Global health, global learning

British Medical Journal, Jan 31, 1998 by Dave Davis

CME--continuing medical education--has become an international discipline. Defined as any and all ways by which doctors learn after the formal completion of their training,[1] CME is being shaped by several forces. Foremost among these are the globalisation of health[2]; cross disciplinary movements such as evidence based medicine; common trends in medical education and the assessment of professional competence; and the impact on health care and professional education of the identification of the determinants of health.[3 4] Add to these electronic mail and the internet allowing instant global communication and virtually unlimited access to medical information and it is not hard to see why CME has become an international concern.[5] This paper reviews the main published work on CME, identifies major themes in its development, and points to ways that may help standardise and support the provision of CME internationally.

Methods

To gather information for this article, I searched the Research and Development Resource Base in CME extensively for articles (published 1986-96) that describe CME activities worldwide, excluding North America and the United Kingdom.[6] At the time this article was written, it contained references to over 7000 articles and monographs devoted to continuing health professional education. I also searched Medline, ERIC, EMBASE, and other databases for articles (published 1986-96), using terms and phrases such as world health, global health, international cooperation, and international educational exchange and continuing medical education terms combined with geographical names. Then I circulated the results of the literature searches and a brief questionnaire to key informants in the field, to identify other articles and to add their opinions about forces for and trends in continuing medical education.

Results

I found 68 articles that met these criteria (table).[7-74] Fourteen focused on determining the learning needs and patterns of clinicians[7-18 73 74]; 22 articles described in general terms an intervention such as a CME teleconference, programme, or course[19-39 72]; 12 evaluated the effect of the CME intervention on doctors' competence or performance or change in health care outcomes[40-51]; and 20 studies provided an overview of the structure, role, or trends concerning CME within the region or country of origin of the article.[52-71] The last section has been enhanced by the addition of comments from key informants in selected countries.

Studies of international continuing medical education

                                             Type of study
                                                     Description of
                                   Surveys, needs     activity or
                                    assessments      intervention
Region                                 (n=14)          (n--21)
Africa (n=5)                             1               3
Asia (n=6)                               3               2
Australia/New Zealand (n=7)              3               1
Caribbean (n=l)
Central Europe (n=26)                    4               6
Central and South America (n=2)
Eastern Europe (n=2)                                     1
Scandinavia (n=5)                                        1
Transnational (n=13)                     3               7

                                   Evaluation of
                                     outcomes        Overview or
                                      (n=1 2)       trends (n=20)
Africa (n=5)                                               1
Asia (n=6)                                                 1
Australia/New Zealand (n=7)                                3
Caribbean (n=1)                         1
Central Europe (n=26)                   4                 12
Central and South America (n=2)         2
Eastern Europe (n=2)                    1
Scandinavia (n=5)                       4
Transnational (n=13)                                       3

Surveys of needs

The studies of needs assessment used tools such as surveys or focus groups to determine knowledge and practice gaps in potential learners. Needs have been analysed by multifocused surveys of rural practitioners in Australia[8 11] and by broad, topic specific studies in Germany in psychogeriatrics[9] and in Egypt in HIV and AIDS.[13] Beyond standard surveys of needs, educators in Sri Lanka have used Delphi techniques to help practitioners evaluate their own clinical skills.[16]

Interventions

While the formal conference or short course remains the staple of orgarrised CME in both developed and developing nations, a variety of alternative educational formats and interventions have been described. Skills training has been studied in the Caribbean in advanced trauma life support[40] and in Japan[17] and in Italy[49] in laparascopic surgery. Innovative educational delivery techniques were exemplified by interprofessional educational experiences in Bulgaria,[41] problem based learning in Sweden,[23] self instructional programs in China,[25] and small group learning in Ireland.[28] Learning contracts for continuing education in radiology have been used in the Urals in Russia (V Sharov, personal communication). Providing potential links for distance education and patient care, teleradiology and telemedicine have been extensively reported, reflecting the issue of geographic isolation in the Middle East[24] and in other developing countries[21]; and patient education programmes as a component of CME initiatives have enjoyed some success in Germany.[19 26 44]