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Continuing Professional Development: Building and Sustaining a Quality Workforce

The health care system in the United States falls short of its goal of consistently providing the best possible care. The nation spends more on health care than any other country in the world—and too often receives care of mediocre quality that is too frequently unsafe. Actions taking place at the local, state, and national levels—most recently through the development of the White House Office of Health Care Reform—show some promise for providing greater access to safe, high quality care for all Americans. Such actions include promotion of systems improvement, measurement and reporting activities of health care processes and outcomes, public engagement, and realignment of payment systems. But these efforts typically overlook a critical piece of improving quality: developing and maintaining a reliable, properly trained health professional workforce. A well-educated workforce is critical to the discovery and application of health care practices to prevent disease, promote well-being, and increase the quality life-years of the public.

THE ROLE OF HEALTH PROFESSIONALS IN IMPROVING QUALITY

Health professionals serve as the bridge between patients, the knowledge generated by scientific research, and the policies and practices to implement that knowledge. As the recipients of care,



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1 Continuing Professional Development: Building and Sustaining a Quality Workforce T he health care system in the United States falls short of its goal of consistently providing the best possible care. The nation spends more on health care than any other country in the world—and too often receives care of mediocre quality that is too frequently unsafe. Actions taking place at the local, state, and national levels—most recently through the development of the White House Office of Health Care Reform—show some promise for providing greater access to safe, high quality care for all Amer- icans. Such actions include promotion of systems improvement, measurement and reporting activities of health care processes and outcomes, public engagement, and realignment of payment systems. But these efforts typically overlook a critical piece of improving quality: developing and maintaining a reliable, properly trained health professional workforce. A well-educated workforce is critical to the discovery and application of health care practices to prevent disease, promote well-being, and increase the quality life-years of the public. THE ROLE OF HEALTH PROFESSIONALS IN IMPROVING QUALITY Health professionals serve as the bridge between patients, the knowledge generated by scientific research, and the policies and practices to implement that knowledge. As the recipients of care, 15

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16 REDESIGNING CE IN THE HEALTH PROFESSIONS the public trusts health professionals to provide care that is safe, efficient, effective, timely, patient-centered, and equitable. The health professions covered by this report are those listed by the Bureau of Labor Statistics as “healthcare practitioner and technical occupations” with baccalaureate or higher degrees (see Appendix B). Examples of included professions are physicians, phy- sician assistants, dentists, dieticians, nurses, and speech-language pathologists. These health professionals undergo extensive formal education, followed by what has become known in the United States as continuing education (CE). CE lasts the duration of a health pro - fessional’s career and is therefore the model of learning that spans the longest period. It serves two functions: maintenance of current practice and translation of knowledge into practice. Educating professionals about new theories and evidence of what does and does not work, and under what circumstances, is one part of promoting the provision of better health care. Because individual learning styles differ greatly, innovative learning meth- ods are developed to help health professionals maintain their com- petencies. Over time, learning methods have evolved from a focus on professionals’ attendance at and satisfaction with a limited set of educational activities to a focus on demonstrably changing pro- fessional practice and improving patient outcomes. Better learning methods need to be developed continuously, as creating appropri- ate methods, processes, and contexts is imperative for professionals to provide the highest quality care possible. Health professionals also need to provide feedback to themselves and the system about what actually works in specific practice settings, as the common wisdom of what “should be” practiced continuously evolves. What is considered to be the best knowledge one day may later be found to be inadequate. Health professionals’ abilities to identify these instances and adapt is critical. With the development of the Internet and Web 2.0, the world of information has expanded at exponential rates—so much so that the breadth of information for which health professionals used to be responsible is now beyond the capacity of any one professional. On average, it now takes 14-17 years for new evidence to be broadly implemented (Balas and Boren, 2000). Shortening this period is key to advancing the provision of evidence-based care, and will require the existence of a well-trained health professional workforce that continually updates its knowledge.

