The Mergansers enjoy an early morning sunbath, sitting on the dock of the bay … 

Mother and offspring reflect on their enjoyment of this lovely morning … 

Mother Merganser, always alert, spies an approaching kayak … 

Ducklings! Into the water!! NOW!!!  

The ACCME commissioned and has just released this literature review:

Cervero RM, Jiang H. The Relationship between Commercial Support and Bias in Continuing Medical Education Activities: A Review of the Literature. Accreditation Council on Continuing Medical Education, June 2008.

Background and Purpose (excerpt) : As the foundations for modern approaches to medical education were being built in the early years of the 20th century, William Osler fretted about the encroachment of pharmaceutical companies. He was concerned that physicians may come to rely on the “specious and seductive pamphlets issued by pharmaceutical houses, the bastard literature which floods the mail” and the salesmen who “are ready to express the most emphatic opinions on questions about which the greatest masters of our art are doubtful” (Osler, 1906, pp. 300-301). What was once a minor distraction in the early part of the last century has turned into a full-blown issue in the past two decades as attention has focused on how commercial interests impact medical practice, research, and education (Angell, 2005; Blumenthal, 2004; Brenann et al., 2006; DeAngelis, & Fontanarosa, 2008). This has become a much more serious issue now because: “Interactions between drug companies and doctors are pervasive. Relationships begin in medical school, continue during residency training, and persist throughout physicians’ careers. The pervasiveness of these interactions results in part from a huge investment by the pharmaceutical industry in marketing” (Blumenthal, 2004, p. 1885). The concern raised in the literature is that industry support of research, education, and practice creates potential “conflicts of interests between physicians’ commitment to patient care and the desire of  pharmaceutical companies and their representatives to sell their products” (Brennan, et. al., 2006). This concern has gained a great deal of traction because of the argument’s face validity that pharmaceutical companies and device manufacturers would make such marketing investments precisely because there was a demonstrable positive impact on product sales. For example, a recent study (Steinman et al., 2006) showed how Parke-Davis’s marketing plan used many avenues, including research, publication, and educational activities, to promote the use of Gabapentin.

From the conclusion:
It is necessary at this time to initiate rigorous scientific studies to address important questions about the relationship between commercial support and bias in CME. The
research could focus on several questions:
• Does commercial support produce bias in CME activities?
• What are the mechanisms by which bias is produced?
• Are accreditation guidelines or other strategies effective in preventing bias?
• In what ways does commercial support of CME contribute to physicians’ adoption of the sponsor’s product in the context of the other influences on their clinical
decision-making?
• As a result of commercially-supported CME, does physicians’ adoption of the sponsor’s product lead to better patient care?

   The 2008 CME Congress was held in Vancouver from May 29 - 31. The conference organizers have kindly made available the PowerPoint presentations of the plenary speakers.   (The documents are in PDF format. And be patient, they download rather slowly.) The slides are not as compelling as are the words of excellent speakers such as Glenn Regehr, unfortunately.

• Holmboe, Dr. Eric. Physician Competence Assessment
• Gilbert, Dr. John. Interprofessional Learning.   Discussant (Frank, Dr. Blye)
• Kilo, Dr. Charles. Educating Physicians for Systems
• Harrison, Dr. Van. Reconsidering CME’s Functions in a System
• Regehr, Dr. Glenn. Contributions from Learning Theory: Self-Assessment, Self-Direction, and Other Myths: Implications for the Self-Regulating Professional.  Discussant (Dr. Dave Davis)
• Tang, Dr. Grace. Advancing the CME/CPD Agenda - Dr. Grace Tang
• Global Challenges in CME/CPD: Dr. Marietjie de Villiers, Dr. Barry Taylor, Dr. Ian Starke, Dr. Eng Hin Lee
• Dauphinee, Dr. Dale. Closing Plenary

Here are the conference brochure and the conference abstracts.  And here is yours truly enjoying the gorgeous rhododendrons.

This May 1 article in The Independent (U.K.) outlines the history and some of the highlights (or lowlights) of the LSD era: Trip of a lifetime: How LSD rocked the world

If you are old enough to remember the 60s, you might enjoy watching these videos from that time. The first records an experiment with British troops, and the second shows an extremely stoned Jim Morrison singing Light my Fire. (Of course, you know what they say about remembering the 60s …)

This chapter is from the final report of Continuing Education in the Health Professions: Improving Healthcare Through Lifelong Learning, the Macy Foundation report on continuing health education.

Moore DE Jr. How physicians learn and how to design learning experiences for them. From: Continuing Education in the Health Professions: Improving Healthcare Through Lifelong Learning. New York: Josiah Macy, Jr. Foundation, 2008, p. 30-62.

