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Invited Commentary

"CME - Agenda for Action"

The recent announcement by the Singapore Medical Council (SMC) that continuing medical education (CME) for doctors would soon be made compulsory comes as no surprise (Straits Times on 15 August 1999). There is a global trend for mandatory CME, audit and re-certification in recent years fuelled by pressure groups and politicians demanding accountability, efficiency and effectiveness of medical practice. The medical profession faced with this onslaught and increasingly constricted resources is advocating CME as a professional tool to ensure that practice is based on proven evidence and expertise.

Professor Balachandran, the SMC President also clarified that the scheme "might be implemented in the year 2005." This window of time is important for the medical profession in Singapore. We have to reflect on, to study and to organise the machinery for administering the CME programme. What are the tasks ahead?


Five tasks

Three years ago, a Singapore Medical Association’s (SMA) memorandum to SMC on the same subject (SMA News of September 1996) listed five tasks that should be undertaken before CME is made compulsory and they are:

1. We need to find out the level of professional knowledge, skills and clinical judgement amongst practicing doctors;

2. We need to find out the extent of usefulness of the present programme and ask for reasons that doctors have for not participating in it;

3. We need to make decisions on having structured curriculum contents of CME, define them and draw them up. They must have at the endpoint a CME programme that enables and reinforces our practice skills as clinicians;

4. We also need to work out the weightage of core skills and the weightage of medical excellence, ensuring that doctors continue to be safe and vocationally competent to deal with core problems that may need to take priority over knowing the latest but untried things that cannot be applied to day-to-day practice; and

5. The administrative mechanism for dealing with those who have not met the requirements of compulsory CME should be drawn up before compulsory CME is implemented.

We now need to urgently and openly address the above tasks. In the exercise, evidence from the medical literature on how CME can be made more effectively should be studied and local research further initiated.


An effective CME programme

What are the ingredients for an effective CME programme? The literature suggests the following:

(1) Adopting adult learning theories and practice enabling CME

There is a consensus that there should be a focus on adult learning and not just traditional teaching based on experts. Information linked to performance and learning through social influence or management support(1) are some techniques employed. Popular and painless CME activities like casual reading of journals and attending ad-hoc lectures are less effective while strategies that use the same media but are structured to enable and/or reinforce appear to work in changing physician performance and health care outcome.

Self-directed learning based on needs assessment and the opportunity to reflect on clinical performance are clearly crucial. Davis (1992) reviewing published papers since 1975 also concluded that CME Interventions using practice-enabling or reinforcing strategies consistently improve physician performance and in some instances health outcome(2). Table 1 (below) lists a model illustrating these principles.

Table 1: Outcome of CME as a systematic attempt to facilitate change

1. Knowledge (information) of procedure

2. Change in ability (skill) to perform the procedure

3. Procedure incorporated into practice – allaying ‘anxiety of change’ and addressing practice and funding issues

4. Improvement in patient outcome

(2) Filling valleys is as important as peaking peaks

Prior need assessment is useful. Tracey in a study in New Zealand(3)  shows that there is apparently a poor correlation between doctors’ self-assessment of their knowledge and their subsequent performance in objective tests. In other words, there are at least some doctors who think they know when they actually do not.

They may also not know what they do not know. In another study, doctors choose CME activities by their ‘comfort zone’ _ choosing activities that they are already familiar with. This may also arise from a delusion that they are already competent in most topics. They are therefore ‘peaking their peaks’ instead of the accepting the anxiety of laboriously ‘filling their valleys’. This is especially important for generalists who must have wide competency in the breadth of medicine.

(3) Implementing local standards auditing and group learning

Cantillon and Jones (1999)(4) reviewed 1,032 articles describing educational activities in general practice in the past 10 years and made the following observations.

O Setting standards by local consensus is an appropriate method for implementation. It should be based on the work that doctors do.

O Standard auditing is effective for behaviour change if it includes targeted feedback. Unsolicited and non-personalised feedback was ineffective.

O Group learning approach aids learning especially for poor learners.

O Importance of reinforcement – In one study a community’s suicide rate declined after multifaceted educational intervention to improve doctors’ management of depression. However after stopping the programme, doctors’ management deteriorated and the rate crept up again.

O Computers can be used to focus or prompt during consultation.

(4) Encouraging organisational learning

Fox and Bennett(5) stressed the importance of "organisational learning" ie. nurturing the structure and culture of learning within learning organisations which take into consideration local problems and needs.


Agenda for Action

The medical profession must now seize this opportunity to make CME effective. It should not be just a public relations exercise. More importantly, it should not be viewed by rank-and-file doctors as yet another statutory barrier to surmount to get on with practice.

The whole profession must therefore get its act together. The various professional bodies, SMC, SMA, the Academy of Medicine and the College of Family Physician must each have clear views of their separate and integrative roles in this endeavour. Only then can ‘good and affordable healthcare’ be the outcome of a compulsory CME system.




1. Wensing M, et al. Implementing guidelines and innovations in general practice: which interventions are effective? Br J Gen Pract 1998 Feb; 48(427): 991-7.

2. Davis DA, et al. Evidence for the effectiveness of CME. A review of 50 randomised controlled trials. JAMA 1992 Sep 2; 268(9):1111-7.

3. Tracey, et al. The validity of GP’s self assessement of knowledge: cross section study. BMJ 1997; 315:1426-28.

4. Cantillon P, Jones R. Does continuing medical education in general practice make a difference? BMJ 1999; 318:1276-1279.

5. Fox RD, Bennett NL. Continuing medical education: Learning and change: implications for CME. BMJ 1998; 316:466-468.