Lifelong learning for the family physician

Joel Dickerman, DO, St. Mary Corwin Hospital, Family Practice Residency, 902 Lakeview, Pueblo, CO 81004.

E-mail address: jldickerman@yahoo.com.

Most young physicians soon learn that graduation from medical school is the beginning of a self-directed lifelong learning process in which there are no textbooks, no lesson plans, and no professors to fall back on. Lifelong learning involves finding and implementing solutions to everyday problems encountered in the clinic, emergency department, surgical suite, or hospital ward, and then retaining that knowledge for future patient care scenarios.1 Thus, lifelong learning is a dynamic process by which physicians continually update their medical knowledge and skills to optimize patient care.

‌Elements of effective lifelong learning

Considered historically as an integral part of medical prac- tice, self-directed, lifelong learning really did not begin to become commonplace until the 1920s with the development of formal Continuing Medical Education (CME) programs. In the 1970s, prescribed CME requirements for licensure, credentialing, and specialty recertification were beginning to be established and implemented.2 By the 1990s, experts had begun to critically assess lifelong learning techniques to determine their relative effectiveness on improving the medical practice of physicians. Research revealed that the traditional CME lecture format was informative but fell far short in improving knowledge and practices.3 Hammond and Collins found that when learners took the initiative, with the support and collaboration of others, students not only learned more effectively but gained a sense of social awareness and responsibility and took personal responsibil- ity for their own learning.4 The knowledge that education could affect practice behavior led to a comprehensive eval- uation of physician lifelong learning by the Institute of Medicine as chronicled in the report “Health Professions Education: A Bridge to Quality.”5 This report concluded that medical education should go beyond the periodic ac- quisition of knowledge and skills to become a continuous process that includes multiple medical competencies5,6 that lead to measurable patient outcomes. Table 1 lists the ideal elements of lifelong learning medical education programs as outlined in this report.

Table 1 Elements of lifelong learning medical education programs—Summary of Health Professions Education: A Bridge to Quality report

Traditional Recommended

Periodic lectures and Continuous Assessment assessment

Knowledge- and skills- based

Focused on single- physician learner

Lecture-based

Outcomes measured by determination of new knowledge acquired (i.e., quiz)

Address multiple competencies (i.e., AOA/ACGME competencies or the Institute of Medicine’s 6 aims of medicine)

Focus learning on interdisciplinary medical teams as well as physician

Use multiple educational models that encourage active learner participation

Measure outcomes based on patient outcomes or direct application of knowledge or skill to patient care

‌Teaching students how to develop self-study habits can prepare them for learning after graduating. Adopting med- ical student and medical resident assessment processes to practicing physician education may help physicians mea- sure educational outcomes based on patient care and out- comes.

As a result of this report, programs have been developed to help support these concepts in medical education. Both osteopathic and allopathic medical students must now par- ticipate in performance evaluations at the second level of national board testing to assess the actual delivery of med- ical skills and knowledge at the bedside. Evaluation in- cludes not just medical knowledge but the ability to synthe- size medical information into a differential diagnosis and medical plan, as well as physician-patient communication and the ability to communicate to peers through a medical record. Both the American Osteopathic Association (AOA) and Accreditation Council for Graduate Medical Education (ACGME) adopted formal policies for graduate medical education that mandates the integration of medical compe- tencies in resident education. Graduate medical programs are encouraged to measure education in these areas by multiple methods including tests, chart reviews, 360-degree evaluations, formal clinical assessment, and medical simu- lation.

Osteopathic Continuous Certification (OCC) and Main- tenance of Certification (MOC) are the new processes pro- posed to replace previous certification programs. In addition to focusing on continuous education and assessment (vs. periodic recertification), OCC/MOC emphasizes self-as- sessment and performance improvement as a means to in- tegrate learning with patient care. Maintenance of Licensure (MOL) is a parallel process aimed at physicians who are not currently board-certified or are not required to undergo ongoing certification (i.e., “one-time” certification). Again the goal is to encourage physicians to take an active role in educational programs that continuously improve patient care.7

As medical education continues to evolve, it is hoped that these learning principles will be adopted into a contin- uous process from medical school to clinical practice.