Excerpt: Researchers from multiple studies over the past several years have reported that there are distressing gaps between the healthcare services that patients receive and those that they could be receiving. These studies show that many patients do not receive the best possible care, receive suboptimal care, or are victims of errors, despite the fact that approaches to care are improving and demonstrating enhanced outcomes. A variety of approaches have been suggested to address this gap. Continuing medical education (CME) has been a longstanding suggestion. For many years, however, people have expressed concerns about the effectiveness of CME. As a result, confidence in the ability of CME to address the identified gaps in healthcare delivery was not high. But significant work over the past 20 years has demonstrated the effectiveness of CME, if it is planned and implemented according to approaches that have been shown to work.

This interpretive essay reviews the evidence that describes how physicians learn and proposes six principles from that evidence and research from other fields that can be used to plan formal educational activities designed to facilitate physician learning. Next, the essay proposes an instructional design approach for designing effective formal CME activities. Finally, the essay briefly discusses assessment of formal CME activities.

Table 1. Stages of Learning
Table 2. Questions Physicians Have at Each Stage of Learning
Table 3. CME Planning that is Responsive to Questions that Physician Have at Each Stage of Learning
Table 4. Educational Methods in Formal CME
Table 5. Planning Pre-disposing CME Activities
Table 6. Planning Enabling CME Activities
Table 7. Planning Reinforcing CME Activities
Figure 1. Systems Overview of CME as an Intervention
Figure 2. Levels of Physician Learning and Assessment
APPENDIX A: How Nurses and Pharmacists Learn

The final report is available as of May 16, 2008:
Continuing Education in the Health Professions: Improving Healthcare Through Lifelong Learning. A Conference Sponsored by the Josiah Macy, Jr. Foundation. Chaired by Suzanne W. Fletcher, M.D., M.Sc. Bermuda,  November 2007. Edited by Mary Hager, Sue Russell, and Suzanne W. Fletcher, M.D., M.Sc. New York: Josiah Macy, Jr. Foundation, 2008.

CONTENTS
I. APPROACHES TO KNOWLEDGE DEVELOPMENT— WHAT WORKS AND WHAT DOES NOT (p. 29)
How Physicians Learn and How to Design Learning Experiences for Them
—Donald E. Moore, Jr, PhD (p. 30-62)
Transforming Continuing Medical Education Through Maintainence of Certification
—F. Daniel Duffy, M.D.
Internet Continuing Education (p. 82)
—Denise Basow, M.D
Informatics Skills Needed!
—Donald A.B. Lindberg, M.D
—David C. Slawson, M.D.

II. FINANCING CONTINUING EDUCATION: WHO, HOW, AND WHY (p. 103)
Financial Support for Continuing Education in the Health Professions
—Robert Steinbrook, M.D.
—Jordan J. Cohen, M.D.

III. DESIGNING SYSTEMS FOR LIFELONG LEARNING TO IMPROVE HEALTH (p. 141)
Continuing Health Professional Education Delivery in the United States
—David A. Davis, M.D., and Trina Loofbourrow, B.A.
—Pamela Mitchell, Ph.D., M.S., B.S.
Learning to Work Together to Improve the Quality of Healthcare
—Maryjoan D. Ladden, Ph.D., R.N.
—Carol Havens, M.D

IV. REACTION FROM THE TRENCHES (p. 195)
—Grant S. Fletcher, M.D., M.P.H.
—James A. Clever, M.D.
—Susan W. Wesmiller, M.S., R.N.
—Regina Benjamin, M.D., M.B.A.

V. MOVING TOWARDS THE FUTURE (p. 209)
Continuing Medical Education: Some Important Odds and Ends
—David C. Leach, M.D.

Discussion Highlights (p. 216)
Conference Conclusions and Recommendations (p. 219)
Additional References Suggested by Conference Participants
Biographical Sketches and Statements of Potential Conflicts of Interest of Conference Participants

For reactions to the chairman’s summary of this report, see this page.

  The article below was recently published in the Journal of Medical Licensure and Discipline. This is the journal of the Federation of State Medical Boards. Copies of the article may be ordered from the journal Web site.

Mazmanian PE, Galbraith R, Miller SH, Schyve PM, Kopelow M, Thompson JN, Aparicio A, Davis DA, Kahn NB Jr. Accreditation, certification, and licensure: How six general competencies are influencing medical education and patient care.  Journal of Medical Licensure and Discipline 2008; 94(1):8-14.

Abstract: Lifelong learning and self-assessment are tenets of medical education and health care improvement; patient safety and quality care are essential to the accreditation of organizations providing either continuing medical education (CME) or patient care. Accredited CME providers must assess the learning needs of physicians. Accredited health care organizations must document physician participation in education that relates to the nature of care, treatment and services provided by the hospi tal. The credentialing and privileging of medical staff requires ongoing focused professional practice evaluation based on six general competencies, including compassionate care, medical knowledge, practice-based learning and improvement, effective communication, demonstrated professionalism and coordinated systems-based practice.

