The prevalence and special educational requirements of dyscompetent physicians

Underperformance among physicians is not well studied or defined; yet, the identification and remediation of physicians who are not performing up to acceptable standards is central to quality care and patient safety. Methods for estimating the prevalence of dyscompetence include evaluating available data on medical errors, malpractice claims, disciplinary actions, quality control studies, medical record review studies, and in-stream assessments of physician performance. These data provide a range of estimates from 0.6% to 50%, depending on the method. A reasonable estimate of dyscompetence appears to be 6% to 12%. Age-related cognitive decline, impairment due to substance use disorders, and other psychiatric illness can contribute to underperformance, diminishing physicians' insight into their level of performance as well as their ability to benefit from an educational experience.Currently, dyscompetent physicians in the United States are identified through either the legal system or peer review. The primary method of resolving issues of underperformance in physicians is through continuing medical education (CME). Although a number of specialized assessment and education programs exist in the United States, these programs are largely underutilized. Similar programs exist in Canada and have provided evidence of the efficacy of a more specialized and individualized educational approach for underperforming physicians. Current specialty programs focused on this population employ individual assessments of knowledge and performance, individually designed educational programs, long-term plans for maintenance of educational activity, and repeated assessment of performance level. Noting that few CME programs offer these requirements, a number of changes to current medical quality assurance programs that might foster such educational requirements for underperforming physicians are provided.     

Interactive on-line continuing medical education: physicians' perceptions and experiences

INTRODUCTION: Although research in continuing medical education (CME) demonstrates positive outcomes of on-line CME programs, the effectiveness of and learners' satisfaction with interpersonal interaction in on-line CME are lower Defined as faculty-learner or learner-learner interpersonal interaction, this study explores physicians' perceptions of and experiences in interactive on-line CME and factors influencing these. METHODS: Focus groups and interviews were undertaken by three Canadian universities. Using purposive sampling, we recruited physicians based on their experiences with interactive on-line CME. Content analysis was applied first, followed by a comparative analysis to confirm themes and findings. RESULTS: Physicians based their perceptions of interactive on-line CME by comparing it with what they know best, face-to-face CME. Although perceptions about access and technical competency remained important, two other themes emerged. The first was the capacity of on-line CME to meet individual learning preferences, which, in turn, was influenced by the quality of the program, the degree of self-pacing or self-direction, opportunity for reflection, and educational design. The second was the quality and quantity of interpersonal interaction, which was shaped by perceptions of social comfort, the educational value of interactions, and the role of the facilitator. Prior experience with on-line CME moderated perceptions. DISCUSSION: The extent that on-line CME programs reflected characteristics of high-quality CME and individual learning preferences appeared to shape perceptions about it. It is important to incorporate the characteristics of effective CME into the design and implementation of interactive on-line programs, considering diverse learning preferences, providing faculty development for on-line facilitators, and grounding this work in learning theory.     

Methodology for targeting physicians for interventions to improve breast cancer screening

INTRODUCTION: Uneven increases in mammography utilization rates call for methods to efficiently target educational interventions to women who do not regularly use mammography and physicians who do not adhere to national guidelines for breast cancer screening. This paper discusses a method for identifying physicians who are nonadherers to breast cancer screening guidelines or in need of continuing medical education (CME) in this area. METHODS: A 1995 community-based telephone survey of randomly selected women aged 50-80, residing in four Long Island, NY, townships was used to identify women who underuse mammography and their regular physicians. Community-based surveys of physicians permitted identification of nonadherent providers. Nonadherence to breast cancer screening recommendations was the primary criterion, but because of anticipated physician reluctance to self report nonadherence with screening guidelines, additional criteria were developed to identify physicians with educational needs relating to breast cancer screening. These criteria included lack of office reminder systems and knowledge relating to breast cancer screening, and lack of confidence in patient counseling and clinical breast examination skills. RESULTS: Overall response rates were 77% for women's survey, and 66% for the physician survey. 3427 women were classified as underusers (38.5%) and 87% of underusers provided the name and address of their regular physicians. By physician self report, 45% of physicians were classified as nonadherers and 42% were identified as having related educational needs. CONCLUSION: A feasible method for identifying physicians who are nonadherers to breast cancer screening recommendations or in need of CME about this is described, permitting efficient targeting of educational interventions to those with patients who underuse mammography. The method is not dependent on access to a specific provider or patient population.     

