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Commentary |
aCell and Cancer Biology Branch, bOffice of the Director; National Cancer Institute, Bethesda, Maryland, USA
Correspondence: Correspondence: John E. Niederhuber, M.D., National Cancer Institute, Office of the Director, 31 Center Drive, Building 31, Room 11A48, MSC 2590, Bethesda, Maryland 20892, USA. Telephone: 301-496-5615; Fax: 301-402-0338; e-mail: niederj{at}mail.nih.gov
Received November 8, 2007; accepted for publication December 13, 2007.
Disclosure: No potential conflicts of interest were reported by the authors, planners, reviewers, or staff managers of this article.
Continuing medical education (CME) has been a mandatory part of the ongoing medical training of physicians in the U.S. since 1934 when the American Board of Urology formalized the education process for urology practitioners [1]. State licensure boards, specialty boards, and professional associations eventually followed with postgraduate educational requirements; their motivation was to enhance the physician's ability to care for the patient in the face of expanding scientific knowledge. New therapeutic modalities, new diagnostic and screening paradigms, innovative approaches to drug development and drug delivery, and the potential for new and innovative designs for clinical trials research will require a well-informed front line of expert caregivers, both in this generation of physicians and the next. Thus, the necessity for an effective career-spanning physician education program is indisputable.
Oncologists in particular, who are now practicing in a rapidly changing discipline with continued and significant knowledge gains still to be made (and vast potential for development of new technologies), will have a great opportunity to parlay new research developments into improved patient outcomes. Current investigations in the prevention, detection, and treatment of cancer, such as cancer stem cells and the importance of the tumor microenvironment, hold the promise of providing numerous opportunities for the translation of potential discoveries into practice. As we move toward highly characterized patient tumors and the pharmacogenetically defined patient, the oncologist of today and of tomorrow will be challenged to provide highly specific treatment solutions rather than the more empiric approaches used today. Now, perhaps more than ever, the rapid pace of discovery leading to an exponential expansion in our understanding of the complexity of the diseases we call cancer requires the practicing oncologist to essentially be in the classroom every day. The hand-held computer will be in the jacket pocket, on an even greater footing than the stethoscope.
The CME system developed for the continuing education of practitioners has its critics. Data compiled by the Commonwealth Fund have shown that, despite leading the member nations of the Organization of Economic Cooperation and Development in per capita health care expenditure, the U.S. lags in key outcome areas. The U.S. performs worse than the median in mortality for chronic respiratory diseases, and in potential years of life lost as a result of malignancy, diabetes, diseases of the circulatory system, and others [2]. While some of this may be attributed to patient access, physician performance has also been implicated in poor outcomes. For example, a study evaluating treatment delivered in comparison with recommended care for 30 acute and chronic conditions and preventive care showed that only 54.9% of recommended care was delivered to patients for their conditions [3].
As the overall intent of CME is to deliver the most current treatments and evidence-based medicine to patients, it is then alarming to find that regular participation in CME does not necessarily translate into appropriate changes in practice. While the assessment of the efficacy of any educational intervention is complex, studies have shown that, in spite of CME intervention, evidence-based health care delivery goals have not been met. A recent meta-analysis by Mansouri and Lockyer [4] showed that, while CME participation had a moderate effect on physician knowledge, the impact lessened when physician performance was evaluated, and it diminished further on assessment of patient health outcomes.
While these statistics are certainly worrisome, the outlook does improve upon further analysis. The efficacy of CME ranges significantly, depending on the type of intervention used. For example, hands-on interactive teaching methods, longitudinal workshops where the teaching takes place over a number of sessions, small-group instruction, specialty-based single discipline learning groups, as well as other variations to traditional didactic instruction significantly improved CME efficacy in three areas evaluated [4]. As any medical student, resident, or attending physician can observe, most everyone learns from bedside experience and problem solving. Therefore, rather than narrowly focusing our CME educational efforts on making incremental adjustments to the didactic instructional methods that have generally fallen short in translating knowledge into practice, we need to expand current instructional strategies in ways that enhance the learning experience for medical professionals as well as take into account the learning habits of a new generation of physicians.
The organizations most concerned with the continuing education of physicians, namely, those requiring CME participation for membership or certification, can play an important role in helping physicians to take advantage of the types of learning activities best proven to achieve results. A first step in getting there is to provide the initial impetus for learning. The ready availability, for example, of relevant, evidence-based practices as a standard against which physicians can measure their own practices and outcomes through the websites of the various governing bodies and specialty societies can help a practitioner to identify areas that may need improvement. Discussion from the same sources emphasizing a mixture of passive and active learning opportunities, as well as the evidence backing this style of learning, can help inform the motivated learner about the most appropriate tools for reaching his or her goals.
A web-based interaction, in addition to offering the opportunity to provide just such tools to all physicians, also represents a step in the evolution of CME. The upcoming generation of physicians has been accustomed to looking to the Internet as a resource for nearly everything, especially information. Current online learning interventions that have been based on the learning strategies proven to be successful in the live setting (i.e., interactive, patient-based, small-group discussions along with the more traditional didactic offerings such as grand rounds) have been shown to be equally or more effective in increasing physician knowledge and changing physician behavior as the most efficacious live offerings [5]. Having these learning opportunities readily available on websites where physicians are likely to go for information—those run by specialty societies or professional journals—offers convenience for the physician and ensures rapid, efficient delivery of the most effective interventions. Online CME holds the additional advantage over live interventions in giving the learner the opportunity to get information at the time the need is identified. In the future, a physician can see that a patient on the schedule has a particular diagnosis. Having been educated on a laptop computer as many students are today, the physician can access a CME platform on the subject that has been prepared or certified by a professional association or licensing board. A tutorial on practice standards and case study discussions on approaches to the problem will prepare the physician to see the patient. Furthermore, the physician has an opportunity to quickly put what has been learned into practice—a built-in, self-directed, hands-on experience—thus reinforcing the lesson. This would have an immediate impact on physician behavior and, depending on the validity of the practice standards, an impact on patient outcomes as well.
In the present, such platforms are not ubiquitous, and perhaps it is not the first instinct of all practitioners to go to the Internet for learning. We have the opportunity to bridge the gap to that future while improving current practice. Promoting or embarking on the design of web-based education strategies, informed by the research on optimal teaching methods discussed above, can help provide the reliable platforms needed to realize the future of CME. Providing the impetus to current physicians to use online education, through information on the efficacy of online learning and workshops to enhance comfort with current technology, will improve its present position.
CME still provides a great opportunity to engage physicians during their practicing years. By adapting this system to take advantage of the newer learning models and technological advances, we have the best chance to prepare ourselves and future physicians for the research-driven transformation of the practice of oncology.
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