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Redesigning Continuing Education in the Health Professions 2 Scientific Foundations of Continuing Education In 1967, the National Advisory Committee on Health Manpower recommended that professional associations and government regulatory agencies take steps to ensure the maintenance of competence in health professionals (U.S. Department of Health, Education, and Welfare, 1967). To support this objective, states in the 1970s began to mandate that health professionals receive continuing education (CE). Requirements were applied unevenly across the United States, however, and there now is variability from state to state and profession to profession regarding how much CE is needed, what kind of CE is needed, and how and when CE should be administered (Landers et al., 2005). In the late 1970s, many observers argued that the time was ripe for change in the CE system, and they raised a number of important questions: Can CE guarantee competence? Are mechanisms available to accurately assess the learning needs of health professionals? How can these learning needs best be met? How many annual contact hours are needed to ensure competence? (Mazmanian et al., 1979). Today, it is clear that this call for change went unanswered. CE has evolved organically, without an adequate system in place to ensure that the fundamental questions raised three decades ago could be addressed to inform the development and maintenance of a CE system. These still-relevant questions provide a springboard toward creating a more responsive and comprehensive system. Pressure from a number of groups, including the Pew Taskforce on Health Care Workforce Regulation (1995) and the Institute
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Redesigning Continuing Education in the Health Professions of Medicine (IOM), has spurred debate about how best to ensure the continuing competence of health professionals. As discussed in Chapter 1, the IOM report Health Professions Education: A Bridge to Quality (2003) details five core competencies deemed necessary for all health professionals: patient-centered care, interdisciplinary team-based care, evidence-based practice, quality improvement strategies, and the use of health informatics. These competencies are intended to help provide a more safe, effective, patient-centered, efficient, timely, and equitable health care system (IOM, 2001). For example, advances in the areas of evidence-based practice and quality improvement require the ability to integrate clinical knowledge with professional practice. Connecting these processes through evidence-based health professional education has the potential to revolutionize the health care system (Berwick, 2004; Cooke et al., 2006). The components of CE—the CE research system, regulatory and quasi-regulatory bodies, and financing entities—are currently ill-equipped to support these core competencies consistently. For example, as this chapter later details, effective CE incorporates feedback and interaction, yet 76 percent of continuing medical education (CME) instruction hours are delivered through lectures and conferences (ACCME, 2008) that typically limit interactive exchange (Forsetlund et al., 2009). Various professions, however, have begun to use different methods of CE, including methods that better take into account the clinical practice setting (Kues et al., 2009; MacIntosh-Murray et al., 2006). Research on CE methods and theories behind adult learning, education, sociology, psychology, organizational change, systems engineering, and knowledge translation have provided an initial evidence base for how CE and continuing professional development should be provided. Additionally, previous works have offered theoretical frameworks for conceptualizing CE and guiding its provision (Davis and Fox, 1994; Fox et al., 1989). This chapter presents summary data on the ways in which CE is typically provided. The chapter discusses the most common methods of providing CE; details findings on the effectiveness of CE in general, as well as the effectiveness of specific CE methods; discusses theories that support what is known about how adults learn; and describes the attributes of successful CE methods and how theory can be applied to improve these methods.
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Redesigning Continuing Education in the Health Professions METHODS OF PROVIDING CONTINUING EDUCATION In its current form, CE consists primarily of didactic activities that are not always related to clinical settings or patient outcomes. Lectures and conference sessions, long the mainstay of CE, remain the most commonly used CE methods (see Figure 2-1). For physicians, courses and regularly scheduled series (e.g., grand rounds) account for 44.1 percent of total reported activities conducted by providers accredited by the Accreditation Council for Continuing Medical Education (ACCME) and 88.1 percent of total activities presented by providers accredited by state medical societies (ACCME, 2008). More than 82 percent of total hours of instruction are in the form of courses or series. The committee made a concerted effort to incorporate data regarding methods of CE delivery from all health professions; however, the data collected for most professions are not robust and are not always reported in comparable formats. Consequently, publicly available data on pharmacy, nursing, dentistry, physical therapy, and other allied health professions’ CE are much more limited than in medicine. In 2007-2008, the Accreditation Council for Pharmacy Education (ACPE) accredited 36,569 activities. Of these, 53 percent were “live activities,” 46 percent were home study, and 11 percent were Internet activities.1 The category of live activities includes lectures, symposia, teleconferences, workshops, and webcasts, but the percentage of each of these activities is unknown. For licensed social workers, survey participation rates provide some insight into the types of CE most often used (Table 2-1). Social workers, like physicians and pharmacists, often participate in formal, didactic workshops. Informal CE activities such as peer consultation, which may not be counted for CE credit by state licensing boards, are the methods most believed by social workers to change their practice behavior (Smith et al., 2006). In many health professions, journal reading is a commonly used avenue to complete CE credits. CE providers are increasingly using an expanding variety of CE methods. A 2008 survey of academic CME providers found an “increasing diversity” of offerings beyond traditional, didactic conferences, courses, and lectures (Kues et al., 2009, p. 21). CE programs more often use multiple educational methodologies (e.g., interaction, experiential learning) and multiple educational techniques (e.g., questioning, discussion, coaching, role play). Table 2-2 provides a 1 Personal communication, D. Travlos, ACPE, June 2, 2009.
