Changing Health
Care Provider
Performance: the
role of effective
CME & CPD
National Coalition for HP
Education in Genetics,
September 2011
Dave Davis, MD
Senior Director, Continuing Education and Improvement
Association of American Medical Colleges
An outline: many questions,
little time…
1. What are CME and CPD? Why are they
‘invisible’?
2. The ‘Does CME Work?’ question: the in-
vitro perspective
3. Does CME work in the real world? - a
look at the in-vivo, clinical care gap and
its relationship to the world of genetics
education
4. So What? Recommendations to a
thoughtful genetics audience: guidelines
for the use of CME & CPD
Question #1
Some definitions:
• What do we mean by CME & CPD?
• ….by the terms diffusion,
implementation?
• ….how have we changed in our thinking?
• Later….what is knowledge
translation/implementation science?
What do we
mean by ‘CPD
and CME’?
• educational materials
• formal CME: lectures,
small groups, courses
• outreach visits
• opinion leaders
• patient-mediated strategies
• audit/feedback
• reminders
(paper, computerized,
interactive, etc)
• comprehensive, QI- or
practice-based
interventions
• web-based tools, PDAs
(borrowed from EPOC, Cochrane
Collaboraitve)
How have we changed…?
Pedagogy (1940’s-50’s)
Andragogy (1960-80s)
Informed Self-assessment
Competency-based
education (2000-)
What do we mean by…?
Diffusion: distribution of information and the
practitioners’ natural unaided adoption of policies
and practices
Dissemination: communication of information to
clinicians to improve their skills
Implementation: putting a guideline in place,
involves effective communication, overcomes
barriers by administrative and educational
techniques
(after Lomas)...
Question # 2
“Does CME (CPD) Work?”
The In Vitro Question
(The Sackett question)
Database of Physician Education
& Change: www.rdrb.utoronto.ca
The Research and
Development
Resource Base
- educational, clinical & health
services literature
•
supported by the
American medical Association,
the North American CME
organizations, Royal College of
Physicians and Surgeons of
Canada, the University of
Toronto and the Association of
American colleges
Now ~25,000 studies
• 12 metropolitan areas, roughly 30 conditions studied, >6,000 patient
records examined
• Substandard care noted in 45% of clinical areas (of this, 46%
underuse; 11% overuse)
• Little variation by region or by type of condition (chronic, acute),
socioeconomic status
• Notable gaps in care in depression, alcohol abuse, diabetes care
(about 45%), pneumonia (39%);
• Better care (>50% compliance with recommendations) noted in
hypertension, cardiac care, but just
•NOTE: the inviible care gap (undiagnosed, undetected – e.g., smoking
cessation, obesity counseling, care gap is HUGE)
www.rdrb.utoronto.ca
www.rdrb.utoronto.ca
1) About educational interventions
Changing Physician Performance - a systematic review of
the effect of CME strategies JAMA 1995;274:700-705
+
The effect of formal CME conferences, symposia, rounds,
meetings, lectures
Effective
Not so Effective
• *Interactive Lecturing
Didactic Teaching
• *Sequenced Sessions
One-time only
• Accurate needs
sessions
assessment
• Successful education has
three elements –
predisposing,
enabling, reinforcing
Other findings…
Needs Assessment appear to be important – the more the better
(subjective needs, objective, gaps and barrier analysis)
No evidence yet about long-term effects (well, some)
Group size: no demonstrated effect
Effective CME may follow Green’s PROCEED model - predisposing,
enabling and reinforcing strategies
Knowledge necessary but not sufficient for change
Quantitative methodology necessary but not sufficient to understand
change
NEW Multiple methods’ effect uncertain; print materials (simple
messages) may not be so bad after all; consider the message; and
consider the setting
2) and about the learner-clinician
• age
• motivation
• (dis)incentives
• experience
• time
• environment
• training
•
•
•
•
Emphasis on knowledge
Inability to detect needs,
evaluate performance
?self-directed learning
?critical appraisal
The Pathman Model
• awareness: of a guideline,
practice innovation,
change
• agreement: with the
innovation or guideline
• adoption: ‘trying out’ the
new practice, irregularly
• adherence: abiding by the
new practice on all
appropriate occasions

Pathman, 1996
The selfassessment
question
Davis & co., JAMA 2006;296:1096-1102
Of 20 comparisons…..
13 demonstrated little, no or an inverse
relationship between self and external assessment:
• Examples: learning needs, EBM skills, simulated knee
injections
• Note: inverse relationships between confidence noted
by Leopold (knee injections), Fox (OSCE
misperception) and Parker (knowledge-based FP
exam)
7 demonstrated a positive relationship:
• Examples: cultural-linguistic competencies, global
performance with dementia patients, comfort with
psycho-social issues in family medicine
Just in case we miss the point:
of 20 comparisons of selfassessments with external assessments
3) About aligning the learner and educator: the
Pathman-PROCEED model stages
Methods/
Stages
Predisposing
Enabling
Reinforcing
Awareness
Agreement
Adoption
Adherence
3) About the cumulative
effect of CCME/CPD
Question # 3:
Does CME/CPD work in the real
world? In the world of effectiveness?
Why or why not?
