Continuous Professional Development: Raising the Bar for Pediatricians

Physicians are increasingly accountable to patients and institutions for proof that they are maintaining medical competence in a rapidly changing health care environment.1 An essential factor in the professional development of physicians is a lifelong commitment to learning. Changes in clinical practice and advances in research have created new educational needs for physicians during the past 2 decades. Coupled with expanded learning methodologies, these needs have prompted unique approaches to traditional continuing medical education (CME).Criticism exists that the current structure of CME may be ineffective in altering physician performance with its distant, disconnected, and teacher-centered approach to education.1–8 In a systematic review of the usefulness of CME strategies, Davis et al6 found that CME in North America is concentrated mostly in formal interventions (eg, conferences) that have limited impact in changing physician performance and/or health care outcomes. They attribute this ineffectiveness in part to the fact that most CME strategies are not individualized to the physician-learner.6 Physicians are expected to learn specific knowledge and skills presented in different formats by experts and then to incorporate this learning into their own practices at a later time. Content in CME activities, especially delivered by lectures, often is not immediately relevant to a participant’s clinical practice. Evidence has shown that if the new knowledge is not directly relevant to the physician, then it is less likely that he or she will be able to integrate it in a way that ultimately enhances patient outcomes.2 There are important aspects to CME that may have value for participants, including confirmation of medical knowledge and reinforcement of good clinical practice.The methods to obtain CME chosen by practitioners are also shifting, as constraints of time and money are becoming increasingly influential in determining CME preferences. As clinical productivity demands have increased, physicians have found less time to allocate to CME activities and now desire more flexibility in meeting CME requirements for licensure and certification. A recent CME Needs Assessment Survey conducted by the American Academy of Pediatrics (AAP) randomly sampled 5500 pediatricians. Of the 1233 respondents (response rate of 22%), the reason most often given for not attending the Annual AAP National Conference and Exhibition was that it “took too much time away from work.”9 A similar physician CME preferences survey conducted on randomly selected members of the American Medical Association also cited meeting length and time away from practice as important factors influencing the decision whether to attend an out-of-town CME meeting.10 These 2 surveys further documented escalating costs as an issue contributing to limited CME attendance, as AAP and American Medical Association respondents respectively ranked it as the second and fifth most important reasons for not attending.9,10On the basis of these trends in physician preferences and a national shift in the process of recertification within medical specialties, CME is beginning to evolve into continuous professional development (CPD), a much broader view of physician activities that are directed at improving physician performance and ultimately clinical care. CPD includes CME activities, as well as self-directed learning moments sparked by clinical experiences or by attempts to monitor and improve one’s clinical care. “In the practice-learning environment, a physician will begin an educational activity not by entering a conference room but by reflecting on his or her practice performance.”3 Questions drawn from clinical experiences will stimulate learning opportunities. A fundamental premise yet to be proved is that self-directed learning, which places physicians in control of what they need to know and what they want to learn, will facilitate deeper and more enduring learning.1–3,7,11–13 New knowledge and skills acquired through this self-directed method may be more readily integrated into practice because the physician recognizes its relevance and application.The Accreditation Council for Continuing Medical Education has recognized “that the professional responsibility of physicians requires continuous learning throughout their careers, appropriate to the individual physician’s needs,” and that this requires them to “evaluate their own achievements.”14 Physicians today are more accountable than ever before, “mean[ing] that doctors now have to demonstrate that they are developing professionally and that their activities are educational and cost-effective and improve their practice.”5 In response to the need for “public accountability and the professional obligation for self-regulation,” professional boards that oversee the certification process have embraced the concept of CPD as a key element in the recertification process.15 The American Board of Pediatrics (ABP), the American Board of Medical Specialists, and the Accreditation Council for Graduate Medical Education have also acknowledged the need for practice-based learning and CPD.16,17 Periodic testing of medical knowledge will no longer be the sole standard by which physicians are