Does continuing medical education in general practice make a difference?

British Medical Journal, May 8, 1999 by Peter Cantillon, Roger Jones

Summary points

The primary purpose of continuing medical education is to maintain and improve clinical performance

Its effectiveness in changing clinical behaviour has come under closer scrutiny as reaccreditation and quality assurance programmes have increased

Continuing medical education for general practitioners should be largely based on the work that they do

Needs assessment is an important component of continuing medical education, but relying entirely on individual doctors' self assessments of their learning needs may be problematic

Significant event audits, peer review, group based learning, and reminders by computer have all been shown to be effective educational strategies for general practice

Continuing medical education (CME) has undergone enormous changes in recent years in terms of its theoretical base, the methodologies used, and the expectations of what it should deliver. It has become an increasingly important concern for governments and patients as well as doctors. As reaccreditation and quality assurance programmes have become more widespread, the effectiveness of continuing medical education in changing clinical behaviour has come under closer scrutiny.

Davis defines continuing medical education as "any and all the ways by which doctors learn after formal completion of their training."[1] Grant and Stanton distinguish between continuing medical education and continuing professional development.[2] Continuing medical education is seen as representing a more teacher based, didactic style whereas continuing professional development implies a more learner centred and self directed approach to learning. These terms are used interchangeably in the literature. For the purposes of this article we will refer to all postgraduate educational events as continuing medical education.

In this review we aim to describe some forces for change in continuing medical education, to summarise the findings of systematic reviews of continuing medical education, and to examine the effectiveness of postgraduate continuing medical education in general practice in particular. Do educational interventions based on general practice change doctors' behaviour and improve patient outcomes?

Methods

We searched the bibliographic databases of Medline, BIDS, ERIC, and Embase between 1990 and March 1999 for (a) systematic reviews of continuing medical education, (b) systematic reviews of postgraduate continuing medical education for general practitioners, and (c) postgraduate educational interventions based on general practice. (The term "postgraduate" is taken to mean educational events occurring after completion of general practice vocational training.) We included intervention studies if they contained a robust evaluation, which examined either the effects of the educational event on subsequent doctor behaviour or patient outcomes. We then retrieved selected references from these papers. The papers were graded by applying a standard hierarchy of evidence, with randomised controlled trials at the top and descriptive studies at the bottom.

Results

The pre-eminence of adult learning theory

Shifts in the underlying theoretical basis of continuing medical education reflect the international changes in how medicine is practised, regulated, and taught.[3] The ideas of mainstream educafionalists[4-6] have been widely incorporated into undergraduate and postgraduate medical education, with the result that adult learning theory has become the standard by which continuing medical education is measured and appraised. The recognition that learning not teaching causes doctors to change their practice has led to a new educational focus.[7] Self directed and lifelong learning are aspirations common to many curricula and educational programmes. Despite this theoretical shift in thinking, traditional styles of expert led teaching still prevail in postgraduate continuing medical education for general practitioners.[8]

The expectations of continuing medical education

The primary purpose of continuing medical education is to maintain and improve clinical performance.[9] Recertification and reaccreditation are part of an international trend to shift the purpose of continuing medical education towards assuring adequate performance.[10] The world in which doctors work has changed enormously. Increasing consumerism and patient empowerment, growing accountability to external bodies, and more emphasis on efficiency and effectiveness have led to an intolerance of variance in medical practice. Quality assurance and the maintenance of standards have become powerful forces for change.[11] In an evidence based medical world it would seem prudent therefore for those planning general practitioners' education to choose educational methodologies that have been shown to work, and to evaluate those that have not.

Systematic reviews of continuing medical education

There is a growing international consensus on what forms of continuing medical education are most effective in stimulating behaviour change. Systematic reviews[12-15] of the educational literature found that although there were comparatively few rigorous evaluations of educational interventions, there were sufficient studies showing that continuing medical education could improve clinical performance and patient outcomes, indicating which methods were best at bringing about change in doctors' behaviour.