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17 CPD: BUILDING AND SUSTAINING A QUALITY WORKFORCE TRAINING, EDUCATION, AND PROFESSIONAL DEVELOPMENT Lifelong learning is the notion that learning occurs along a con- tinuum, from elementary and secondary education to undergradu- ate and graduate education, lasting through the end of one’s career. There are several stages of learning, including training, education, and professional development. These terms are used somewhat interchangeably, but clear distinctions should be made due to their varying abilities to both promote and confine learning. Training often refers to the standardization of a process to yield similar results. Education refers to the process by which people learn to apply solutions to problems and adapt to new situations. Professional development transcends both concepts and includes areas such as self-directed learning, systems changes, and quality improvement; it teaches people not only how to apply solutions but also how to focus on actual performance and how to identify problems. Within this schematic, continuing education is largely teacher- driven, focuses on clinical education, and predominantly builds on education theory. CE often is associated with didactic learning meth- ods, such as lectures and seminars, which take place in auditoriums and classrooms. In theory, the purpose of continuing education is to update and reinforce knowledge, which should ultimately result in better patient care. But in practice, there often are conflicting ideas about the purpose of CE. Some health professionals see CE as a means to attain credits for the licensure and credentialing they need to practice their occupations. Employers often view CE as a way to keep staff up to date and to improve quality. Many regulators believe the purpose of CE is to maintain competence and improve quality. In recent years, a broader concept, called continuing profes- sional development (CPD), has been emerging that incorporates CE as one modality while adding other important features. CPD is learner-driven, allowing learning to be tailored to individual needs. CPD uses a broader variety of learning methods and builds on a broader set of theories than CE. CPD methods include self-directed learning and organizational and systems factors; and it focuses on both clinical content and other practice-related content, such as com- munications and business. Although CPD is a relatively new term to some U.S. health professionals, the term is used widely in Canada, New Zealand, and the European Union, including the United King- dom (see Appendix C). CPD encompasses more diverse learning formats than those in CE (e.g., clinical reminders and academic detailing, where practitioners learn about drug prescribing from noncommercial sources) (Davis et al., 2003), and takes place in more

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18 REDESIGNING CE IN THE HEALTH PROFESSIONS diverse settings, such as clinical settings. CPD can be defined as the system for maintaining, improving, and broadening knowledge and skill throughout one’s professional life. CPD is focused squarely on promoting effective practice, and is better positioned than other stages of learning to effect change because it occurs when profes- sionals are most likely to be aware of their needs. It also integrates content and educational design for individual practitioners in the practice setting. Given its narrower focus, CE can limit a health professional’s learning, as it does not seem to offer the broader opportunities for learning that CPD does. As some groups have already done (e.g., Accreditation Council for Pharmacy Education, American Medical Association), this report adopts the term CPD to recognize the impor- tance of more comprehensive, lifelong learning. In the context of this report, CPD is used to address the future state and CE is used when addressing past and current continuing education efforts, even though some elements of CPD are being used in limited contexts. Table 1-1 illustrates the various features of training, education, and professional development, including continuing professional development. TABLE 1-1 Comparing Training, Education, and Professional Development Professional Training Education Development Purpose “To impart a set “To introduce, To encourage of established review, or alter systematic facts and skills knowledge and maintenance, without the competencies” self-directed necessity of (Fox, 2003) improvement, [a] trainee’s and broadening understanding of knowledge and why [he] skills should act in the prescribed manner” (Carney, 2003) Targets A uniform, Altered Outcomes-focused predictable knowledge, development behavior skill, or of personal and attitudes professional qualities necessary through a professional career or life