The association between community physician's attendance at a medical center's CME courses and their patient referrals to the medical center

This study attempts to quantify an overall association between CME course attendance and referrals. Attendance at formal CME courses given by the University of Michigan Medical School and referrals to the University Hospitals were examined over a two-year period. Attendance and referrals were linked to physicians in Michigan identified through the Michigan Department of Licensing and Regulation and through the American Medical Association. For physicians who are office-based and likely to be in active practice (age less than 70), those who attended at least one of the University's CME courses referred more patients than those who did not attend one (means of 1.9 referrals per physician and 1.3 referrals per physician, p less than .001). The causal direction of the relationship is not clear, but probably operates in both directions. It is reasonable for medical center marketers to consider CME as an indirect method for marketing clinical services. It is also reasonable for CME directors to identify referring physicians as high-priority groups for marketing CME. Both marketing efforts may be significantly enhanced by linking data bases for referrals and for CME attendance. CME directors must also ensure that marketing efforts do not compromise the objectivity and integrity of the content of the institution's CME program.     

A community-based trial of an online intimate partner violence CME program

BACKGROUND: There is a broad need to improve physician continuing medical education (CME) in the management of intimate partner violence (IPV). However, there are only a few examples of successful IPV CME programs, and none of these are suitable for widespread distribution. DESIGN: Randomized controlled trial beginning in September 2003 and ending in November 2004. Data were analyzed in 2005. SETTING/PARTICIPANTS: Fifty-two primary care physicians in small (fewer than eight physicians), community-based medical offices in Arizona and Missouri. INTERVENTION: Twenty-three physicians completed a minimum of 4 hours of an asynchronous, multi-media, interactive, case-based, online CME program that provided them flexibility in constructing their educational experience ("constructivism"). Control physicians received no CME. MAIN OUTCOME MEASURES: Scores on a standardized self-reported survey, composed of ten scales of IPV knowledge, attitudes, beliefs, and self-reported behaviors (KABB) administered before randomization and repeated at 6 and 12 months following the CME program. RESULTS: Use of the online CME program was associated with a significant improvement in eight of ten KABB outcomes, including physician self-efficacy and reported IPV management practices, over the study period. These measures did not improve in the control group. CONCLUSIONS: The Internet-based CME program was clearly effective in improving long-term individual educational outcomes, including self-reported IPV practices. This type of CME may be an effective and less costly alternative to live IPV training sessions and workshops.     

Standardizing evaluation of on-line continuing medical education: physician knowledge, attitudes, and reflection on practice

INTRODUCTION: Physicians increasingly earn continuing medical education (CME) credits through on-line courses, but there have been few rigorous evaluations to determine their effects. The present study explores the feasibility of implementing standardized evaluation templates and tests them to evaluate 30 on-line CME courses. METHODS: A time series design was used to compare the knowledge, attitudes, and reported changes in practice of physician participants who completed any of 30 on-line CME courses that were hosted on an academic CME Web site and a CME Web portal during the period from August 1, 2002, through March 31, 2003. Data were collected at baseline, at course completion, and 4 weeks later Paired t tests were used to compare the means of responses across time. RESULTS: U.S. physicians completed 720 post-tests. Quality of content was the characteristic of most importance to participants; too little interaction was the largest source of dissatisfaction. Overall mean knowledge scores increased from 58.1% to 75.6% at post-test and then decreased to 68.2% at 4 weeks following the course. Effect sizes of increased knowledge immediately following the course were larger for case-based than for text-based courses. Nearly all physicians reported making changes in practice following course completion, although reported changes differed from expected changes. CONCLUSIONS: Increases in physician knowledge and knowledge retention were demonstrated following participation in on-line CME courses. The implementation of standardized evaluation tests proved to be feasible and allowed longitudinal evaluation analyses across CME providers and content areas.     