certified. Instead, physicians will be required to document their ongoing educational activities and to demonstrate evidence of practice change as a result of these efforts.16 Key elements of the ABP’s recertification program include professional standing, commitment to lifelong learning and involvement in periodic self-assessment, cognitive expertise, and evaluation of practice performance. The common threads that highlight this recertification process are 1) the importance of linking with practice-based activities, 2) the need for self-evaluation, and 3) the establishment of a lifelong and continuous approach to professional development.The implementation of a program of CPD will require the use of sophisticated data management systems. Fortunately, the rapid growth in technology has provided physicians with resources and tools to aid them in a more individualized approach. The use of computers and the Internet will offer new possibilities for self-directed learning, specifically in the areas of clinical practice management and distance learning. Parboosingh18 with the Royal College of Physicians and Surgeons developed the Maintenance of Competence program in 1993. In this innovative program, physicians used paper diaries (and later, software) to manage their self-directed learning activities. Self-directed learning is essential in CPD because it gives practitioners control over how and when they seek and acquire knowledge and then how they link it to their daily practice. In addition, self-directed learning addresses the growing practical concerns of time and cost needed to complete traditional CME by allowing increased flexibility in the development of educational plans that meet the individual needs of physicians.Currently there are >150 web sites that offer online CME courses in comparison with only 13 just 3 years ago.19 Physicians who once struggled to find the time to dedicate to CME can now learn at their own pace, from the comfort of their own home or office computer. With an increase in the number of physicians who have computers and Internet access in their practices, current technology theoretically makes it possible to ask a question, learn about a topic in depth, find the answer, and then integrate it into practice without ever leaving the office.20 It is uncertain how quickly and how extensively physicians will use the Internet to meet their educational needs or to facilitate maintenance of certification. Considering the trends that we have cited, we believe that a significant proportion will adopt and embrace this technology.So what does this mean for pediatricians? The AAP recently launched PediaLink, an online home for CPD. The final report of the Future of Pediatric Education II Project21 suggested that the lifelong educational needs of pediatricians are best met when they have an established “CME home.” According to this report, a “CME home” should be designed to incorporate an assessment of the educational needs of the individual pediatrician, a database to facilitate access to local and national CME resources, and a system for constructing a professional learning plan unique to each individual pediatrician.PediaLink was designed as an Internet-based learning system to meet these needs.8 The PediaLink home page (Fig 1) serves as a portal to its major features: CME, Resources, and Advanced Features. Within the CME area, pediatricians find and register for courses, maintain their transcripts of educational activities and credit hours, or participate in online curricular offerings. Resources enables access to clinical information, the educational resources of the AAP and its CME activities, practice guidelines, and policy statements. In the future, Resources will also include a host of reviewed and reliable non-AAP materials, such as journals, textbooks, drug databases, patient information, practice management tools, and hyperlinks to other web sites. Within the Advanced Features section, users can organize and manage aspects of CPD with documentation tools and materials to link learning activities with practice changes. On the basis of the ABP’s requirements for maintenance of certification, PediaLink offers an approach to help meet these licensure and certification requirements.16The conceptual model of PediaLink is based on a theory of clinical problem solving adapted from Donald Schön’s cycle of learning22 (Fig 2). In day-to-day practice, pediatricians are confronted by clinical problems, questions, and surprises. Many of these questions may be answered almost instantaneously with tacit knowledge; other questions may provoke a quick search for an answer by accessing information sources (eg, looking up a drug dose or side effect). When a question stimulates thinking about how to answer or resolve the issue, the process is referred to as “reflection-in-action.” Inferences and conclusions drawn from these brief reflective moments may provide a broader understanding of the topic or lay the groundwork for future learning. It is not clear whether knowledge gained from accessing rapid information sources in this manner results in learning that is enduring.In contrast, when physicians record their clinical “I don’t knows” and later search for the answers to these questions, this process is referred to as “reflection-on-action” and