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19 CPD: BUILDING AND SUSTAINING A QUALITY WORKFORCE TABLE 1-1 Continued Professional Training Education Development Outcomes Passive activity; Observation, Reflecting on conditioned analysis, and practice, identifying reflex action questioning problems to formulate hypotheses and make conclusions; actions modified according to conclusions or solutions Continuing Professional Continuing Development Education (CPD) Description Serves to update Deals with and reinforce personal, knowledge (e.g., communication, management of managerial, and heart attacks, team-building diagnosis of skills in addition to HIV) content Frequently May be based on based on acquiring credits acquiring credits or on processes of self-accreditation and reflection (e.g., personal portfolios) May be Systems for considered monitoring CPD a subset of require flexibility continuing so professionals professional can participate in development a variety of CPD activities

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20 REDESIGNING CE IN THE HEALTH PROFESSIONS HISTORICAL CONTEXT Continuing education has long been a core part of being a health professional, beginning with Florence Nightingale encouraging nurses to continue to learn (Gallagher, 2006) and the first recorded continuing nursing education course dating back to 1894 (Stein, 1998). In medicine, CE was often confused with graduate medical education in the 1920s and 1930s as a way to address the issue of improperly trained physicians, but this ended with the advent of internship and residency, which extended formal physician training. After World War I, medical faculties became increasingly concerned with the need to spur professional growth of physicians in practice, and continuing medical education (CME) was used as a way to help well-trained practitioners keep up to date with the advanc - ing knowledge. Although reports from the 1930s and 1940s called for the continuation of medical education beyond undergraduate and graduate level education, it was not until after World War II that these calls were acted on (Commission on Graduate Medical Education, 1940; Shepherd, 1960). Today’s construct of using CME to improve performance began in the late 1970s when CME was sug- gested to be a continuous process based in practice settings (Lloyd and Abrahamson, 1979). Calls for the professionalization of medicine have also signifi - cantly impacted medical education. One of the first studies about physicians’ preferred continuing education methods crystallized the need to better identify effective CE methods and courses (Vollan, 1955). The objectives and competencies needed to be learned by medical students and other health professionals that shape today’s health professions education were not clearly delineated until recently (AAMC, 1998; IOM, 2003). In addition to the changing context and goals of CE, its struc- ture has also evolved. In medicine, changes to residency programs required greater faculty attention, and there arose a growing sense among faculty that teaching CME was less than prestigious. In the 1950s, studies showed that pharmaceutical sales representatives were the most important sources providing physicians with new information; this trend led to the development of a new industry tying together pharmaceutical companies, advertising, and physi - cian behavior. This new industry soon became subject to criticism about the potential conflicts of interest between pharmaceutical companies and physicians, and such issues have been the focus of periodic congressional hearings since the 1960s (Randall, 1991; United States Senate Committee on Finance, 2007; United States Sen- ate Subcommittee on Antitrust and Monopoly, 1962). Regulation of

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21 CPD: BUILDING AND SUSTAINING A QUALITY WORKFORCE CME began largely as a method for the American Medical Associa- tion, and eventually state medical societies, to monitor pharmaceuti- cal influence on physician education. As a result, CME increasingly came to be provided by a combination of specialty societies, state and local medical organizations, and pharmaceutical companies (Ludmerer, 1999; Podolsky and Greene, 2008). Health professionals are currently regulated by state health licensing boards; providers of CE are regulated by national accrediting organizations (e.g., National League of Nursing). The CE industry has grown rapidly over the past 10 years and has increasingly involved commercial support from the medical edu- cation and communication companies that began appearing in the early 1980s. Continuing medical education activities have become increasingly extravagant (Podolsky and Greene, 2008), raising ques- tions not only of the effectiveness of the education being provided but also of the level of influence commercial entities should have on physician learning. Currently, financial support, accreditation mechanisms, and CE methods are intertwined and difficult to ana- lyze separately in medicine. Limited data also suggest that similar trends are taking place in nursing and pharmacy but not in the allied health professions. Significant change in health professions education is not unprec- edented. Specific to medicine, the report Medical Education in the United States and Canada, better known as the Flexner Report, was published in 1910. The report dramatically changed the culture and landscape of medical education and became the basis of under- graduate medical education in the United States. At the time of the Flexner report, many observers were concerned that there were too many medical schools and that physicians were being poorly trained. There also were concerns about the perceived lack of stan - dardized prerequisites and curriculums across medical schools; the reliance on education through lectures and memorization, not at a patient’s bedside; and the proprietary nature of medical education. These concerns about undergraduate medical education in the early 1900s mirror today’s concerns about the continuing education of all health professions, as highlighted in the report Work and Integrity (Campbell and Rosenthal, 2009; Cooke et al., 2006; Flexner, 1910; Sullivan, 2005). STUDY CONTEXT Continuing education differs widely among and within health professions in terms of content, delivery or learning methods,