Workplace injury management: using new technology to deliver and evaluate physician continuing medical education

Objective: Physicians typically receive little continuing medical education (CME) about their role in workplace injury management as well as on workplace injuries and disease. Although new technologies may help educate physicians in these areas, careful evaluation is required, given the understudied nature of these interventions. The objective of this study is to evaluate two promising new technologies to deliver CME (online learning and videoconferencing) and to compare the effectiveness of these delivery methods to traditional CME interventions (large urban traditional conference lectures and small group local face-to-face outreach) in their impact on physician knowledge related to workplace injury management. Methods: This study utilized a prospective, controlled evaluation of two educational programs for BC physicians: 1) The Diagnosis and Management of Lateral Epicondylitis; and 2) Is Return-to-Work Good Medicine? Each educational module was delivered in each of four ways (Outreach Visit, Videoconference Session, Conference Lecture, Online) and physicians self-selected their participation—both in terms of topic and delivery method. Questionnaires related to knowledge as well as learner attitude and satisfaction were administered prior (pre-test) and following (post-test) all educational sessions. Results: 581 physician encounters occurred as a result of the educational interventions and a significant percentage of the physicians participated in the research per se (i.e. there were 358 completed sets of pre-test and post-test ‘Knowledge’ questionnaires). Overall the results showed that the developed training programs increased physicians’ knowledge of both Lateral Epicondylitis and the physician’s role in Return-To-Work planning as reflected in improved post-test performance when compared to pre-test scores. Furthermore, videoconferencing and online training were at least as effective as conference lectures and instructor-led small group outreach sessions in their impact on physician knowledge. Conclusions: Use of effective videoconferencing and online learning activities will increase physician access to quality CME related to workplace injury management and will overcome access barriers intrinsic to types of CME interventions based on instructor-student face-to-face interactions.     

Physician Internet medical information seeking and on-line continuing education use patterns

INTRODUCTION: Although physician Internet use patterns have been studied, little attention has been paid to how current physician learning and change theories relate to physician Internet information seeking and on-line learning behaviors. The purpose of this study was to examine physician medical information-seeking behaviors and their relevance to continuing education (CE) providers who design and develop on-line CE activities. METHODS: A survey concerning Internet use and learning was administered by facsimile transmission to a random sample of 2,200 U.S. office-based physicians of all specialties. RESULTS: Nearly all physicians have access to the Internet, know how to use it, and access it for medical information; the Internet's professional importance to physicians currently is in the area of professional development and information seeking to provide better care rather than for patient-physician communication. A particular patient problem was the most common reason for seeking information. The credibility of the source, quick and 24-hour access to information, and ease of searching were most important to physicians. Barriers to use included too much information to scan and too little specific information to respond to a defined question. DISCUSSION: The importance of the Internet to physician professional development is growing rapidly. Access to on-line continuing medical education must be immediate, relevant, credible, and easy to use. A sense of high utility demands content that is focused and well indexed. The roles of the CE provider must be reshaped to include helping physicians seek and construct the kind of knowledge they need to improve patient care.     

Randomized controlled trials of continuing medical education: what makes them most effective?

INTRODUCTION: It is essential that professional standards of excellence are demonstrated in the continuing medical education (CME) curriculum and research. METHODS: This review examines 20 randomized controlled trial (RCT) studies in CME and their effect on physician performance and/or patient health care outcomes. A systematic evaluation of the 20 RCT articles was performed. The investigators of the trials were interviewed using a standardized interview schedule. Citations from science and social science publications were compiled to obtain an unobtrusive measure of the influence of the trials. RESULTS: Investigators were most often motivated to build on earlier research of others, their own earlier research, or a combination of others' earlier research and their own. The most effective educational strategies used multiple interventions, two-way communications, printed and graphic materials in person, and locally respected health personnel as educators. Statistically significant findings more often related to physician performance than to patient health care outcomes. The most effective studies were the ones in which the educational methods were cost effective, findings could be generalized to other physician groups, the studies were implemented elsewhere in multisite health care and health-related programs and had the most citations. Investigators interviewed about their RCTs provided advice for future directions of CME curriculum development and research. DISCUSSION: CME program directors should determine what physicians need to learn, should reach out to nonparticipating physicians, and should focus on relevant problem areas. These problem areas should be ones in which it is possible to make changes, particularly in patient health care outcomes.     