‌Challenges to lifelong learning

Physician self-assessment of educational needs is consid- ered the cornerstone to lifelong learning. Each specialty and individual practice demands a variety of skills, necessitating each physician to develop skills in medical knowledge and skills assessment. Self-assessment can prove challenging, however. Without proper training in self-assessment, phy- sicians tend to identify need based on what they enjoy or already know.8 This may reflect the negative aspect of medical school and residency training that tends to belittle students for admitting “I don’t know.” Unfortunately phy- sicians have been conditioned to focus more on what they do well and not on what needs improvement.

Striving to improve can also hinder the educational pro- cess. Learning often involves initial failure, followed by re-evaluation and eventual success. Physicians have been trained to excel, often to the point they do not want to admit to their mistakes or take on new learning challenges. This tendency presents a unique challenge to performance im- provement education. The goal of performance improve- ment education is to connect practice improvement with medical education. If physicians fear failure, they may not be willing to take on difficult performance improvement activities, or they may discount the knowledge learned from an activity that does not initially improve performance.9

Physicians must also learn how to evaluate the true effectiveness of new medical knowledge in actual patient care. Physicians sometimes rely on anecdotal evidence (i.e., personal experience in one case) to develop generalizations to all patients with a similar medical issue. Although what works for one patient may work for others, physicians need to develop skills in the critical evaluation of medical out- comes to determine whether their own observations reflect the more general population.10

Conversely, physicians may quickly abandon an effec- tive medical strategy on the basis of one negative outcome. One study by Cairney et al. found that negative reinforce- ment by preceptors of the application of evidenced-based medicine discouraged its use by residents.11 Physicians must learn how to evaluate the patient outcomes of a par- ticular medical process or knowledge application worked for their patient, and how to systematically apply medical evidence in clinical practice.

First, lifelong learning cannot be an expensive or an obtrusive process. There is some concern that as models for OCC/MOC and MOL are developed, they will be viewed simply as new revenue streams for medical educators. Sec-

Table 2 Challenges to lifelong learning

Requirement

Self-assessment of educational needs

Evaluation of the impact of medical education of clinical outcomes

Adopting “new” medical knowledge and skills to clinical practice

Comprehensive ongoing physician education and assessment

Challenge

Physicians may not be skilled in the identification of educational needs

Physicians may not be skilled in how to measure clinical outcomes related to medical education

Physicians must learn to overcome historical biases to changes in clinical practice

Cost to physician and fear process will require extended periods of time away from practice

ond, they cannot require physicians to take extended leaves from clinical practice to complete. It is hoped that medical school and residency educators will work with specialty colleges, state licensing boards, and national board exam- iners to share resources and skills to develop lifelong learn- ing programs that are effective, efficient, and readily acces- sible. A summary of the challenges to lifelong learning is listed in Table 2.

‌Innovations in physician educational needs self-assessment

One method of improving physician self-assessment of ed- ucational needs is for physicians to “audit” their clinical performance against performance benchmarks. In this pro- cess, outside organizations such as the Agency for Health- care Research and Quality (AHRQ) or specialty colleges identify both the quality measure and the recommended standard.12 Physicians then compare their own performance against these standards to determine possible educational need and identify educational programs to improve clinical performance.

Tools that may assist in the audit process include the AOA Clinical Assessment Program (CAP),13 the AHRQ Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient survey instrument,14 and the ACGME Assessment Toolbox.15 The CAP program is designed to allow providers to assess their clinical performance against national standards in diabetes, coronary artery disease, and women’s health screening. The CAHPS instrument can be used to evaluate patient experiences both in ambulatory and facility environments. The ACGME Assessment Toolbox was designed to assess residents in postgraduate training. Tools include performance checklists, the 360-degree eval- uation, and chart review. All of these instruments are de- signed to assist physicians in the performance of an audit of their own practice and provide tools for them to compare

practice results with national benchmarks. Results can help identify areas of need for future education and improve- ment.

In recent years, physician self-assessment of educational needs and integration of learning with practice improvement have been encouraged through Performance Improvement CME activities (PICME).16 The process includes: (1) Iden- tification of a performance measure to evaluate clinical performance (i.e., how often a foot examination is done in the physician’s diabetic patient population); (2) data collec- tion and analysis regarding current performance; (3) devel- opment of a plan to improve performance; and (4) re- evaluation of performance through data collection and reflection on why (or why not) the intervention improved performance. The process often involves a literature review to assist with the development of effective interventional strategies.