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22 REDESIGNING CE IN THE HEALTH PROFESSIONS regulation, and financing. Currently, CE is largely driven by state requirements and regulatory bodies that often focus on number of hours spent in CE courses, calculated in terms of some units for all professions. But even this basic measure differs markedly across states. For example, physicians in Alabama are required to have 12 CME credits per year, while those in Michigan need 50 credits per year, and many states have no requirement at all. Some states require a minimum number of credits in ethics, while others require mandatory content such as courses in infectious disease and patient safety. Depending on the state, annual hours or credit requirements differ among professions: nurses generally need 5-15 contact hours, pharmacists need 10-60 hours, and when required, social workers need anywhere between 3 and 25 hours. A greater problem, how- ever, compounds the variations in CME requirements among states and professions: current data is insufficient to determine how much CE is really needed to maintain competence, to support learning, or to affect performance. This gap brings into question the current regulatory focus on credits and hours. How learning is best achieved is another question to be addressed when evaluating CE. Potential sources for better learn- ing methods may lie in the field of adult education research and theory. Research in such areas as andragogy, experiential learning, self-directed learning, lifelong learning, and critical reflection may offer information that can be incorporated in designing CE delivery methods. Methods for delivering CE vary widely and include more traditional methods such as conferences, grand rounds, and pub- lished materials. As technology has improved, the various types of computer-based and Internet-based learning modes have evolved to include interaction with CD-ROMs, webinars, and videoconfer- ences. CE is now also delivered within the context of care, often termed practice-based learning and point-of-care learning. Maximiz- ing learning is critical to developing a better system of continuing professional development. Regulation of how much and what type of CE health profes- sionals must obtain is conducted at the federal, state, and local levels through licensure and certification, which set the minimum standards of competency for a profession. In most cases, profession - als must receive a license before they are allowed to practice. Licen - sure and relicensure requirements vary by profession and generally vary by state. Certification is provided by professional societies and boards, which acknowledge competence in a particular specialty, often requiring more in-depth knowledge than licensure. Creden- tialing occurs at the level of the health care organization and veri -

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23 CPD: BUILDING AND SUSTAINING A QUALITY WORKFORCE fies that a health professional has received training up to the level required by the organization. Accreditation is provided by organiza- tions often associated with professional organizations that evaluate programs delivering CE to individual health professionals. A major problem that stems from this fragmented system is that many of the regulatory agencies do not work together, although there is a recent trend toward collaboration among some profes- sions. The regulatory system ought to consider placing emphasis on the relationship between quantity of hours or CE activities, prac - titioner performance, and clinical outcomes, both for individual professionals and for organizations. The CE industry is funded in part by professionals, profes- sional societies, professional schools, publishing/education compa - nies, and the health care delivery system. Medicine is the largest of the professions in terms of CE income, with more than $2.5 billion of total income in 2007. Commercial funds represent more than 50 percent of total CME income, or $1.5 billion. Physician member- ship organizations, publishing/education companies, and schools of medicine have the largest profit margins of all CME organizations, with profit margins of 46.6 percent, 34.9 percent, and 13.8 percent, respectively (ACCME, 2008). In social work and allied health, con - tinuing education is often paid for by professionals themselves and not reimbursed by employers, although data are scarce about the many allied health professions. A critical assessment of the effectiveness of CE on the perfor- mance of health professionals is needed at the individual and aggre- gate discipline levels, on the various modes of CE delivery, and on the ability of health professionals to close the gap between current and optimal health system performance. This assessment is made difficult, however, by the relative lack of high quality studies in the published literature. Importantly, no evidence exists to determine exactly how much CE is needed for professionals to, at a minimum, maintain competence and practice at the highest level. STUDY CHARGE AND APPROACH In 2007, the Josiah Macy, Jr. Foundation held a conference to discuss the future of continuing health professions education (Hager et al., 2007). The conference, which brought together a diverse set of stakeholders, concluded that CE in the United States is currently inadequate. The conference summary states that CE currently is more focused on numbers of credits than on health professionals’ actual performance, is funded in large part by organizations with