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Redesigning Continuing Education in the Health Professions FIGURE 2-1 Accredited methods of CE by hours of instruction. SOURCE: ACCME, 2008.
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Redesigning Continuing Education in the Health Professions TABLE 2-1 Methods of CE Reported by Social Workers Activity Participation Rates % N Workshops 97.0 223 Peer consultation 76.5 176 Reading books or journals 73.5 169 In-service training 66.1 152 Supervision or mentoring 47.4 109 Academic courses 7.8 18 SOURCE: Smith et al., 2006. list of common approaches. Data on the use of these approaches are not always available. For example, the rate at which health professionals participate in self-directed learning is not available from CE providers or accreditors because in most health professions, CE credits—the metric for CE activities—cannot currently be earned for participation in self-directed learning. The use of e-learning has become increasingly widespread in the training of health professionals. e-Learning modalities include educational programs delivered via electronic asynchronous or real-time communication without the constraints of place, or, in some cases, time (Wakefield et al., 2008). Although some professionals prefer traditional learning formats that include more face-to-face contact (Jianfei et al., 2008; Sargeant et al., 2006), e-learning has the advantage of enabling health professionals to set their own learning pace, review content when needed, and personalize learning experiences (Harden, 2005). Lower costs, potentially greater numbers of participants, and increased interprofessional collaborations are additional benefits of e-learning (Bryant et al., 2005). e-Learning can facilitate, for example, interprofessional team-based simulation training (Segrave and Holt, 2003). The ways in which various formats of e-learning may be used in professional practice are summarized in Table 2-3. DEFINING OUTCOME MEASURES Assessing the effectiveness of CE methods requires clarifying desired outcomes. Traditionally, efforts to measure CE effectiveness were constrained by a lack of consensus around ideal measures for evaluating CE learning outcomes (Dixon, 1978). Participation rates, satisfaction of participants, and knowledge gains—as evaluated by postactivity exams—were used to show that participants in a CE
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Redesigning Continuing Education in the Health Professions TABLE 2-2 Common Approaches to Providing CE Method Description Experiential and self-directed learning A professional’s experience factors into learning activities; the structure, planning, implementation, and evaluation of learning are initiated by the learner (Davis and Fox, 1994; Stanton and Grant, 1999) Reflection An individual marks ideas, exchanges, and events for teaching-learning (Fox et al., 1989; Schön, 1987) Academic detailing Outreach in which health professionals are visited by another knowledgeable professional to discuss practice issues Simulation The act of imitating a situation or a process through something analogous. Examples include using an actor to play a patient, a computerized mannequin to imitate the behavior of a patient, a computer program to imitate a case scenario, and an animation to mimic the spread of an infectious disease in a population Reminders Paper or computer-generated prompts about issues of prevention, diagnosis, or management delivered at the time of care and point-of-care Protocols and guidelines A set of rules generated by piecing together research-based evidence in the medical literature, representing the optimal approaches to managing a medical disease Audit/feedback Health care performance is measured and the results are presented to the professional Multifaceted methods Comprehensive programs designed to improve health professional performance or health care outcomes using a variety of methods Educational materials Publications or mailings of written recommendations for clinical care, including guidelines and educational computer programs Opinion leaders Individuals recognized by their own community as clinical experts with well-developed interpersonal skills Patient-mediated strategies Techniques that increase the education of patients and health consumers (e.g., health promotion media campaigns, directed prompts)
