Middle East Journal of Family Medicine

Do other classroom activities change primary care physicians' health care practice?
..........................................................................................................................

1st Author:
Dr.Abdul Sattar Khan
MBBS, MPH, MCPS (FM), FRIPH (UK)
Specialist Trainer,
Post graduate Centre for Family Medicine,
Ministry of health. Riyadh, Saudi Arabia

2nd Author:
Dr. Mohammed Al-Doghether
MD, DPHC, SBFM, ABFM
Director & Consultant,
Postgraduate Centre for Family Medicine, Ministry of Health. Riyadh, Saudi Arabia

3rd Author:
Dr. Dr. Abdul Mohsin Al-Tuwijri
MD, DPHC, SBFM, ABFM
Consultant Trainer,
Postgraduate Centre for Family Medicine, Ministry of Health. Riyadh, Saudi Arabia

Address for correspondence:
Dr. Abdul Sattar Khan
P.O.BOX: 220856,
RIYADH 11311,
RIYADH, SAUDI ARABIA
Tel # 00966-1-508972723
drsattarkhan@hotmail.com
drsattarkhan@yahoo.com
..........................................................................................................................

ABSTRACT

The objective of this review is to highlight the importance of continuous, flexible and practical forms of medical education. It is very clear that basic and medical sciences are expanding exponentially, thus it is impossible for any medical doctor to be aware of all the new technology and knowledge in this field. The physicians themselves cannot appreciate their needs sufficiently to maintain a base of current medical knowledge. Therefore, all physicians should be encouraged to improve their medical knowledge and skill by means of continuous medical education (CME), but the question is how?

The studies demonstrated that there is very weak effect of formal CME activities on physician's performance depending upon the methods of those activities .It is also stated that didactic CME modality has little or no role to play, however informal types of CME activities have their own impact.

Thus, it is suggested that learning should not be confined with boundaries and it should be continuous, flexible and practical (Continuous Professional Development-CPD), allowing physicians to choose from a menu of learning formats after having identified which style best suits them.

Key words: CME, CPD, Physicians practice, Tomorrow's doctors, Recertification
..........................................................................................................................

The history of the medical profession itself has documented high levels of error, far higher than other industries tolerate. All payers, either governmental or private have focused on unnecessary care and unmanageable costs. Novel techniques and practices to address these problems need to be developed. Indeed, it is developed but not in full and it has not able to produce any change so far1. Continuing study was suggested as far back as 1786 as one of the solutions of problem as to how to handle the exponential growth of medicine. The Dean of Harvard Medical School explained the need for CPD in 1947 by saying: "The rate and magnitude of publication. Indeed, probably half of what you know is no longer true, but what troubles me more is that I don't know which half it is."2

Continuing medical education (CME) is but one component of Continuous Professional Development and is traditionally viewed in terms of knowledge update - extremely important for doctors working in specialties where the knowledge base is expanding rapidly. However, there is a range of other academic, vocational, and professional activities that are essential for effective practice. There is no sharp division between continuing medical education and continuing professional development, as during the past decade continuing medical education has come to include managerial, social, and personal skills, topics beyond the traditional clinical medical subjects. 3, 4

Learning needs assessment is a crucial stage in the educational process that leads to changes in practice, and has become part of policy for continuing professional development. Learning needs assessment can be undertaken for many reasons, so its purpose should be defined and should determine the method used and the use made of findings. Exclusive reliance on formal needs assessment could render education an instrumental and narrow process rather than a creative, professional one, whereas didactic lectures, which are a familiar part of undergraduate medical education, are not effective in changing doctors' behavior. New techniques have therefore been developed to facilitate learning. Although many physicians participate in these activities, it is not clear how effective they are for individual physicians. 5, 6