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24 REDESIGNING CE IN THE HEALTH PROFESSIONS conflicted interests, is not focused on learning based in practice and patient care, does not provide incentives for interprofessional care, and does not take advantage of advances in Internet technology. Conference attendees recommended that a continuing education institute be created for the purpose of “advancing the science of CE” and that the Institute of Medicine (IOM) appoint a committee to discuss the development of such an institute. The Macy Foundation subsequently asked the IOM to review issues in continuing educa- tion and consider the establishment of a national interprofessional continuing education institute (see Box 1-1). In response, the IOM convened the Committee on Planning for a Continuing Health Pro - fessional Education Institute. In accordance with its statement of task, the IOM study com- mittee reviewed a variety of issues surrounding the state of continu- ing education for health professionals, but did not try to identify specific educational methods or approaches to be used in CE. The committee focused only on postlicensure learning, although it rec- ognizes the importance of strengthening the entire continuum of health professional learning. Using its review findings as a basis, the committee considered issues that would relate to the establishment of a national CE institute, including how such an institute might best be established and how it should operate. Despite the inclu - sion of “Institute” in its name, the committee examined a number of possible alternatives to establishing an institute and considered whether the objectives of the institute could be met with a different organizational structure. BOX 1-1 Statement of Task An ad hoc IOM committee will undertake a review of issues in continu- ing education (CE) of health care professionals that are identified from the literature and from data-gathering meetings with involved parties to improve the quality of care. Based on this review, the committee will consider the establishment of a national interprofessional CE Institute to advance the sci- ence of CE by promoting the discovery and dissemination of more effective methods of educating health professionals over their professional lifetimes, by developing a research enterprise that encourages increased scientific study of CE, by developing mechanisms to assess research applications, by stimulating new approaches to both intra- and interprofessional CE, by being independent and composed of individuals from the various health professions, and by considering financing (both short and long term).

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25 CPD: BUILDING AND SUSTAINING A QUALITY WORKFORCE The Macy Foundation approved two other grant proposals at the same time it approved the IOM study. The first of these grants was awarded to the Association of American Medical Colleges (AAMC), in collaboration with the American Association of Col- leges of Nursing, to hold a stakeholders workshop to discuss the translation of CE research findings into practice. The workshop, held in February 2009, resulted in a paper made publicly available in fall 2009 (AAMC and AACN, 2010). The second grant was awarded to the Institute for Health Policy at Harvard University to conduct economic modeling for alternative financing models for continuing medical education, and the researchers presented their findings in a white paper (Campbell and Rosenthal, 2009). The IOM committee considered in its deliberations the information presented in both papers, but the committee developed its conclusions and recom- mendations independently and reported its findings to the Macy foundation separately. IOM Committee Methods The committee met three times during the course of the 12- month study and conducted a literature review on the effectiveness of continuing education methods (see Appendix A). The commit - tee also received public statements from a large variety of stake- holders, including regulatory bodies, funders, health professionals, and consumers. Representatives from medicine, pharmacy, nursing, social work, and allied health professions provided statements to the committee at a public workshop (see Appendix E), sharing their perspectives on the purpose of CE and the need for change. These statements and others received during the committee’s process were instrumental to the development of this report. Previous IOM Reports This report builds on and is consistent with previous IOM reports that have emerged from a 10-year quest to identify ways to improve the quality of care that patients receive, improve patient outcomes, and better protect patient safety. The call to improve quality and patient safety was sounded by To Err Is Human: Building a Safer Health System (1999) and expanded by Crossing the Quality Chasm: A New Health System for the 21st Century (2001a). As a cen- tral theme, these reports cited the need to improve the quality of the health professional workforce. Other IOM studies dealing with the health care workforce have focused on specific care set-

