Letters to the Editor
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"CME - Agenda for Action"
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?
Three years ago, a Singapore Medical Associations (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:
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
(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.
(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.
A/PROF CHEONG PAK YEAN
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 GPs 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.