Physicians are encouraged to use evidenced-based re- sources to develop effective performance improvement (PI) interventions. The focus of PI activities should include the educational process, not just practice outcomes. Failure to improve a clinical performance issue can provide as much education to the physician as an improvement in perfor- mance and should not discourage physicians from partici- pating in PI educational activities. Table 3 lists resources for physician educational needs self-assessment.

‌Technology and lifelong learning

Technological advances have made lifelong learning not only effective, but efficient and readily accessible to the practicing physician.17 Technological advances include the development of distance-learning technology (i.e., live and recorded Web-based presentations), multimedia education (e.g., videos, slide presentation, recorded narration, interac- tive questions and quizzes), medical simulation, and the de- velopment of Internet-based medical information. These de- velopments can make medical education readily available at any time and any place regardless of schedule or practice location. In addition, the electronic nature of these resources means they can be updated readily much more quickly than print media. Finally, these advances can promote a variety of learning methods and styles, making medical education much more effective for a diverse group of learners.

Point of care learning (PoCL) is an example of how technology has been used to develop an effective lifelong program. PoCL is the process of answering a clinical ques- tion or researching a medical issue at the time of patient care.18 Three factors have made this process readily avail- able and efficient at the time of care: (1) Development of evidence-based resources readily available on the internet (i.e., UpToDate, Cochrane reviews); (2) development of smart phone– and smart pad– based devices that make In- ternet-based resources readily available at the time of a patient visit; and (3) development of searchable Internet-

Table 3 Physician educational needs self-assessment resources

Self assessment process Auditing tools

Quality measures and guidelines

Resources

AOA Clinical Assessment Program (CAP) http://cap.osteopathic.org/

AHRQ Consumer Assessment of Healthcare Providers and Systems (CAHPS) patient survey instrument https://www.cahps.ahrq.gov/default.asp

ACGME assessment toolbox http://www.acgme.org/outcome/assess/assHome.asp QualityNet

http://www.qualitynet.org/ HealthTeamWorks

Guidelines and Supplemental Materials http://www.healthteamworks.org/guidelines/guidelines.html AHRQ

National Guideline Clearinghouse http://www.guideline.gov/

based journal databases (i.e., PubMed, Google Scholar, MEDLINE) that allow for rapid access to the most current medical information. Although searching for medical infor- mation itself is not necessarily an educational experience, formal PoCL consists of four components: (1) Identification of a medical question/issue related to direct patient care; (2) identification of an evidenced-based medical resource to answer the question (which may include a formal literature search); (3) critical review of that medical resource as it pertains to a patient’s care; and (4) reflection on the clinical outcome of the application of that medical information to patient outcome (i.e., did it help, why or why not, how would I use this information in future cases?). The Ameri- can Medical Association has developed guidelines and re- sources to assist in the PoCL process to ensure that it truly supports lifelong learning.16

Simulation in medical education has gained increasing interest in the past few years with the recognition that simulation in airplane pilot training can serve to educate and train without putting others at risk.19,20 Medical simulation can provide students a means to practice new techniques before applying them to a real patient. Simulation not only provides a means of learning a specific skill or technique, but it can provide a student the possibility of applying a newly learned skill in a variety of settings such as the emergency department, medical ward, outpatient clinic, or in the field. Simulation can also provide an opportunity for interdisciplinary teams to practice response to a medical scenario and practice intercommunication skills.

High-tech simulators, such as anesthesia or obstetrical simulators, are best used to simulate complex procedures and complex medical scenarios. Low-tech simulators, such as advanced cardiac life support, basic cardiac life support, or suturing simulators, are ideal for providing training in common procedures to large numbers of students. Both high-tech and low-tech simulation can be self-contained learning experiences or used in a process called simulation in situ. Simulation in situ consists of creating a mock med- ical scenario in an actual medical setting where a simulator is used to represent an actual patient. Simulation in situ

provides an opportunity for interdisciplinary teams to prac- tice an emergent medical scenario in a real medical setting, including the practice of emergency procedures and tech- niques.21 Simulation in situ is ideal for preparing teams to respond to respiratory arrests, obstetrical emergencies, acute traumas, and cardiac arrest.

