Chapter 5 Consider the two scenarios presented below. These are not uncommon scenarios; many physician-teachers and course organizers are confronted with the challenge of making presentations to colleagues, to other health professional audiences, even to the public and, when given the opportunity to reflect, have a strong desire to improve this ‘product’, to make it more effective. From a personal perspective, doing a ‘good job’ brings the satisfaction of having accomplished a task well, most often recognized by the audience to which you are presenting. There is, however, another perspective, sizably different from the case in undergraduate teaching or residency training. Like the work of clinicians themselves, teaching by well-prepared faculty and the effective educational intervention itself can bring about practice change and affect healthcare outcomes (Davis et al 1995) on a more immediate and possibly rewarding basis than undergraduate teaching and residency training. Further, while the steps to improving continuing professional development (CPD) are important, perhaps even self-evident in any teaching exercise, they assume far greater importance in the realm of practice. Here, one is engaged in a process of communication with peers: colleagues with their own practice needs, styles and requirements, and, moreover, their own areas of expertise. Consider the first scenario. In the Canadian context, ‘primary care clinicians’ can imply many types of practitioners, from semi-autonomous physician assistants or nurse practitioners to independent, self-regulating physicians who may be general practitioners (neither trained in family medicine nor certified by the national body) or family physicians, often with two or more years of specialty training in this complex discipline. In the United States, primary care is more eclectic in its mix: paediatricians, obstetricians, general internists, physician assistants, nurse practitioners and family physicians (general practitioners) may comprise the audience. ‘Primary care clinicians’ might also comprise teams, given the increasing emphasis on interprofessional collaboration as a means to improve healthcare and patient outcomes, and the role of interprofessional education in fostering the skills and behaviours necessary for effective collaboration (Health Canada Interprofessional Collaboration 2011). Thus, the primary care ‘team’ may consist of a range of healthcare professionals, such as physicians, nurses, social workers, dieticians and pharmacists, each bringing a particular role and perspective to the primary care setting (Goldman et al 2010, Meuser et al 2006). Other participants’ attributes that may be relevant are methods of payment and practice types or settings since these affect learners’ abilities to maintain or deliver practice competencies. In the second scenario, declining rounds attendance may imply a strict fee-for-service environment, a frequent occurrence in the North American setting, in which time away from practice settings is not reimbursed. It may also imply that grand rounds activities frequently address only the resident case of the week or research project, or highlight a visiting speaker, and are often not related to the daily activities of most attendees. In some instances, physicians may receive incentives for attending CPD activities. For example, physician practices enrolled in the Practice Incentives Program in Australia may receive payment for participating in Quality Prescribing Incentive activities (such as clinical audits, case studies, practice visits) (Australian Government Department of Human Services 2012). On the other hand, there are countervailing forces in the form of professional and regulatory guidelines that may compel physicians to participate in such events. In regards to licensure, there are guidelines that suggest a minimum number of hours of formal continuing education or CPD for a wide variety of physician groups. It is useful to know what these are for each jurisdiction and, where possible, to tailor interventions to meet them. For example, in the case of the Royal College of Physicians and Surgeons of Canada, additional CPD ‘points’ may be gained by asking physicians to perform pre-workshop chart audits, post-lecture structured reading and reflection exercises, or personal learning projects resulting from participation in a CPD activity (Royal College of Physicians and Surgeons of Canada). Similarly, in the United States, there are programmes based on recertification or maintenance of certification (American Board of Family Medicine, American Board of Internal Medicine, American Board of Medical Specialties). Further, the Accreditation Council for CME (ACCME) increasingly requires proof of competence, such as pre-/post-multiple choice tests, or performance, such as hospital measures, in addition to attendance at such activities (Accreditation Council for Continuing Medical Education). Some states in the United States have required CME topics such as human sexuality and risk management; tailoring the message to these issues where appropriate and relevant might increase attendance and participation (American Medical Association 2010). Subjective needs assessments reflect physicians’ perceptions of problems and their experiences and learning styles and provide insight into their priority learning areas. These assessments can stimulate participation in CPD since physicians may be motivated to acquire additional knowledge in these identified areas (Moore 2003). Although self-assessment may seem straightforward, evidence suggests that physicians have difficulties performing accurate assessments by themselves, uninformed by external observations or data (Davis et al 2006). Given that self-assessment has been criticized for the lack of abilities in ‘self-reporting’ (Lockyer 1998), objective information and data on which to base judgments are also required. The work of Fox and his colleagues (1989) is enlightening (and possibly humbling) to the CPD provider: it reveals that multiple factors affect practice changes and the diverse types of practice changes. In this qualitative study, over 300 North American physicians were asked, ‘What did you most recently change in your practice? What caused that change? How did you acquire your learning in order to make that change?’ Answers to each of these questions may help the CPD provider, whether teacher or organizer, prepare for this audience. First, physicians undertaking any change disclosed that they had an image of what that change was going to look like, such as a surgeon envisaging competently performing a new laparoscopic technique. Second, the forces for change in this study were widespread: while some drew from educational and CPD experiences, many more were intrapersonal (e.g. a recent experience with a dying relative, a life or career transition) or arose from changing patient demographics (e.g. ageing or changing populations and patient demands). Third, the changes varied from smaller ‘adjustments’ or accommodations (e.g. adding a new drug to a therapeutic armamentarium within a class of drugs already known and prescribed) to much larger changes characterized as ‘redirections’ (e.g. adopting an entirely new way or method of practice, or adding a nursing home to a practice population which previously included few elders). Smaller modifications in practice might be accomplished with a brief CPD presentation, or even a didactic lecture; however, larger changes require a much richer CPD experience, perhaps encompassing a combination of a highly interactive session such as a hands-on workshop, and possibly a refresher or practical experience in the work setting. A useful question to ask when preparing a presentation is ‘What do audience members know or believe in regards to this particular issue?’ A valuable model to use to address this question is that of Pathman et al (1996). In this model, Pathman outlines a continuum from awareness to agreement to adoption to adherence in regard to new information or clinical knowledge. The agreement stage is important in the case of clinical practice guidelines: for example, in the adoption stage a practice is picked up and implemented, though not uniformly or regularly, and in the adherence stage the clinical knowledge is consistently applied effectively and appropriately. Which CPD format is used at which stage depends on the particular stage along the continuum being targeted (Davis et al 2003). For example, didactic lectures may be chosen to promote awareness of an issue, while peer input and small group learning would be more appropriate for the agreement stage. Objective needs are practice gaps or areas in which clinical evidence has not been readily translated into practice. Examples of such gaps are not difficult to find. The Institute of Medicine’s 2011 report titled ‘Relieving Pain in America’ points to large gaps in knowledge and skills among American physicians and other health professionals in pain diagnosis and management (IOM Report 2011). There are many other examples of clinical care gaps, varying only by country, clinical area, healthcare setting and other variables. There are also many tools available to measure these gaps; they are presented in the following. Each needs assessment strategy enables the collection of different types of information and has an extensive body of literature on methods and effectiveness. The purpose of the needs assessment should determine the strategies used; a combined approach provides a more comprehensive understanding of the situation (Grant 2002). It is useful to think of the format or educational process in CPD less as a lecture or presentation and more as an intervention. In this manner one broadens the scope and possible perception of the educational encounter and makes the provider/teacher think more creatively about ways in which he or she can affect performance change in the learner and improve practice outcomes. Green’s PRECEED model (Green et al 1980), which incorporates the elements of predisposing, enabling and reinforcing, helps with this concept. This chapter has already dealt with much of the preparatory work for the CPD intervention. In contrast, this section will deal with two key concepts: making the presentation (rounds, lecture, refresher programme, update or other conference) as effective as possible and using other methods to enable the transfer of information into the practice setting. Many years ago Miller (1967) described the classical learning experience as ‘rows of lecture desks, laden with pitchers of water’, with a speaker at the front communicating in a one-way manner. Although research regarding formal CPD methods (Davis et al 1999) has moved us forward, there are still many gaps in the practice of effective CPD. Further, while there are many elements to the theories of adult education (Knowles et al 1998), two key concepts, derived from Steinert and Snell (1999), stand out as crucial to the provision of effective CPD: engagement in the learning experience and relevance to the practice setting or needs of the learner. Interactivity and relevance can be increased by improving teaching delivery methods and by providing case-based material. Not all learning takes place in the classroom or conference centre, of course. Advances in Internet-based technology have made it possible to engage with learners before, during, and after a face-to-face education activity. A recent systematic review by the U.S. Department of Education (2010) showed better outcomes for learners participating in blended learning, combining online and face-to-face instruction. It is possible that the additional learning time and instructional elements, rather than merely the mode of learning, play a role in the enhanced outcomes (U.S. Department of Education 2010), and therefore programme planners are encouraged to consider strategies to extend the learning beyond the particular face-to-face programme. ‘Advance organizers’, whereby information is provided in preparation for the formal programme, is one strategy that can also be used to engage learners (Ausubel 1960, Kiewra et al 1997). Such an advance organizer can take the form of an e-mail message directing participants to a website where they can sign in, access materials and begin interacting with each other. Another strategy is to request that participants complete learning tasks prior to attending a conference. For example, in situations in which cases might be employed at the conference, learners might be encouraged to complete a short patient-audit form of five similar cases of a particular disorder to post online or bring to the conference.
Continuing professional development
Introduction
Know the audience
Know the topic
Subjective needs assessment: Learning and change in the lives of physicians
Objective needs assessments and the clinical care gap
Examples of objective needs assessment tools:
Know the format
Overview: Enabling learning: The CPD ‘intervention’
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
Basicmedical Key
Fastest Basicmedical Insight Engine
For effective CPD, the teacher, workshop leader or other faculty members should:
There is also reason embedded in [the findings of well designed, longitudinal studies] for optimism about the effect a carefully planned and implemented methodology on patient outcomes. [Such studies allow] many observations about evidence, physician practice, and the roles that an effective continuing education presence can occupy in health care and its quality and reform efforts, arenas in which this presence is often invisible, unconsidered, and neglected.
‘Know the audience’ means, among other things, knowing the discipline, training, practice environment and continuing education or CPD requirements of the physician-learner involved in the event.
Examples of subjective needs assessment tools:
“Formal needs assessment can identify only a narrow range of needs and might miss needs not looked for, so breadth and flexibility of needs assessment methods should be embraced.”