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26 REDESIGNING CE IN THE HEALTH PROFESSIONS tings (e.g., long-term care [IOM, 2001b]), specific populations (e.g., aging [IOM, 2008], children and family [IOM, 2000]), and specific disciplines (e.g., mental health and substance use [IOM, 2006], rural health [IOM, 2005], and public health [IOM, 2007d]). A number of studies on nursing and emergency care professionals also con - cluded that their workforces must be strengthened (IOM, 2004, 2007a, 2007b, 2007c). The current report also draws in important ways on the IOM report Health Professions Education: A Bridge to Quality (2003), which identified five core competencies that all health professionals should have and made recommendations for improving the testing and assurance of health professionals’ competencies. The five core com- petencies include being able to provide patient-centered care, work in interdisciplinary teams, employ evidence-based practice, apply quality improvement strategies, and use health informatics. REPORT STRUCTURE Across its breadth, this report illustrates the importance of changing the current CE system and provides principles that will help in moving to a broad-based continuing professional develop- ment system over the next 10 years. The report is organized into seven chapters, of which this intro - ductory chapter is the first. Chapter 2 discusses the scientific founda- tions of continuing education and includes a critical assessment of the effectiveness of CE methods. Chapter 3 explores CE regulation and financing. Chapter 4 builds a case for improving continuing education and explores the various alternatives to a CE institute. Chapter 5 discusses what a better CE system would look like in 10 years. Chapter 6 describes the function and structure of a continuing professional development institute, and Chapter 7 explores steps toward the implementation, research, and evaluation of such an institute. Recommendations and conclusions are embedded within each chapter. REFERENCES AAMC (Association of American Medical Colleges). 1998. Learning objecties for medi- cal student education: Guidelines for medical schools. https://services.aamc.org/ publications/showfile.cfm?file=version87.pdf&prd_id=198&prv_id=239&pdf_ id=87 (accessed September 4, 2009). AAMC and AACN (American Association of Colleges of Nursing). 2010. Lifelong learning in medicine and nursing: Final conference report. http://www.aamc.org/ meded/cme/lifelong/macyreport.pdf (accessed January 13, 2010).