Computer-based simulators are programs that can pro- vide multimedia education for a number of medical scenar- ios. Programs usually consist of case presentations, didactic education, and videos of procedural skills.22 Computer- based simulation can be used to train students before actual clinical practice or as a pre-educational module for more formal simulation. Table 4 summarizes technology-based resources for medical education.

Although technology can help support lifelong learning, it is not without its critics. Technology-based learning may be efficient and accessible, but it does not easily lend itself to interactive physician discussion. CME lectures and con- ferences not only provide a venue for case discussion but may also provide an opportunity to develop skills in peer- to-peer communication and professional development. There is also concern that patient care may “lose the human element,” being distilled simply to a series of computer- based decision-making models. Reliance on computers or smartphone technology at the time of patient care may also interfere with direct physician-patient interaction. In addi- tion, rural physicians may have limited high-speed Internet access or reliable smartphone signals.

‌Programs in lifelong learning: Osteopathic Continuous Certification

The OCC program was developed to combine many of the elements of lifelong learning listed here into a comprehen- sive educational process.23 The five elements of OCC are:

(1) Maintenance of an unrestricted medical license, (2) continuing medical education, (3) cognitive assessment, (4) practice performance assessment and improvement, and (5)

Table 4 Technology and lifelong learning Technology Advantages

Web-based presentations Readily available to learner; may be available

anytime if recorded

Web-based evidence-based Readily available, especially with smartphone medicine resources technology; easy to keep updated

Web-based journal databases

Rapid access to searchable journal databases

Limitations

May limit learner participation in educational experience

May make medical care “cookbook”; physicians must still be able to “critically appraise” resource; should not interfere with patient-provider dialog

Not all full-text journals available without a fee; physicians may get “caught-up” in literature search and lose track of time

Multimedia education Can provide multiple educational formats including Can sometimes overwhelm the learner (too much

Simulation

procedural videos, slide shows, and interactive questions/quizzes; very good for preparing for a medical procedure or process

High-tech simulators can simulate high-risk procedures and scenarios; low-tech simulators can help teach common procedures and provide preparation for high-tech simulation

input); requires training in multimedia production; limited use for PoCL education

High-tech simulators can be very costly and require specialized training staff; physicians may find it difficult to immerse themselves into simulation

continuous AOA membership. This process is to be imple- mented by January 1, 2013. The goal of this program is to promote lifelong learning through a continuous process of education, assessment, and application of learning to the delivery of optimal patient care. This process parallels the MOC process developed by the American Board of Medical Specialties.24 Osteopathic physicians who currently possess lifetime certification are not required to participate in this program but are encouraged to do so as a means to facilitate lifelong learning. Osteopathic physicians who have time- limited certification will find the process to mirror current certification processes, with the addition of a performance improvement CME activity. For many physicians, this per- formance improvement activity can be undertaken as an integral part of the daily practice of medicine. Each osteo- pathic certifying board is currently developing specific guidelines and tools for the OCC process.

‌Future directions in lifelong learning

Over the past decade, there has been a significant push to train students in techniques that will enable them to be lifelong learners. These changes have generated new inter- est in the development of medical education systems that will be applicable to the practicing physician. To be truly effective, lifelong learning programs must reflect the com- plexities of clinical practice and incorporate the needs and preferences of physicians. They must also be cost-effective and readily available to the actively practicing physician.

Future developments and challenges to lifelong learning will include defining the role of assessment in medical education and how to make lifelong learning and continuous practice improvement seamless. Both conversations can serve to improve the efficacy and safety of medical care

delivery, even as new medical information and technology continue to evolve in the coming decades.

The authors welcome any comments or feedback on this article and on the topic of lifelong learning.

