Wednesday, July 22, 2015

CME, Industry and Outcomes

Recent medical literature describes the challenges of demonstrating the impact of CME on physician learning (with a focus on the lack of impact), and the need to reform the current system.  Writers suggest that it really is not having the impact that it should, given the financial resources provided.  Others have questioned how it is funded, suggesting that it may be biased given the resources provided by industry, and that it should be changed. 

While I admit my own bias as an Associate Dean for CME for a major medical school, I feel that it is important to study the peer-reviewed literature to best understand this important topic.

First, is the industry influence really that significant?  A piece by Cervero discusses this, and found limited evidence of the impact of industry influence on CME.  In the recent ACCME 2014 report (Table 8), only 11% of accredited CME received commercial support from industry.  My interpretation of this is that the commercial support is certainly not an overwhelming part of CME programs (our own institutional data would definitely mirror this finding).

Second, what is the real impact of CME?  The same above author recently published a piece in JCEHP (full disclosure: I am the social media editor for this journal, but was not involved in any way in the creation, revision, or decision to publish this manuscript) that concluded that CME can indeed impact patient outcomes and physician behavior (the former more than the latter).

Third, improvements in how CME is disseminated should occur.  Within this realm, patients should be included, and interprofessional learning should occur in team environments; this is highlighted by the new President and CEO of the ACCME, Dr. Graham McMahon, in a Viewpoint piece in JAMA that came out online earlier this week.

So where should we go from here?  I think there are several things we can consider.  Most importantly, physicians and other healthcare providers should continue to learn in order to provide optimal care of their patients in a changing environment; CME is one way to aid this learning.  Those in the field have been thinking about how to restructure it for many years and have made major strides in focusing on quality improvement.  Second, we should also consider learning healthcare systems as a way to promote learning for those who provide care for patients.  Lastly, we should be diligent about using technology to make our learning more effective.  Examples include online journal clubs and virtual communities of practice.  Given the complexities that abound in medicine in the current environment, anything that can make the process of learning how to "keep up" and best care for our patients easier should be welcomed.  

Tuesday, July 14, 2015

Learning Theory vs Learning Approach

I had the privilege of giving a grand rounds presentation recently on the topic of lifelong learning in healthcare.  In the presentation, I discussed how adults learn within medicine, and reviewed literature on "adult learning theory".  Malcolm Knowles wrote extensively on the topic of Adult Learning, creating "principles of adult learning" also coining the phrase "andragogy" (as opposed to "pedagogy").

Others have questioned the concept of Adult Learning Theory, and have evidence to suggest that having one learning style is a misnomer.  In fact, an article this month suggests that, at the undergraduate medical education level, we should consider a focus on learning approach rather than teaching to a specific learning style.  Learners may not learn optimally with their self-proposed best learning style, and it is hard to say that a learner can learn with only one particular style.  See here  for a great review of this.

So what should educators do, given this dichotomy?   Should we focus on the content and a delivery style that "meets the needs of today's learners"?  Should it be about teaching the content to the learners, and nothing more?

In clinical medicine, where I spend most of my time, I do think it is critically important to focus on not just the content, but also the context in which that content is delivered.  Learning environment, sometimes referred to as learning climate, is critical to making the learning process successful.  It is the backbone upon which is built the process where ideal learning can take place.  Given the IOM description of the Learning Healthcare System, this is essential.  After all, where there is a healthy learning environment, there is an opportunity for all to learn with and from each other in order to provide the best care of the patients for whom we are privileged to care.