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Redesigning Continuing Education in the Health Professions TABLE 2-3 Examples of e-Learning Computer or Internet Simulation EHR and EMR Portable Computing Internet-based case discussions Mixed mode (live + web) Webinars Clinical practice guidelines Practice reminders InfoPOEMS Social networking, Web 2.0 Knowledge co-creation Micro- or macrosystem dashboards Data representation and reflection Web case simulations Lo- or hi-fidelity simulations Team-based simulation exercises System modeling Care mapping Self-audit of case series Learning portfolios Individual dashboards Pop-up case-sensitive dialogue boxes Interprofessional EHRs PACS System audits e-portfolios Podcasting 3G videos Smart phone-based videoconferencing Decision support tools (e.g., ePocrates, Up-to-Date) Smart phone-based social networking tools NOTE: 3G = 3rd generation wireless communications; EHR = electronic health record; EMR = electronic medical record; PACS = picture archival communications system. activity had reached at least the “knows” outcome level indicated in Table 2-4. The science of measuring outcomes is advancing beyond measuring procedural knowledge as researchers have come to focus on linking CE to patient care and population health (Miller, 1990; Moore et al., 2009; Tian et al., 2007). An effective CE method is now understood to be one that has enhanced provider performance and thus improved patient outcomes (Moore, 2007). The relationships among teaching, learning, clinician competence, clinician performance, and patient outcomes are difficult to measure (Jordan, 2000; Mazmanian et al., 2009; Miller, 1990) and complicated by the inherent challenges in measuring actual, not just potential or reported, behavior. In health care settings, it may remain difficult to measure dependent variables (Eccles et al., 2005) because linking participation in CE to changes in the practice set-
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Redesigning Continuing Education in the Health Professions TABLE 2-4 Continuum of Outcomes for Planning and Assessing CE Activities Miller (1990) Moore et al. (2009) Description Participation The number of health professionals who participated in the CME activity Satisfaction The degree to which the expectations of the participants about the setting and delivery of the CME activity were met Knows Learning: Declarative knowledge The degree to which participants are able to state what the CE activity intended them to know Knows how Learning: Procedural knowledge The degree to which participants are able to state how to do what the CE activity intended them to know how to do Shows how Competence The degree to which participants show in an educational setting how to do what the CE activity intended them to be able to do Does Performance The degree to which participants do in their practices what the CE activity intended them to be able to do Patient health The degree to which the health status of patients improves due to changes in the practice behavior of participants Community health The degree to which the health status of a community of patients changes due to changes in the practice behavior of participants SOURCE: Adapted from Moore et al., 2009. ting is a complex process that cannot easily be tracked using current methods. Additionally, the provision of interprofessional care makes it difficult to attribute the education of one professional to a patient outcome (Dixon, 1978). Furthermore, due to the nature of some types of professional work, such as social work, evaluating outcomes of
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Redesigning Continuing Education in the Health Professions client-professional interaction is inherently difficult if not ethically impossible (Griscti and Jacono, 2006; Jordan, 2000). Continuing education is concerned with both health professional learning processes and broader outcomes, including patient outcomes and organizational change. Therefore, CE is itself part of a complex learning system and relies on evidence-based research that is driven by theory. Theories are developed over time and continuously build on evidence-based practice, practice-based learning, and outcomes. However, the transition between research and practice is often difficult. Closing the gaps between research and practice, as depicted in Figure 2-2, may be achieved by blending clinical practice and knowledge (MacIntosh-Murray et al., 2006). In the absence of data on patient outcomes, health professionals’ self-reported knowledge gains and behavior change resulting from participation in a CE activity may provide insight into learning. In some cases, self-reported gains have been shown to reflect actual behavior change (Curry and Purkis, 1986; Davis et al., 2006; Parker III and Mazmanian, 1992; Pereles et al., 1997; Wakefield et al., 2003), but self-reported knowledge gains and behavior change may not always be accurate and valid (Gordon, 1991). Self-reports FIGURE 2-2 Closing the research-practice gaps for health care professionals and continuing education professionals. SOURCE: MacIntosh-Murray et al., 2006.