Approaches to learning and complex interaction of the environment, personal factors, and opportunities are known to affect undergraduate learning. The work place is promoted as a deep approach to learning. The achieving approach to learning (competitive and focusing on achieving high grades) found in university students was not evident in the workplace and surface approach to learning (rote memorization, lack of understanding) divided into surface rational (feeling overwhelmed by work) and surface disorganized (preference for order, detail, and routine) approaches. Doctors value educational time away from their clinical practice to reflect and to make social and informal professional contact. An important aspect of CPD is the discussion obtained outside the lecture theatre, known as the "corridor effect," or over coffee or a good meal. It is possible that politicians and managers are missing the point. CPD should also provide recharging of the batteries; by allowing doctors time to discover and fulfill learning needs, increase job satisfaction, improve performance, and increase self-esteem. 7, 8

Problem based learning is perhaps the most effective but least recognized learning method of CPD. It may comprise problem-solving, feedback through investigation results, specialist opinions, observation, reflection, on difficult cases, discussions of critical incident, and education by patients. New cases should be more than repetitions of previous scenarios and doctor should avoid becoming "comfortable" with their deficiencies in a particular area. Acknowledgement of problem or work-based learning may promote self-awareness of such "blind spots". 9 Evidence- based medicine (EBM) is a style of practice in which doctors manage problems by reference to valid and relevant information. Unfortunately, research consistently has shown that clinical decisions rarely are based on the best available evidence. 10

QA is another of the acronyms increasingly used in health care however many of the principles of quality assurance are derived from industry and business, which has resulted in an increasing emphasis on measuring performance and outcomes, but not always that which comes from having experience of the "coalface" on the ward or clinic. 11 To use the political jargon, sustainable development should be planned for new future generations of doctors rather than outcome measure oriented physicians.

In its updated publication Tomorrow's Doctors 12 the General Medical Council, U.K, recommends that undergraduate curriculums should "foster the knowledge and understanding, attitudes and skills that will promote effective lifelong learning and support professional development." CPD should be allied to CME to ensure that "high levels of clinical competence and knowledge are maintained." CPD should be initiated at the undergraduate level in the areas of critical appraisal, healthcare ethics and the law, self-directed problem based learning, communication skills, and information technology skills. In addition, skills should be developed in teaching, research, management, interviewing, and committee work, recognizing that future working conditions may be based on changing condition, flexible employment, fixed term contract, a life long learning society.

Approaches differ widely around the world, but most rely on professional self-regulation. Increasingly there are common features between specialties and across borders and recognition of such between national and international bodies. Whatever system adopted or legislated, however, every doctor has a personal responsibility to participate in continuing professional development and has a choice of a wide range of accredited educational activities to fulfill that responsibility. 13, 14

Most of the developed countries are using an hours based credit system to quantify educational activities15, in which one hour of educational activity equates to one credit. Different countries have either three or five year cycles, and the number of credits required varies from 50 to 100 per year. Other countries are considering introducing an hour's based system, but there is much debate as to whether this system of accumulating hours of educational activity is a valid measure of such activity. Changes in behavior or outcome measures are more valid, but their objective measurement is difficult. Some examples are;

Designing behavior change programs and evaluating their effects on patient care has been a persistent challenge in research on continuing medical education. The challenge becomes even more complex when we aim to change behaviors that are interactive and highly influenced by the formal and informal institutional context. A legitimate concern is that many physicians will fail to recognize new and necessary changes in practice and patient care will suffer as doctors become outdated and their performance deteriorates over time.

Physicians perceived CME events as beneficial. Confidence levels rose, and the events provided a break from practice that refreshed and relaxed, thus indirectly benefiting patients. As part of a an assessment of the attitudes of general practitioners to continuing education depicted that almost all the respondents (99%) agreed that commitment to CME is lifelong 16

Nevertheless, other study 17 revealed that few responders identified major changes in their practice as a result of formal CME events, and information was seldom disseminated among practice colleagues. The results of this study challenge educators who claim that CME has its own impact on quality of care! But there is another approach which was evaluated by Daly MB et al 18 that is, Academic detailing in the office of physicians might be fruitful.