‌References

1. ‌Schweinfurth JM: Lifelong learning in otolaryngology: self-directed learning. Otolaryngol Clin North Am 40:1323-1330, 2007‌

2. ‌Brandt B, Shanedling J: Is the CME system obsolete? Minnesota Medicine November 2010

3. ‌Davis DA, Thomson MA, Oxman AD, et al: Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 274:700-705, 1995

4. ‌Hammond M, Collins R: SDL: Critical Practice. New York: Nichols/ GP Publishing, 1991

5. Institute of Medicine of the National Academies: Health professions education: a bridge to quality. 2003. Available at: http://www. iom.edu/Reports/2003/Health-Professions-Education-A-Bridge-to- Quality.aspx. Accessed February 25, 2011.

6. Association of Medical Colleges: Lifelong learning initiative. Avail- able at: https://www.aamc.org/initiatives/cme/92604/lifelong/. Ac- cessed February 25, 2011.

7. American Osteopathic Association: Inside the AOA. AOA backs main- tenance of licensure. 2010. Available at: http://www.osteopathic. org/inside-aoa/news-and-publications/media-center/2010-news-releases/ Pages/aoa-backs-maintenance-of-licensure-for-physicians.aspx. Ac- cessed February 27, 2011.

8. ‌Davis DA, Mazmanian PE, Fordis M, et al: Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA 296:1094-1102, 2006

9. ‌Staker LV: Teaching performance improvement: an opportunity for continuing medical education. J Contin Educ Health Prof 23(Suppl 1):S34-S52, 2003

10. Bowen S, Erickson T, Martens PJ, et al: More than “using research”: the real challenges in promoting evidence-informed decision-making. Healthc Policy 4:87-102, 2009

    
    

11. Cairney W, Saunders J, Saunders K, et al: How family practice residents learn and apply new medical knowledge. Medical Monograph. 2005. Available at: https://sites.google.com/site/cahead5/practice-based-researh- network. Accessed February 27, 2011.‌

12. ‌Duffy FD, Holmboe ES: Self-assessment in lifelong learning and improving performance in practice: physician, know thyself. JAMA 296:1137-1139, 2006

13. American Osteopathic Association: AOA Clinical Assessment Program. Available at: http://www.osteopathic.org/inside-aoa/development/quality/ cap-for-hysicians/Pages/default.aspx. Accessed February 27, 2011.

14. Agency of Healthcare Research and Quality: Consumer Assessment of Healthcare Providers and Systems. Updated 2011. Available at: https:// www.cahps.ahrq.gov/default.asp. Accessed August 22, 2011.

15. ACGME: Outcomes Project–Toolbox of Assessment Methods. http:// www.acgme.org/outcome/assess/toolbox.asp. Accessed August 22, 2011.

16. American Medical Association: The Physicians Recognition Award and credit system. 2010 revision. Chicago: AMA, 2010, pp 6 –7. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/455/pra- booklet.pdf. Accessed February 28, 2011.

17. Lowe MM, Aparicio A, Galbraith R, et al; American College of Chest Physicians Health and Science Policy Committee: The future of con- tinuing medical education: effectiveness of continuing medical educa-

    ‌tion: American College of Chest Physicians Evidence-Based Educational Guidelines. Chest 135(3 Suppl):69S-75S, 2009

18. ‌Sinusas K: Internet point of care learning at a community hospital. J Contin Educ Health Prof 29:39-43, 2009

19. Ziv A, Wolpe PR, Small SD, et al: Simulation-based medical educa- tion: an ethical imperative. Acad Med 78:783-788, 2003

20. ‌Issenberg SB, McGaghie WC, Petrusa ER, et al: Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach 27:10-28, 2005

21. ‌Kobayashi L, Dunbar-Viveiros JA, Sheahan BA, et al: In situ simu- lation comparing in-hospital first responder sudden cardiac arrest re- suscitation using semiautomated defibrillators and automated external defibrillators. Simul Healthc 5:82-90, 2010

22. ‌Scalese RJ, Obeso VT, Issenberg SB: Simulation technology for skills training and competency assessment in medical education. J Gen Intern Med 23(Suppl 1):46-49, 2008

23. American Osteopathic Association: Osteopathic Continuous Certi- fication Program. Available at: http://www.osteopathic.org/inside- aoa/development/aoa-board-certification/Pages/osteopathic-continuous- certification.aspx. Accessed March 1, 2011.

24. American Board of Medical Specialties: Maintenance of Certifica- tion Program. Available at: http://www.abms.org/Maintenance_of-

_Certification/. Accessed March 2, 2011.