Teaching performance improvement: an opportunity for continuing medical education

Practicing physicians generally are not engaged in either the methods of performance improvement for health care or the measurement and reporting of clinical outcomes. The principal reasons are lack of compensation for such work, the perception that the work of performance improvement adds no value and is a waste of time, the lack of knowledge and skill in the use of basic tools for outcomes measurement and performance improvement, the failure of medical educators to teach these skills, and the inability of mentors to model their use in practice. In this article, an overview of the history of quality improvement or performance improvement in general and the adoption of two methods of improvement (Plan-Do-Study-Act and SIX SIGMA) by health care is given. Six simple tools that are easy to understand and use and could be used in every continuing medical education (CME) program are then explained and illustrated. Postgraduate medical educators and CME program directors must step up to the challenge of teaching these skills. By learning to include them in planning, evaluation, policy making, and needs assessments of CME programs, the skills of every physician could be improved. Additional goals of every CME program could be accountability for outcomes, reduction of errors, alignment of incentives, and advocacy for the very best in evidence-based health care. To develop activities that affect physician practice and population health, CME professionals must partner with performance improvement experts for needs assessment and evaluation of outcomes data. An understanding of performance improvement principles helps those in performance improvement and those in CME to determine which educational activities might be expected to influence physician competency and performance.     

On-site to on-line: barriers to the use of computers for continuing education

BACKGROUND: Continuing education/continuing medical education (CE/CME) programs that adopt self-directed, computer-based instruction formats via the Internet or CD-ROM can ease the demands placed on clinicians who are required by licensing boards to accumulate CE/CME credits as part of their career-long learning. Despite the benefits and availability of computer-based instruction, on-site programs still dominate current CE/CME delivery modes. In order to increase the use of computer-based CE/CME programs, it is important to identify the barriers that inhibit their use. METHOD: A survey was conducted to assess the practices, preferences, and barriers to use of CE/CME delivery methods among physicians, nurse practitioners, and physician assistants in Nevada. RESULTS: Of 3,213 surveys sent, 1,120 were completed and returned for an overall response rate of 35%. In-person conferences (93%) and print-based methods (66%) were the most frequently reported methods of acquiring CE/CME. The majority of respondents had access to computer-based technologies. Respondents with more years in clinical practice were less likely to have access to or to use computer-based technologies. The top three preferred CE/CME delivery modes, in rank order, were in-person conferences, print-based self-study, and CD-ROM. The least preferred method of receiving CE/CME was interactive audioconference (telephone conference calls). "Not knowing how" was the most frequently reported reason for not using the Internet for computer-based training and the second most frequent reason for not using a CD-ROM. IMPLICATIONS: Program planners may wish to offer training in new technologies during on-site conferences, provide CD-ROMs as take-home instructional materials, or promote technology awareness in other ways to help clinicians prepare for changes in the electronic delivery of health care and education.     

A continuing medical education lecture and workshop, physician behavior, and barriers to change.

BACKGROUND: Continuing medical education (CME) is undertaken with the intention that it will affect the practice of medicine at the level of choices made by individual physicians. Inherent in this effort is the assumption that CME is sufficient to effect a change in physician behavior. METHODS: To further examine the relationship between a CME activity and physician behavior, we conducted a study of behavior and barriers to change associated with a CME lecture and workshop on breast cancer risk assessment and treatment. Using the assessment of learning outcomes model of the International Association of Continuing Education and Training, we developed an instrument for assessing physician behavior and barriers to change. RESULTS: Throughout the United States and Canada, the instrument was administered on-site immediately after a CME activity implemented at 79 hospitals and cancer centers. It was administered again 6 months after the CME activity. There were 1,244 responses collected from 4,537 participants. This study reports the survey findings of 176 physician-paired responses to both the first and second waves of surveys. Some physicians changed their behavior with regard to performing risk assessments on all of their eligible patients. Ninety-two of the 176 physicians indicated that they had changed their practice regarding the use of tamoxifen therapy. Twenty-one physicians indicated that they were already using tamoxifen in their practice setting. Three influential barriers to change were identified: a lack of consensus among colleagues and peers, lack of time for assessment and patient counseling, and lack of reimbursement by the patient's insurance companies. FINDINGS: The CME activity was effective in changing the self-reported behavior of some physicians. Others attended the CME activity to obtain more information or to become more skilled about a procedure they had already implemented. Because of formidable barriers, it is unlikely that a single educational intervention will be sufficient to effect a change in the clinical practices of all physicians who participate in a CME activity.     

