, in order to help learners and practicing clinicians alike to apply the best evidence-based principles. Finally, the application of that evidence-based knowledge in practical, real-world settings aligns with the need for more robust, useful, and accessible evidence and with the call to incorporate practical quality and patient safety curricular elements across the continuum.20
The process of learning
Medical education must focus not only on the content but also on the process of learning, shifting from the delivery of information to the creation of a better clinician–learner. Examining the problem-based learning strategies used in UME21 and studying the Accreditation Council for Graduate Medical Education description of practice-based learning and improvement (PBLI) may help effect this realignment in CME.22
Although the literature points to, for CME, alternative formats and teaching methods beyond the standard lecture, tradition and culture have inhibited their uptake.23 These formats feature interactivity, simulations, audience response systems, small-group and individualized training sessions, sequenced learning, and multiple media techniques.24 Educational interventions beyond the conference model include academic detailing (i.e., educational visits by health professionals to practicing physicians) and cultivating local opinion leaders (i.e., educationally influential clinicians identified by their peers and trained to educate and improve care in their local communities or practice settings). Nontraditional education interventions also include point-of-care reminders, audit and feedback, and the use of information and communication technologies. Electronic health records offer not only the possibility of providing reminders and decision support systems at the point of care but also the potential for a seamless education-to-practice translational vehicle. Just as faculty members are not universally skilled in teaching quality improvement or EBM, they are not all ready to employ these new methods in educational venues, and thus medical educators must develop strategies and curricula for including these in faculty development. Albanese et al25 and Moores et al24 have described models in which practice settings have embedded such educational strategies, specifically reminders at the point of care and audit/feedback methods, and others have documented success with nontraditional strategies.26
The context of learning: The educational home
In the complex regulatory world surrounding CME and clinical practice, physicians express confusion about wide and varying expectations inherent in relicensure and recertification and about new formats of CME, which they often perceive as unrelated to direct patient care. The idea of extending the supportive environment provided by UME and GME programs serves as the genesis for an educational home for practitioners. We envisage the possibility of a “home” provided by the academic health center (i.e., the medical school of graduation and/or the teaching hospital that provided residency training).
The educational home, featuring several electronic and human elements, would offer the potential of resolving aspects of information overload. The physician could capture his or her learning, clinical performance, and quality reporting activities via electronic formats such as knowledge management systems and learning portfolios. Knowledge management systems facilitate searching the literature, retrieving and categorizing relevant results, and applying the findings to patient care, whereas portfolios act as repositories for acknowledging gaps in knowledge or practice that must be filled, for following competency-based test results and quality improvement initiatives, and for tracking other educational data and resources. A system with both knowledge management and portfolio elements provides both the “pull” of the clinician's motivation to learn and seek solutions to clinical problems and the “push” of external feedback or new or updated evidence.
Further, an educational home could also feature human resources, such as links to faculty members for consultation, ongoing learning relationships, and/or mentoring. Finally, from a programmatic perspective, the educational home offers an assessment tool, affording the opportunity to provide feedback to enable curricular modifications in UME and GME.
Assuming Responsibility: The Role of Academic Medicine, the Role of Faculty
Although many solutions to the problem of closing the clinical care gap and addressing the questions of CME are possible, some lie beyond the scope of this article. Well within its scope, however, lie answers in the purview of academic medicine. The answers are geared to increasing faculty engagement in the medical education continuum, and in the process, keeping physicians, including faculty members themselves, up-to-date. Full faculty engagement, however, cannot occur absent the engagement of the entire academic medical enterprise—medical schools, research institutions, and clinical settings.
Our working group achieved consensus regarding the importance of training and supporting a cadre of faculty to create a seamless, evidence-based curriculum across the continuum of medical education. The implementation of such a curriculum requires the further development of these faculty members as teachers, planners, and agents of change. We feel that four goals are essential to creating this seamless medical education continuum: (1) creating a better clinician–learner, (2) supporting faculty members as they engage and educate practicing clinician–learners, (3) extending the notion of an educational home beyond UME and GME to include practicing clinician–learners, and (4) pursuing a larger national dialogue about CME.