may be more provocative, more stimulating to learning, and more influential in changing practice. Unfortunately, data show that many questions go unanswered.23,24 When questions are explored and answers are found, however, the learning that takes place is then directly linked with a clinical problem, which in turn may motivate physicians to change their practice. Ultimately, this cycle of learning should result in enhanced patient care. As clinicians continue to encounter new clinical problems in day-to-day practice, the cycle of learning repeats itself and forms a major element of a clinician’s CPD.With this learning cycle as its foundation, PediaLink has been designed as a system to facilitate and document the process of self-directed learning. In Fig 2, the conceptual model of PediaLink is depicted with its 3 major components, superimposed within our adaptation of the Schön model. Figure 2 demonstrates the relationship between Learner Profile, Learning Plan, and Learner Portfolio within the cycle of learning. A pediatrician’s Learner Profile includes personal and professional data and individual learning needs with a system to prioritize and record topics that arise from clinical practice or as result of online self-assessment (eg, Pediatrics Review and Education Program). The Learning Plan facilitates self-directed learning by linking needs with resources and prompting the user with its built-in reminder system, thus making possible the transition from reflection-in-action to reflection-on-action. The final step in incorporating learning into practice is facilitated by the Learner Portfolio in which pediatricians document their practice changes and enhancements to patient care. Computer technology via the interface of the Internet has enabled efficient and rapid searches and made integrative distance learning possible.To understand how PediaLink facilitates the learning cycle, it is helpful to imagine how a pediatrician might use the system and replicate our adapted learning cycle of Schön, as described in the following case scenario: The start of the new millennium marks a major shift in expectations for professional development and the maintenance of professional standing. In the past, it was sufficient to demonstrate periodically via written examination a base of professional knowledge for continuing certification within a field of medicine. Now we are obligated to maintain professional excellence in a time of enormously expanding knowledge and to ensure public trust. Furthermore, there is a pressing need to apply new knowledge to patients more rapidly to have more favorable outcomes. Raising the bar of expectations is intended to ensure public trust in the medical profession and to optimize the health status of our population.At the same time that expectations for professional standing are in flux, patients have access to more medical information, bringing new challenges to the practice of medicine. The Internet is providing a quick reference to the latest knowledge for both physicians and patients. “More patients are showing up for office visits with up-to-the-minute information about their condition gleaned from Internet browsing. To keep pace, physicians have no choice but to use the same resources.”25 To be effective in this age of information, physicians need to adjust their methods of acquiring and applying knowledge in practice. Although many physicians reject the notion of patients as “ consumers,” patients often are active consumers in their health care, especially in the acquisition of medical knowledge and information. This change in the knowledge and information demanded by patients may be an impetus for physicians to remain current in medical knowledge and might hasten the application of new knowledge to practice.Despite the explosion of medical information and dramatic changes in practice, the transformation of the learning process for physicians may lead to a more unifying and simplistic approach adapted from the concept of the reflective practitioner.21 In this approach, learning is self-directed and focused on enhancing patient outcomes. We believe that PediaLink is a comprehensive learning system that offers 1 method to support this essential paradigm for continuous professional development. It will be very important to evaluate the PediaLink learning management system, exploring several research questions relating to its use, its utility, and, ultimately, its effectiveness in affecting the care of patients and the practice patterns of pediatricians. PediaLink is still in its early stages, but with increased use of the system and with updates and refinements of the web site (http://www.pedialink.org), the intent is to build an individualized system that will meet the objectives of promoting lifelong learning, improving practice, and maintaining professional excellence.We have described both the driving forces for change in medical education and 1 system for managing the CPD of pediatricians. Although there will undoubtedly be other learning management systems available to physicians, the AAP has a commitment to provide its members with the same standards of authoritativeness, editorial oversight, reliability, and responsiveness that have always characterized their CME activities and helped achieve the mission of the AAP.