Continuing medical education: where next?

Doctors must manage their own education

The recent BMJ series on continuing medical education highlights the need for more efficient, up to date, and accountable programmes. Over the past three to four years the royal medical colleges in Britain have implemented their own schemes of formal continuing education. Adequate educational opportunities now exist for most British clinicians,1 though much of the education offered is a diet of lectures, symposiums, and specialist society meetings. Given that lectures are not the ideal vehicle for adult learning, what other initiatives are available for practising doctors and what can we learn from new developments in Britain and world wide?

There are two ground rules. Firstly, every doctor has a personal responsibility to keep up to date and, secondly, trained professionals must be responsible for directing their own lifelong learning. 2 3 Accordingly, to help clinicians cope with the prodigious growth of information and to focus their effort, colleges and specialist societies have introduced, or are introducing, journal articles specifically designed for continuing medical education: many include an element of interaction between the reader and the topic which helps validate the learning. For example, the Royal College of Obstetricians and Gynaecologists has two paper based distance learning resources, PACE (personal assessment in continuing education) and LOGIC (learning in obstetrics and gynaecology for in-service clinicians), which provide up to date reviews written by experts and self assessment tests (PJD Milton, personal communication). It is now introducing a multimedia approach to distance learning.4 The Royal College of Pathologists offers similar exercises and allows participants to compare their performance (anonymously) with that of their peers in the same specialty group.5

The profession is now well placed to reap the benefits of the electronic revolution. The medical knowledge self assessment programme of the American College of Physicians is now available on CD ROM, and interactive case based CD ROMs are also being distributed. Computer conferencing is increasingly being used, and educational programmes, such as that run by EuroTransmed, are delivered by satellite and on the internet. In Canada the innovative maintenance of competence programme (MOCOMP) of the Royal College of Physicians and Surgeons6 encourages clinicians to manage their own continuing medical education using the philosophy that we should focus on what can be learnt from everyday practice. PCDiary software is used by participants to define their learning needs and to keep a portfolio of learning experiences.

We disregard many of the commendable, but underused, educational resources readily available within the NHS. Learning visits to experts or centres of excellence, not commonly regarded as formal education, can be of great practical help. If necessary these learning visits could be extended to longer secondments, particularly if consultants need to take new skills back to their own hospital. This type of challenge is being met by the Raven department of education at the Royal College of Surgeons of England, which teaches specialist skills to postgraduates and established consultants.

Peer review visits, pioneered and implemented by the Royal Australasian College of Physicians,7 and now being pursued by several British specialist societies,8 are manifestly of value to both the reviewed and the reviewers. Initial fears that they might prove hostile or intrusive have largely been dispelled, but the expense of site visits in America has been prohibitive.9

Continuing medical education doesn't just mean keeping up to date with one's own speciality interests. It has to be extended into the wider aspects of continuing professional development, including computer literacy, ethics, appraisal, management, and evidence based medicine. It also means facing the challenge of interprofessional collaboration and making teamwork a reality.10 Striking the correct balance for each individual is not without difficulty.

The royal medical colleges have never regarded continuing medical education as a tool to deal with poor performance. With a fair system in place to help doctors who do not perform well,11 continuing medical education should no longer be seen as a measure to identify bad doctors. It should be seen as prevention. The colleges' attention will remain focused on standards of medical care in a changing health service.

Questions remain whether continuing medical education should be mandatory. In Britain the colleges have agreed that formal schemes are necessary if they are to retain their self regulatory privileges. Self reporting systems are developing and compliance is high, but many doctors, while enjoying their education, find its documentation a chore. Few realistic and practical alternatives to formal college administered credit systems have, however, emerged. Fulfilment of educational requirements is no guarantee of clinical effectiveness or performance, but employers, insurers, and medicolegal agencies need to know that a doctor's continuing medical education is of good standing. If doctors are to be encouraged to “keep up to date” it is essential that time and reasonable funding are made available, particularly for those in the neglected non-consultant career grades.12 Continuing medical education now needs to move on. Those who smugly reassure themselves by saying, “There's no need to change, we do it all anyway,” will find themselves left behind.