As those charged with assessment and program evaluation are challenged to produce valid and reliable results to improve education and health care, United States licensing authorities are defining good medical practice and considering competency-based maintenance of licenses. The present paper offers a framework to advance the discussion of relative value credits for gains assessed in knowledge, competence and performance of physicians. A more synchronized and aligned consortium of medical licensing boards, specialty boards and organizations granting practice privileges is recommended to inform the design of education and physician assessment to assure patient safety and quality improvement.

From the same issue:
What’s That Knocking?
Medical licensing boards, if they existed in a state, were unable to measure physician competence because there was no agreement on the core knowledge or skills required to be a competent physician . Medical practice has seen some profound transitions during the past few decades …

State Medical Board Responses To An Inquiry On Physician Researcher Misconduct
Misconduct in clinical research jeopardizes the integrity of medical science. Physician researcher misconduct that produces flawed results has consequences, including the subsequent inability of other physicians who rely on erroneous data to provide informed consent and/or accurate assessment of pharmaceutical and medical device efficacy and safety. This deviation from acceptable medical practice can directly harm patients. How state medical boards address this clinical problem is uncertain. To examine this issue, we asked 51 U.S. medical boards to search their databases for disciplinary action in response to physician researcher misconduct (PRM) from 1996 thru early 2007. We compared their responses with data from federal agencies responsible for disciplinary actions against clinical researchers. Our results demonstrated:
 i) a high percentage (45 percent) of U.S. medical boards indicated that they did not have or could not provide access to data adequate to address whether or not disciplinary action for PRM had been levied in their states and
 ii) of respondents able to make relevant information available, we identified only 13 cases of physician disciplinary action for PRM. In contrast, several dozen examples of disciplinary action against physicians for serious clinical research misconduct could be readily documented in publicly accessible data from federal regulatory agencies.

   This new BEME Guide was just published in Medical Teacher:

Colthart I, Bagnall G, Evans A, Allbutt H, Haig A, Illing J, McKinstry B.  The effectiveness of self-assessment on the identification of learner needs, learner activity, and impact on clinical practice: BEME Guide no. 10. Med Teach 2008 Mar;30(2):124-45. [subscription required]
Read the full abstract       View the full issue

Excerpt:
Background: Health professionals are increasingly expected to identify their own learning needs through a process of ongoing self-assessment. Self-assessment is integral to many appraisal systems and has been espoused as an important aspect of personal professional behaviour by several regulatory bodies and those developing learning outcomes for clinical students. In this review we considered the evidence base on self-assessment since Gordon’s comprehensive review in 1991. The overall aim of the present review was to determine whether specific methods of self-assessment lead to change in learning behaviour or clinical practice. Specific objectives sought evidence for effectiveness of self-assessment interventions to:
a. improve perception of learning needs;
b. promote change in learning activity;
c. improve clinical practice;
d. improve patient outcomes.

Practice points:
*There is no solid evidence base within the health professions’ literature which establishes the effectiveness of self-assessment in: identifying learner needs; influencing learning activity; changing clinical practice.
*The accuracy of self-assessment in clinical training may be improved by increasing the learner’s awareness of the standard to be achieved.
*There is some indication that practical skills in clinical training may be better self-assessed than knowledge-based activities.
*Self-assessment needs to be used as one tool amongst other sources of feedback to provide a more complete appraisal of competence in health care practice.
*Future research should address the role that self-assessment plays in the everyday practice of health care decision-making.

See also   BEME Guides in Medical Education: the series

  The Task Force on Industry Funding of Medical Education has issued its final report for consideration in June by the AAMC Executive Council. The task force included institutional leaders; faculty; residents; students from the AAMC governance; CEOs from the pharmaceutical, biotechnology, and medical device industries; ethicists; and public representatives. It was funded by the Josiah Macy, Jr Foundation.

See also this April 29 editorial from the New York Times: Should They Send a Thank-You Note? ; The bloggers are also commenting on the AAMC report ;
See also  Continuing Education in the Health Professions: Improving Healthcare Through Lifelong Learning (Macy Foundation)

The report: Association of American Medical Colleges. Report of the AAMC Task Force on Industry Funding of Medical Education to the AAMC Executive Council.  For consideration, June 18-19, 2008. Washington: AAMC, 2008.

From the report:
The Report acknowledges the new policy directions being implemented in many medical schools and teaching hospitals to address industry support of medical education, and it urges all academic medical centers to accelerate their adoption of policies that better manage, and when necessary, prohibit, academic-industry interactions that can inherently create conflicts of interest and undermine standards of professionalism. Although the charge to the Task Force was focused on funding from the pharmaceutical and device industries, institutional policies on conflicts of interest should be comprehensive and encompass providers of equipment and services as well.  Concomitantly, industry should voluntarily discontinue those practices that compromise professionalism as well as public trust.

More on AAMC Financial Conflicts of Interest in Academic Medicine