Virtual Journal Club – Celebration of the Decades

In coordination with SACME’s upcoming 50th anniversary, a special series of Virtual Journal Clubs have featured seminal articles of each decade. What follows is a very brief summary of the first three sessions in the series. SACME members may access the complete recordings for each session which can be found at SACME.org/VirtualJournalClub.

1970s: The Early Days of CME Scholarship

1980s: How Physicians Learn and Changes

1990s: Does CME Work?

Looking back to the 1970s, Don Moore provided a contextual frame as he kicked off the first Virtual Journal Club (VJC) in the five-part series of Celebration of the Decades. The learning objectives outlined for this session were as follows:
• List factors that were contributing to changes in CME and its environment in the 1970s
• Describe the bi-cycle approach of Brown and Uhl (JAMA, 1970) and Brown and Fleisher (NEJM, 1971)
• Discuss how to use this bi-cycle approach as one way to design and offer performance improvement CME/CPD

Don described the key factors that called for change in medical education during the period leading up to the 1970s which included: 1) Concern about the quality of health care and CME; 2) Oversight of health care and regulation of physicians; and, 3) Developing communications and computer technology. Do those sound familiar?

This session primarily focused on a review of The Bi-Cycle Approach which was influenced and developed by critics of the traditional form of CME, whereby topics were determined by faculty and delivered in lecture format (with little opportunity for interaction). George Miller was a serious critic of this educational planning process, as it was not considered to be an effective means to change physician behavior. Rather, George and his colleagues proposed that learning be linked to problems encountered in a physician’s practice.

For those in CPD who work with PI/QI initiatives, the two cycles in the model will appear strikingly familiar. The two cycles are:
• A patient care evaluation / audit that identified deficiencies in the physician’s practice
• An improvement cycle which was designed to correct the deficiencies.

In the Brown and Eul model, the focus was initially centered around a CME activity. In later renditions of the model, of which there were several, it became appropriate to envision almost any kind of intervention (formal or informal) that would help a physician improve their practice.

Don briefly displayed the graphic from the original article outlining the Bi-Cycle model during the VJC. It was complex, the labels in the model did not align with the descriptions, and it is not easy to decipher or translate into action. For that reason, and presumably for the purpose of this VJC discussion, Don developed a modified graphic as a means to map out how the concepts of the Bi-Cycle approach relate to physician practice.

The VJC ended with a brief reference to what constitutes a seminal article. It did not appear that the three articles which served as the springboard for this discussion drew nearly the level of interest that one would have expected (or hoped). Perhaps that says more about how the field of CPD scholarship needs to broaden its lens, as opposed to suggesting there is a lack of interest in leveraging the power of education as a link to PI/QI.

On that note, I will add….Don is currently working with a team of SACME volunteers and a reference librarian at Vanderbilt Medical School to spearhead a special project that will involve bibliometric analysis. This analysis will allow us to reveal what the relationships are across published works in the field of CPD. Perhaps that will contribute to our understanding of what constitutes a seminal article. It is not too late to join in on this effort. If you wish to volunteer, please contact ____________

Notably, this VJC involved a discussion of concepts from published work that appeared more than 50 years ago. Some aspects of the critique made me question how we might define our current view of “traditional CME”. There is no time like the present to reflect on our ability to consistently advance impactful education. It is painfully clear to me that too many CPD offices struggle to consistently demonstrate how they are able to contribute to PI/QI initiatives that align with workforce and/or organizational priorities.

Summary generated by: Ginny Jacobs, PhD, M.Ed, MLS, Chief Editor, CE News

The 1980s Celebration of the Decades VJC featuring Robert Fox (and Friends) involved a reflective look back at what has been labeled “The Change Study”. It summarized the fascinating research project coordinated through the Society of Medical College Directors of Continuing Medical Education (the group we now lovingly know as SACME).