Continuing medical education, professional development, and requirements for medical licensure: a white paper of the Conjoint Committee on Continuing Medical Education

To provide the best care to patients, a physician must commit to lifelong learning, but continuing education and evaluation systems in the United States typically require little more than records of attendance for professional association memberships, hospital staff privileges, or reregistration of a medical license. While 61 of 68 medical and osteopathic licensing boards mandate that physicians participate in certain numbers of hours of continuing medical education (CME), 17 of them require physicians to participate in legislatively mandated topics that may have little to do with the types of patients seen by the applicant physician.Required CME should evolve from counting hours of CME participation to recognizing physician achievement in knowledge, competence, and performance. State medical boards should require valid and reliable assessment of physicians' learning needs and collaborate with physician and CME communities to assure that legislatively mandated CME achieves maximal benefit for physicians and patients. To assure the discovery and use of best practices for continuing professional development and for maintenance of competence, research in CME and physician assessment should be raised as a national priority.     

Place matters in physician practice and learning

Since the early 1960s, most discussions about the improvement of continuing medical education (CME) have begun by seeking a better understanding of how physicians learn. The goal of this movement has been to put physician learners and their learning needs, not new research findings, at the center of the educational process. This has led CME away from the update model of education and into many innovative and exciting educational developments. However, as the conditions of medical practice have been changing in the past 20 years, the possibilities and conceptions of CME have also changed. Many in medicine and CME now recognize that the real world of physician decision making takes place in a highly charged political-economic context, where the interaction between the patient and physician is perhaps the least complex element. From this fundamental starting point, an emerging discourse has begun in CME that addresses physicians' changing work environments, the accountability schemes and financial incentives built into medical practice, and the importance of physicians' community of peers in making practice changes. We need to build on these observations to change the focus from "how physicians learn" to "where physicians learn." From this new perspective, physician practice and learning are seen as fundamentally social acts, and our attention is drawn to all of the ways in which "place matters." Attention to where physicians practice and learn can be used to improve CME.     

Promoting physician preventive practices: needs assessment for CME in breast cancer detection.

Needs assessment for a continuing medical education (CME) intervention directed at increasing breast cancer screening of women 50 years of age and older included a survey of target primary care physicians (n = 370) to explore areas of interest for CME in breast cancer detection and to establish baseline screening practices. The survey was completed at community hospital department meetings or by mail with a response rate of 87% (n = 323). Strategies for enhancing response rate and participation in planning included involvement of local physician organizations, use of a focus group of physicians, and attendance at community hospital department meetings. Survey results indicated that the topics of greatest interest for CME included improving patient compliance, risk factors, and patient education. A total of 48% of physician respondents reported referring all their asymptomatic female patients 50 years of age and older for regular screening mammograms; 63% indicated that they perform breast examinations on all such women regularly. Physician concerns that were reported to influence physical breast examination or referral for mammography are discussed, as well as current use of related office systems (e.g., for recall reminders and/or breast self-examination instruction). The results of a survey of women in the target age group residing in the same community are also reviewed in terms of mammography utilization (e.g., the proportion who had a screening mammogram within the last year was 19%) and specific concerns about mammography. The lack of a doctor's recommendation was the most common reason given (45%) for never having had a mammogram. The uses of the data from both surveys for CME program planning are discussed, including the content and design of the programs, along with organizational aspects and strategies for enhancing attendance.     