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Redesigning Continuing Education in the Health Professions afford health professionals a voice in evaluating themselves and their motivations. Although self-reports should never be the sole basis for decision making regarding the general effectiveness of continuing education, they may serve important purposes by enabling CE providers to identify motivations and gaps in knowledge (Eva and Regehr, 2008; Fox and Miner, 1999). MEASURING THE EFFECTIVENESS OF CONTINUING EDUCATION The effectiveness of continuing education has been researched, debated, and discussed for decades. An oft-cited review of CME found that the weakness of most published evaluations limited possible conclusions about the effectiveness of CME (Bertram and Brooks-Bertram, 1977), while a seminal review of eight studies provided evidence that formal CME helped physicians improve their clinical performance (Stein, 1981). Soon after publication of that review, however, a benchmark study in the New England Journal of Medicine stated that “CME does not work” (Sibley et al., 1982). To evaluate these contradictory statements and findings in the contemporary context, the committee reviewed evidence on the effectiveness of CE methods. The committee synthesized results from a literature search of more than 18,000 articles from fields including CE, knowledge translation, interprofessional learning and practice, and faculty development in three rounds of detailed assessment of each study’s design, method, outcomes, and conclusions. A total of 62 studies and 20 systematic reviews and meta-analyses relevant to CE methods, cost-effectiveness, or educational theory were included (see Appendix A). Studies from a variety of health professions were included. The literature review revealed that researchers have used a range of research designs to address a broadly defined research agenda, but the research methods used generally were weak and often lacked valid and reliable outcome measures. Several authors (Davis et al., 1999; Marinopoulos et al., 2007; O’Brien et al., 2001; Wensing et al., 2006) have questioned the propriety of systematic reviews as a tool for CE research due to a lack of a widely accepted taxonomy for the comparability of CE methods. Indeed, for several decades, authors have maintained that data on CE effectiveness are limited because studies of CE methods do not uniformly document the major elements of the learning process (Stein, 1981). Although 29 of the evaluated studies were randomized controlled trials assessing changes in clinical practice outcomes based on participation in
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Redesigning Continuing Education in the Health Professions a CE method, none had been validated through replication. While controlled trial methods produce quantifiable end points, they do not fully explain whether outcomes occur as a result of participation in CE (Davis et al., 1999); thus, a variety of research methods may be necessary. Cohort and case-control designs may be more appropriate (Mazmanian and Davis, 2002). In general, more robust research methods must be developed and used to assess CE effectiveness adequately. Research studies measuring outcomes in terms of behavior, clinical behavior, and/or patient outcomes were generally weak in quality and results. Of the 62 studies reviewed, 8 used patient outcomes (e.g., mortality, smoking cessation, cardiac complications) to assess a health professional’s learning resulting from participation in a CE activity. In lieu of CE outcomes measures linked directly to patient outcomes, self-reported behavior change was used to assess effectiveness in 9 of the 62 studies. Fourteen studies used the prescribing process to determine changes in prescription trends that may have resulted from a health professional’s participation in a CE activity. Overall Effectiveness of CE Although CE research is fragmented and may focus too heavily on learning outside of clinical settings, there is evidence that CE works, in some cases, to improve clinical practice and patient outcomes. For example, a seminal, qualitative study of physicians explored how physicians change, finding that CME can be a “force for change” within a comprehensive strategy for learning (Fox et al., 1989). A recent, comprehensive analysis of CME identified 136 articles and 9 systematic reviews summarizing the evidence regarding CME effectiveness in imparting knowledge and skills, changing attitudes and practice behavior, and improving clinical outcomes (Marinopoulos et al., 2007). Although this analysis could not determine the effectiveness of all CME methods covered, CME was found, in general, to be effective for acquiring and sustaining knowledge, attitudes, and skills, for changing behaviors, and for improving clinical outcomes. Some evidence has supported the overall effectiveness of CE in specific instances (Davis et al., 1995; Fox, 2000; Mazmanian and Davis, 2002; Robertson et al., 2003), but too little evidence exists to make a compelling case for the effectiveness of CE, under specific circumstances.