The premise of the project was to understand how learning relates to change in order to better design education to facilitate the necessary shifts in physician behavior. Robert described how the study was created with a two-fold purpose:
1) Develop a theory of how/why doctors learn and change their practice
2) Create a movement toward thinking of ‘learning’ rather than ‘education’
This unique study involved a group of 40 members of the Society (as principal investigators, writers, data collectors, etc.) from across 24 universities. The findings were drawn from qualitative analysis of interview data systematically gathered from 340 physicians. The analysis examined a solid dose of real life medical practice, as told by physicians through 775 stories of change.

Robert highlighted how this study was an example of how research can change practice. It offered a framework for conceptualizing continuing education and he believes it changed the way CME was perceived, eventually leading to the notion of making a distinction between CME and CPD.
Robert emphasized how “culture is the fabric of meaning in the world” and language is the most important part of culture. There was an obvious need to create a culture in SACME and what better way than to study this complex learning and change phenomenon and complete this project able to say “I now know what CME means”. I appreciated the analogy Robert shared when describing CME as the programs we put on (a side dish, if you will), whereby CPD encompasses the entire cadre of activities which learners engage in to become better doctors (“the whole diet”).

The study suggested that a qualitative approach to discovering variables of lifelong learning may be more productive than the traditional quantitative and correlational approaches.

Conclusion:
Interestingly, the triggering event for this study was the publication of an article in the NEJM that argued (enthusiastically) that CME had no effect, no impact. Understandably, that created what was described as “an existential crises within the field”. If the NEJM says CPD is no longer relevant, how long do we have before we expire?

Have we successfully moved past that threat (some 40+ years later)? I suspect the conversation of relevance and impact sparks a familiar tone in today’s CPD community. Have you participated in discussions of CPD’s Return-on-Investment (ROI)? Is that the best (and possibly only) lever that works when striving to maintain critical funding from your institution’s leadership? Are we able to convincingly make a case for how CPD does make a positive difference?

In terms of an on-going field of CPD study, Robert stated this study should be labeled “the first change study” and not THE change study. We as a field should acknowledge the importance of steadily pursuing the ‘how’ and ‘why’ of change in today’s healthcare system.

It was evident from the many colleagues who were on the call that this earlier research initiative promoted a strong sense of community. Many of the professional connections and friendships that were formed through the Society have withstood the test of time. That is a testament to the power of a member organization – one that assembles a team of dedicated professionals with a clear sense of purpose.

Summary generated by: Ginny Jacobs, PhD, M.Ed, MLS, Chief Editor, CE News

The featured article which appeared back in 1998 concluded that strategies which enable and/or reinforce appear to “work” in changing physician performance or health care outcomes. That finding has had significant impact on the delivery of CME, and has also prompted further research into physician learning and change.

Drawing from that discussion, Dave Davis spends this virtual journal club reviewing the changes CME underwent in the 1990s to make it more effective. Both then and now, the primary CME activity created was the didactic lecture; however, in the 1990s, there was an increasing realization that lecturing alone was insufficient to change behavior ultimately. It was a good way to disseminate knowledge, but since the ultimate goal of CME is to improve patient care by changing behavior, it was falling short of its objective.
Two significant changes in education that started in the 1990s are still evident today.

1) Problem-Based Learning – using case-based education, which was facilitated by non-experts, to improve clinical reasoning

2) Evidence-Based Medicine – This decade ushered in the start of using evidence that was statistically meaningful and applicable to the current situation to direct patient care. The use of EBM required a deeper understanding of trials than case series and prior experience and has resulted in statistical analysis becoming a cornerstone of medical education.

The timing of these changes also correlated with the broader use of the PRECEDE health educational planning framework

1) Predisposing Information given before an action
2) Enabling the in-the-moment reminder to initiate a change
3) Reinforcing Review the results of the training for changes

The use of this framework also led to the creation of additional workshops and skills-based training to facilitate behavioral change, as lecturing alone addressed only the predisposing aspect of the model.
Despite the many headwinds currently altering medical education, Dave Davis closes with a statement worth repeating: “This is a difficult time for us, in healthcare and in education, but I think this is the time for us to do something big.”

Summary generated by: Raghav Wusirika, MD, Associate Editor, CE News