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27 CPD: BUILDING AND SUSTAINING A QUALITY WORKFORCE ACCME (Accreditation Council for Continuing Medical Education). 2008. AC- CME annual report data 2007. http://www.accme.org/dir_docs/doc_upload/ 207fa8e2-bdbe-47f8-9b65-52477f9faade_uploaddocument.pdf (accessed January 16, 2009). Balas, E., and S. Boren. 2000. Managing clinical knowledge for health care improve - ment. Yearbook of Medical Informatics. Stuttgart: Schattaver Verlasgesellschaft. Campbell, E. G., and M. Rosenthal. 2009. Reform of continuing medical education: Investments in physician human capital. Journal of the American Medical Associa- tion 302(16):1807-1808. Carney, A. L. 2003. Factors in instructional design: Training versus education. Pre - sented at the Instructional Technology Lab Seminar at the University of Illinois, Chicago. Commission on Graduate Medical Education. 1940. Graduate medical education. Chicago: University of Chicago Press. Cooke, M., D. M. Irby, W. Sullivan, K. M. Ludmerer. 2006. American medical ed - ucation 100 years after the Flexner Report. New England Journal of Medicine 355(13):1339-1344. Davis, D., M. Evans, A. Jadad, L. Perrier, D. Rath, D. Ryan, G. Sibbald, S. Straus, S. Rappolt, M. Wowk, and M. Zwarenstein. 2003. The case for knowledge trans - lation: Shortening the journey from evidence to effect. British Medical Journal 327(7405):33-35. Flexner, A. 1910. Medical education in the United States and Canada. New York: Carnegie Foundation for the Advancement of Teaching. Fox, R. D., ed. 2003. Encyclopedia of education, second edition. Edited by J. W. Guthrie. New York: Macmillan Reference USA. Gallagher, L. 2006. Continuing education in nursing: A concept analysis. Nurse Educa- tion Today 27(8). Hager, M., S. Russell, and S. Fletcher. 2007. Continuing education in the health profes- sions: Improing healthcare through lifelong learning. Proceedings of a conference sponsored by the Josiah Macy, Jr. Foundation, Bermuda, November 28-December 1. New York: Josiah Macy, Jr. Foundation. IOM (Institute of Medicine). 1999. To err is human: Building a safer health system. Wash- ington, DC: National Academy Press. ———. 2000. From neurons to neighborhoods: The science of early childhood deelopment. Washington, DC: National Academy Press. ———. 2001a. Crossing the quality chasm: A new health system for the 21st century. Wash- ington, DC: National Academy Press. ———. 2001b. Improing the quality of long-term care. Washington, DC: National Acad- emy Press. ———. 2003. Health professions education: A bridge to quality. Washington, DC: The National Academies Press. ———. 2004. Keeping patients safe: Transforming the work enironment of nurses. Wash- ington, DC: The National Academies Press. ———. 2005. Quality through collaboration: The future of rural health. Washington, DC: The National Academies Press. ———. 2006. Improing the quality of health care for mental and substance-use conditions. Washington, DC: The National Academies Press. ———. 2007a. Emergency medical serices at the crossroads. Washington, DC: The Na- tional Academies Press. ———. 2007b. Emergency medical serices for children: Growing pains. Washington, DC: The National Academies Press.

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28 REDESIGNING CE IN THE HEALTH PROFESSIONS ———. 2007c. Hospital-based emergency care: At the breaking point. Washington, DC: The National Academies Press. ———. 2007d. Training physicians for public health careers. Washington, DC: The Na- tional Academies Press. ———. 2008. Retooling for an aging America: Building the health care workforce. Washing- ton, DC: The National Academies Press. Lloyd, J. S., and S. Abrahamson. 1979. Effectiveness of continuing medical education: A review of the evidence. Ealuation Health Professions 2:20. Ludmerer, K. 1999. Time to heal. New York: Oxford University Press. Podolsky, S. H., and J. A. Greene. 2008. A historical perspective of pharmaceutical promotion and physician education. Journal of the American Medical Association 300(7):831-833. Randall, T. 1991. Kennedy hearings say no more free lunch—or much else—from drug firms. Journal of the American Medical Association 265(4):440-442. Shepherd, G. R. 1960. History of continuation medical education. Journal of Medical Education 35(8):740-758. Stein, A. M. 1998. History of continuing nursing education in the United States. Jour- nal of Continuing Education in Nursing 29(6):245-252. Sullivan, W. M. 2005. Work and integrity: The crisis and promise of professionalism in America (2nd edition). The Carnegie Foundation for the Advancement of Teach- ing. San Francisco: Josey-Bass. United States Senate Committee on Finance. 2007. Committee staff report to the chair- man and ranking member: Use of educational grants by pharmaceutical manufacturers . Washington, DC: U.S. Government Printing Office. United States Senate Subcommittee on Antitrust and Monopoly. 1962. Report on ad- ministered prices: Drugs. Washington, DC: U.S. Government Printing Office. Vollan, D. D. 1955. Scope and extent of postgraduate medical education in the United States. Journal of the American Medical Association 157(9):703-708.