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Redesigning Continuing Education in the Health Professions Self-directed Learning If health professionals choose to learn only as problems arise, they may not be performing critical self-examinations to identify situations before they become problematic. Therefore, internal needs assessment, in which adult learners assess their own learning needs, plays a role in learning. The underlying theory behind self-directed learning comes from Knowles’ theoretical assumptions regarding adult learners (see Table 2-6). Self-directed learning offers opportunities for health professionals to assess their previous experiences and existing knowledge and then set learning goals, locate resources, decide on which learning methods to use, and evaluate processes (Brookfield, 1995). Self-directed learners thus are more purposeful, motivated, and reactive (Knowles, 1975). Self-directed learning activities are meant to be more closely tailored to the needs of the learner than activities that are controlled and directed by others. Individuals, because they are “inherently self-regulating,” can and do identify clinical questions, set their own learning goals, develop strategies to address them, implement actions, and evaluate the success of those approaches (Mann and Ribble, 1994, p. 71). Evidence suggests that adults consistently seek to direct their own learning (Fox et al., 1989; Long, 1997) and that they plan and direct self-learning projects on a regular basis (Tough, 1971). The central motivations that lead physicians, for example, to initiate learning include a desire for enhanced competence, the perception that their clinical environment presses for a change, and social pressures relating to relationships to colleagues in the same institution or profession. Additionally, professionalism, which is an internalized set of socially generated expectations, is a powerful agent for change (Fox et al., 1989). These findings indicate that comparing a health professional’s performance against that of his peers can be a facilitator in identifying learning needs. TABLE 2-6 Theoretical Assumptions of Andragogy: “The Art and Science of Helping Adults Learn” 1. Adults move toward self-direction as they mature (i.e., they become more independent) 2. Experience is a resource for learning 3. Motivations to learn are oriented to the usefulness of the knowledge 4. Orientation to learning shifts from subject-centered to problem-centered SOURCE: Knowles, 1980.
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Redesigning Continuing Education in the Health Professions Reflection Reflection is a learning tool with implications for the teaching-learning process (Schön, 1983, 1987), particularly for health professionals who must learn from practice (Benner and Tanner, 1987). Professionals, despite operating in “zones of mastery,” sometimes face unique and complex situations that are not resolved by using habitual practices (Schön, 1983). Through reflection, health professionals can incorporate new knowledge into practice. Two different methods of reflection can facilitate learning: reflection-in-action and reflection-on-action. Through reflection-in-action, a health professional can reframe the experience to determine if or how it fits with his existing knowledge base (Schön, 1983, 1987). Reflection-in-action, which has been termed “thinking on your feet,” problem solving, and “single-loop learning,” involves looking to experiences, especially when workplace pressure prevents a professional from asking questions or admitting he does not know (Bierema, 2003; Smith, 2001). In contrast, reflection-on-action, also termed “double-loop learning,” occurs when evaluating how an experience can guide action (Argyris, 1991; Schön, 1983). Teaching health professionals to engage in reflection-on-action is a key component in developing the skills necessary to be a self-directed learner. The point at which a health professional does not know the answer—the point at which he can engage in reflective practice—is a teachable moment that may be ignored by health professionals who are unaware of or choose not to use reflection and self-assessment (Davis et al., 2006; Eva et al., 2004; Hill, 1976). Teachable moments, which are also referred to as clinical questions, are essential to health professionals’ learning (Moore and Pennington, 2003). Learning may best occur in the context of patient care when it is directly applicable to clinical questions (Ebell and Shaughnessy, 2003). Habits, frames of reference, feelings, and value judgments can influence the way a professional thinks, acts, and reflects (Mezirow, 1990). For example, a recurrent theme in cognitive research on decision making is that humans are prone to biases. In CE, this might indicate a change in perspective: CE providers may show the pervasive nature of biases and instruct professionals how to recognize the infrequent situations in which biases tend to fail (Regehr and Norman, 1996). Reflection allows health professionals to become aware of these underlying assumptions and biases, influencing how thinking and action occur.