Role of state medical boards in continuing medical education

The evaluation of physician competency prior to issuing an initial medical license has been a fundamental responsibility of medical boards. Growing public expectation holds that medical boards will ensure competency throughout a physician's career. The Federation of State Medical Boards (FSMB) strongly supports the right of state medical boards to require physicians to demonstrate continuing qualification for medical licensure. The FSMB views continuing medical education (CME) as an important component of any maintenance-of-competence initiative. Most medical boards require CME as part of their license renewal process. Learner-focused CME with measurable outcomes enables the medical profession's emphasis on core competencies, training, and assessment, and the general public's expectation for maintenance of physician competence. To effectively move their licensee populations toward the most effective CME tools and structure, medical boards must recognize physicians' educational needs and preferences. Medical boards can be proactive by fostering educational consortia involving medical boards, medical societies, and academic medical centers and featuring educational sessions that represent the best in current CME practices.     

Learning associated with participation in journal-based continuing medical education

INTRODUCTION: Medical journal reading is a standard method of increasing awareness among physicians of evidence-based approaches to medical care. Theories of physician learning and practice change have suggested that journal reading may be more influential at some stages of behavioral change than at others, but it is not clear how journal reading may influence the learning process that can lead to behavioral change. METHODS: A random sample of 170 continuing medical education (CME) participants who had read three journal articles and completed a CME evaluation form received a CME credit certificate with a brief survey appended. The survey asked participants to report their stage of learning on each article topic before and after reading the three articles. RESULTS: Of the 170 CME participants, 138 (81.2%) responded to the survey. Most (106 of 138; 76.8%) reported a progression in stage of learning on the topic of at least one of the three articles read for CME credit. More than one-fourth of the respondents (37 of 138; 26.8%) made a commitment to change practice related to the topic of one or more articles. CME participants were more likely (relative risk 1.14; 95% confidence interval 1.06-1.22) to report a progression in stage of learning if they had recorded a commitment to change practice related to the same article topic on the CME evaluation form. DISCUSSION: Journal-based CME activities may be educational at all stages of the learning process, and journal-based learning episodes may result in commitments to change practice.     

Continuing medical education in the United States: why it needs reform and how we propose to accomplish it

As the continuing medical education (CME) enterprise evolved over the last half century, a variety of rules, national and state regulations, and reporting requirements developed, with a resultant substantial variation in what is required of a physician. That CME needs fundamental reform is not news to those who read the literature. Yet many of the physicians who are served by the current CME system are comfortable with it. Following an initial report of the Council of Medical Specialty Societies, representatives of major stakeholders in CME met voluntarily over 3 years to explore, agree on, and finally propose changes to the present CME system. Their belief in the need for change and their recommendations achieved a collegial outcome; fundamental systemwide changes must occur in CME. This involves educational methods and physician performance, particularly in self-assessment. It also involves the leadership of organized medicine in accreditation, certification, credentialing, licensure, and credit recording, reporting, and funding. The multiple parties involved who control various aspects of CME agreed to focus on the physician end user and to create a revised CME system that would allow simplified and identical reporting of the CME experience and credits for individual physicians. The system also would offer a simplified and more rational approach to credit. Recommendations and action plans to accomplish the objectives were agreed on and have been assigned to organizations according to commitment and relevant historical interest.     

Provider Portrayals and Patient–Provider Communication in Drama and Reality Medical Entertainment Television Shows

Portrayals of physicians on medical dramas have been the subject of research attention. However, such research has not examined portrayals of interactions between physicians and patients, has not compared physician portrayals on medical dramas versus on medical reality programs, and has not fully examined portrayals of physicians who are members of minority groups or who received their education internationally. This study content-analyzes 101 episodes (85 hours) of such programs broadcast during the 2006–2007 viewing season. Findings indicate that women are underrepresented as physicians on reality shows, though they are no longer underrepresented as physicians on dramas. However, they are not as actively portrayed in patient-care interactions as are male physicians on medical dramas. Asians and international medical graduates are underrepresented relative to their proportion in the U.S. physician population, the latter by almost a factor of 5. Many (but certainly not all) aspects of patient-centered communication are modeled, more so on reality programs than on medical dramas. Differences in patient–provider communication portrayals by minority status and gender are reported. Implications for public perception of physicians and expectations regarding provider-patient interaction are discussed.