A study 19 discovered that more than two-thirds of the studies (70%) displayed a change in physician performance, while almost half (48%) of interventions produced a change in health care outcomes. Community-based strategies such as academic detailing (and to a lesser extent, opinion leaders), practice-based methods such as reminders and patient-mediated strategies, and multiple interventions appeared to be cost effective activities. On the other hand, it is also observed 20, 21 that the Internet-based intervention was associated with a significant increase in the percentage of high-risk patients treated with pharmaco-therapeutics according to guidelines (pre-intervention, 85.3%; post-intervention, 90.3%; P = .04). Mixed results and weaker outcomes were demonstrated by audit and educational materials, while formal CME conferences without enabling or practice-reinforcing strategies, had relatively little impact.

Many CME providers have difficulty defining the nature of the outcomes, much less documenting the outcomes for which they are responsible. The vague nature of the terms "outcome," "impact," or "result" in the complexity of health care and medical education environments is a particular obstacle to many education providers. To overcome these barriers, there was model created to identifying major domains of possible outcomes for CME interventions; these are the domains of individual participants, employee teams, the larger organization, patients, and the community. These domains are useful in either assessing a single CME activity's outcomes or comprehensively assessing a CME provider's outcomes-assessments strategy. While a few studies22, 23 showed that there was no relationship between global quality-of-care and quantity of the physicians' formal CME activities. 24

Differences in the sources of information that physicians utilize in their practice have several implications for the quality of care delivered and the dissemination of medical information. It is also observed that primary care internists have a greater preference for consulting the medical literature, while family physicians more often rely on colleagues and specialists as sources of information. 25, 26

These differences suggest that the focus of information dissemination through journals or textbooks may be more effective for internists, while colleagues or "educationally influential" physicians in the community may be more effective vehicles for information dissemination to family physicians. Thus general practitioners are generally satisfied with the different CME courses; however, they would have preferred a greater emphasis on informal tutorials rather than formal lectures, and practical procedures rather than recent advances in physiology and neonatology. 27

Since primary care is the essential foundation in effective health care systems, it follows that providing evidence-based primary care would reflect positively on the community's health28 Text showed that respondents of many studies mainly welcomed EBM and agreed that its practice improved patient care. But they had a low level of awareness of extracting journals, reviewing publications and databases, and even if aware, many did not use them. Only 16% had access to bibliographic databases and 10% to the worldwide web. The respondents showed a partial understanding of the technical terms used in EBM. The major perceived barriers to practicing EBM were patient overload and lack of personal time. Respondents thought that the most appropriate way to move towards EBM was by learning skills of EBM (43%), followed by using evidence-based guidelines developed by colleagues (37%). Hence these results emphasized that teaching all the primary health care physicians (PHCPs) literature searching and critical appraisal skills29 by feasible and friendly methods should be considered. But there are few areas where physicians still are feeling lack of skill and even lack of information and communication.30 The literature emphasizes unstructured time should be included in formal CME which is perceived as crucial in aiding the process of applying knowledge to practice.

Thus learning should be continuous, flexible and practical (Continuous Professional Development) and allow recognition and application of new evidence and ideas and enable the development of new skills. It should be supple and allow doctors to choose from a menu of learning formats after having identified which style best suits them. Ultimately, in an evidence-based culture the ideas put forward need to be evaluated to ascertain the clinical effectiveness of Continuous Professional Development.

Clearly, too, a single training model could not be designed to fulfil all needs of such a diverse group of specialties and staff, and it will need to be able to take on a "select and blend" approach to their professional development, depending on their particular needs. The opportunities provided by formal events for informal learning and exchange of ideas, with peers in general practice are highly valued. The relevance of the subject to practice, and the suitability of the educational format, was considered paramount importance. In addition, resources and people are required to drive the process; otherwise Continuous Professional Development may become a "great aspiration" of politicians and managers rather than a reality.