Recommendation #1: Creating a better clinician–learner
Educators in faculty development must be competent in facilitating the training of faculty in the practice, teaching, evaluation, and support of PBLI—including the competencies of, among others, lifelong learning, evidence-based practice, numeracy, and bioinformatics—across the continuum of medical education. Likewise, faculty development educators must also be competent in assessing the effectiveness of this training. The content of medical education can be optimized to prepare a better clinician–learner by increasing faculty members' focus on critical appraisal, EBM, quality improvement, informatics, knowledge management skills, and the attributes of lifelong learners. And the process of educating clinician–learners would include incorporating new clinical settings and practice-based teams into educational venues; identifying, as teaching topics, quality improvement and other issues related to practice; improving medical education by using more interactive and effective educational techniques; and identifying and using better evidence for clinicians and trainees.
Recommendation #2: Engaging and supporting the educational continuum
Leaders of academic health centers should provide adequate support—in the form of services, programs, resources, salary, and recognition—to faculty for academic careers focused on delivering medical education to practicing physicians and other health professionals.
Given both the current emphasis on UME and GME teaching and the lack of recognition and support for lifelong learners, faculty members and academic leaders in clinical, educational, and research environments must realize that a seamless, evidence-based curriculum requires not only alignment across mission areas but also real and ongoing work. Academic health center leaders must recognize that such an alignment requires the dedication of adequate time, space, and resources to the integration of CME and lifelong learning into the fabric of academic medicine.
Recommendation #3: Providing an educational home
All academic institutions should provide physicians with an educational home for continuous professional development. Continuous access to contemporary PBLI resources, programs, and communities should be a responsibility of each institution. The education home should support the continuum across UME, GME, and CME. The development of a platform for lifelong learning accessible by clinicians regardless of their stage of training or retraining is essential to the continuum of medical education. In an educational home, faculty members interact with learners at all levels, permitting those learners access not only to peer-reviewed, evidence-based learning resources and methods but also to a community of practice.
Recommendation #4: Pursuing a national dialogue
To promote best practices in patient care, outcomes, and safety, a summit to engage a variety of stakeholders who serve the public should be held. The summit would focus on CME, specifically on redirecting the CME process toward PBLI and on moving to outcomes-based CME. Stakeholders at that summit would provide ideas on how best to support capacity building and research. The educational and regulatory worlds of practicing clinician–learners require the involvement of many stakeholders external to the academic health center—among them, specialty societies, specialty boards, and licensing bodies. Given these institutions' extensive involvement in continuing education, we suggest involving their representatives in a national conversation on the subject of physician lifelong learning and CME.
We believe that the creation of a seamless, evidence-based continuum of medical education—and its support by an appropriately realigned academic medical enterprise—will assume the same importance, and achieve the same impact, as Flexner's report of the last century. Moving from a simplistic model of keeping up-to-date to an integrated system, linking the clinician–learner, best evidence, and the health care and educational systems carries the potential to effect improvements in the ways physicians achieve quality standards, deliver quality health care, and attain excellent outcomes for patients—all important components of the evolving health care system. Preparing physicians for lifelong careers that require learning new competencies could potentially lead to better integration of the tripartite mission of academic health centers.
Such a reformation comes at a cost, however; it requires the full engagement of many players, in particular the academic medical community and its faculty. To achieve an integrated system linking education at all points of the continuum with EBM and interactive teaching and learning methods, we recommend an active faculty development process to develop strong clinician–learners, the full engagement of academic health center leaders, the development of an educational home for clinician–learners, and a national, ongoing, meaningful conversation on the subject of CME.
The authors wish to acknowledge the Baylor College of Medicine leadership and staff for organizing and developing the 2020 Vision of Faculty Development Across the Medical Education Continuum conference.
Each author's institution provided travel and accommodation support for attending the 2020 Vision of Faculty Development Across the Medical Education Continuum conference, held February 2010. Further funding for conference participation, logistics, and follow-up was obtained from Baylor College of Medicine, the Josiah Macy Jr. Foundation, and the Medallion Fund.
A summary of the recommendations was presented to the attendees at the conclusion of the 2020 Vision of Faculty Development Across the Medical Education Continuum conference.