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Redesigning Continuing Education in the Health Professions Experiential Learning The start and end of any teachable moment or period of reflection should involve self-assessment through which the professional critically reflects on how the learning experience should inform future decisions about both clinical care and learning (Gibbs, 1988). Experiential learning informs a health professional’s experiences with theory about what should be done (Stanton and Grant, 1999). The cycle of experiential learning begins and ends in active experiences that include the planning, learning, and application of new knowledge (Dennison and Kirk, 1990; Kolb, 1984). The planning phase may include needs assessment and curriculum design, while the learning phase itself may incorporate a variety of educational methods, such as peer appraisal, self-reflection, case studies, and role play (Stanton and Grant, 1999). Experiential learning is based on the idea that teaching should be grounded in learners’ experiences and that these experiences represent a valuable educational resource. ATTRIBUTES OF SUCCESSFUL CE METHODS Health professionals face contextual influences when attempting to apply learning in the workplace. Processes, systems, and traditions can facilitate a learner’s use of new knowledge in practice. Thus, support for change, resources, and opportunity to apply learning can both positively and negatively affect a learner’s application of new knowledge (Ottoson and Patterson, 2000). While practice context can affect educational outcomes, so can the ways in which CE is delivered. The committee determined that effective CE activities have the following features: Incorporate needs assessments to ensure that the activity is controlled by and meets the needs of health professionals; Be interactive (e.g., group reflection, opportunities to practice behaviors); Employ ongoing feedback to engage health professionals in the learning process; Use multiple methods of learning and provide adequate time to digest and incorporate knowledge; and Simulate the clinical setting. The foundations of these attributes are contained in bodies of theory that explain how and why CE fosters behavior that causes health professionals to evaluate their existing knowledge base when
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Redesigning Continuing Education in the Health Professions faced with clinical questions. These attributes indicate ways in which CE providers can best affect the learning of health professionals and explain, for example, why effective methods (e.g., reminders, academic detailing) tend to be more active and are used as part of a multimethod approach. The attributes provide credence to the provision of reinforcement through techniques such as audit and feedback, because these methods may motivate health professionals to change clinical behavior if their behavior is not aligned with best practices or the behavior of peers (Eisenberg, 1986; Greco and Eisenberg, 1993). Professionals themselves, however, are primarily responsible for being self-directed, lifelong learners. They must take personal responsibility for developing their own short- and long-term learning goals and using the best available evidence to address clinical questions. Health professionals give a number of reasons for not engaging in learning outside of required CE, including lack of time, insufficient compensation (e.g., money, CE credits), or poor system support. Some health professionals see little reason to engage in self-directed learning because they believe themselves to be experts by virtue of their titles. To counteract this tendency, health care organizations and CE providers could foster a culture in which health professionals do not always feel satisfied by their current performance and understand the need for additional, advanced learning (Bierema, 2003). CONCLUSION The literature review of concepts that span academic disciplines provides evidence that some methods of CE—including some traditional, formal methods; informal methods; and newer, innovative methods—can be conduits for positive change in health professionals’ practice. There also is evidence that health professionals often need multiple learning opportunities and multiple methods of education, such as practicing self-reflection in the workplace, reading journal articles that report new clinical evidence, and participating in formal CE lectures, if they are to most effectively change their performance and, in turn, improve patient outcomes. The evidence is also strong, however, that continuing education is too often disconnected from theories of how adults learn and from the actual delivery of patient care. As a result, CE in its present form fails to deliver the most useful and important information to health professionals, leaving them unable to adopt evidence-based approaches efficiently to best improve patient outcomes and popula-
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Redesigning Continuing Education in the Health Professions tion health. Closing the gap will require defining research problems (Geiselman, 1984), using rigorous research techniques (Felch, 1993), developing “scholarly practitioners” (Fox, 1995, p. 5), and researching results relevant to practitioners (Conway and Clancy, 2009). A comprehensive research agenda should do the following: Identify theoretical frameworks. Despite repeated calls for moving toward evidence-based CE (Davis et al., 1992, 1995; Mazmanian and Davis, 2002), appropriate theoretical frameworks have yet to be fully identified and tested. Determine proven and innovative CE methods and the degree to which they apply in various contexts. The literature does not conclusively identify the most effective CE delivery methods, the correct mixture of CE methods, or the amount of CE needed to maintain competency and improve clinical outcomes. CE providers have little evidence base for adopting proven and innovative methods of CE, and health professionals do not have a dependable basis for choosing one CE method over another. Define CE outcome measures. Educational theory emphasizes that effective learning requires matching the curriculum to desired outcomes. While CE aims to improve competence and thus close the gap between evidence and practice, outcomes of CE (i.e., what CE methods should explicitly aim to achieve) have not been defined for or by CE regulators, providers, or consumers. This complicates the ability of regulatory bodies to hold CE providers accountable. Determine influences on learning. The committee identified the following attributes and principles essential to the effectiveness of a CE method: needs assessments should guide CE, CE should be interactive, ongoing feedback should be employed, and CE should employ multiple learning methods. More research is needed to better understand how internal and external characteristics are associated with CE outcomes. This might include formal inquiry into the reflexivity of learning in professional practice. REFERENCES ACCME (Accreditation Council for Continuing Medical Education). 2008. ACCME annual report data 2007. http://www.accme.org/dir_docs/doc_upload/207fa8e2bdbe-47f8-9b65-52477f9faade_uploaddocument.pdf (accessed January 16, 2009).
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