The In Vivo Questions
The Clinical Care Gap
• Overuse
• Underuse
• Misuse
Chassin, 1998
The clinical care gap
Ideal, evidence-based practice
clinical care gap
clinical care gap
Current practice
What causes the gap?
The evidence-to-practice puzzle
No time…
No, Thursday’s out. How about never-is never
good for you?
“Information management is
like having your mouth to a
firehose”
David Naylor, President, University of Toronto
What causes the gap?
the educational
delivery
System and knowledge
translation/
implementation science
An emerging field; one concept, two terms
“Knowledge translation is the effective and
timely incorporation of evidence-based
information into the practices of health
professionals in such a way as to effect optimal
health care outcomes and maximize the potential
of the health system”
– Adapted from the Canadian Institutes for Health Research
definition, 2001
Implementation Science is the scientific study
of methods to promote the systematic uptake of
research findings and other evidence based
practice into routine practice thus to improve the
quality and effectiveness of health care and
services. ..adapted from the NIH, USA
Question #4:
How do CME and CPD play a role in
genetics & genetics education ?
The guideline process: evidence-toaction
‘Consideration of clinician learning
style, needs
The goal:
effective
implementation
Effective CME/PD
How an we use CME/CPD in
evidence/message/guideline
development in genetics?
Recommendation #1:
Guideline Development/adaptation
Consider CME/CPD in any evidence development process: from
learner and educational perspectives (for example, guard against
knowledge overload, consider already-held knowledge)
a. secure buy-in; involve the end-user in guideline
development/adaptation
b. employ adult learning principles in guideline statements
(format, spacing, language)
c.
consider recommending effective educational strategies in
the guideline itself
….educational issues to consider
within the guideline, evidence
itself
•
compatibility
•
complexity
•
cost
•
relative advantage
•
accessibility
•
format
•
patency of evidence, process of development
•
opportunity; trial-ability
One attempt to fix the Message:
The Guidelines Advisory Committee, Ontario
(now the Center for Evidence-based practice)
• Joint body of the Ontario Medical Association and the
Ministry of Health and Long term Care, Ontario
• Chooses a topic area; reviews all guidelines in that area;
scores them by the Cluzeau/AGREE instrument
• Mounted them on a website
–
–
–
–
–
Quick, 30 second synopsis
Clear language
Appropriate format
Parallel patient synopsis
The apple-score
How an we use CME/CPD in genetics
education ?
Recommendation # 2:
Include CME/CPD in any guideline implementation
strategy
a) Consider the learner
- mode of current learning
- stage of awareness-adherence at which clinicianlearners exist
b) Consider effective educational strategies
The CPG implementation toolkit
Formal CME
Lectures, workshops,
small groups
Informal education
Audit/Feedback
Reminders
Policy, CQI
administrative
techniques
Print
Patient Strategies
Multiple Strategies
M&M conferences
Quality-based rounds
Journal Club
Team training
Handover/off rounds
How can we use CME/CPD in
genetics education?
Recommendation # 3:
Consider CME/CPD in a staged fashion, depending on
stage of adoption of information, by individuals,
groups; use appropriate educational strategies
Example #1: a new guideline describes the use of a
new disease screening test…..
Methods/Stages
Predisposing
Enabling
Reinforcing
Awareness
Print material,
Lectures,
Conferences
Academic
detailing,
Media
Agreement
Adoption
Adherence
Interactive
sequential
sessions
Small groups,
opinion leaders
Pt. education,
workshops,
opinion leaders
Reminders,
audit/feedback
Reminders,
audit/feedback
Example #2: many primary care providers fail to use
a simple genogram when taking patient history
Methods/Stages
Awareness
Agreement
Print material,
Reinforcing
Adherence
Patient
education and
advocacy
Predisposing
Enabling
Adoption
Small groups,
opinion leaders
Pt. education,
workshops,
flow charts
Reminders,
audit/feedback
Reminders,
audit/feedback
Example #3: a national campaign: a project of
the Association of American Medical Colleges
• Launch, June 2011
www.aamc.org/bestpractices
• Tools, resources, and support
for AAMC members
• Collaborative learning
sessions
• National Faculty Development
Initiative
• Roughly 250 med schools &
teaching hospitals participating
Participating medical schools and
teaching hospitals have committed to:
•
Teach quality and patient safety to the next generation of doctors
•
Ensure safer surgery through use of surgical checklists
•
Reduce infections from central lines using proven protocols
•
Reduce hospital readmissions for high-risk patients
•
Research, evaluate, and share new and improved practices.
This list of commitments will grow over time.
The Pathman-PROCEED model applied to AAMC’s
BPBC campaign
Methods/Stages
Awareness
Predisposing
Emails,
Conferences,
Media
Enabling
Reinforcing
Agreement
Adoption
Adherence
Group work at
meetings,
conference
calls
Learning
collaboratives,
workshops,
Web-tools,
webinars
Reminders,
audit/feedback,
Awards
Reminders,
audit/feedback
And a few final last words
• Large and growing body of evidence about the
effect of CME/CPD now imbedded in models of
change- no longer an invisible (and ineffective)
intervention
• Huge clinical care gap, no less so in genetics
• Considerable support for consideration of
CME/CPD practices and principles – based on
best evidence.
Dave’s contact info:
ddavis@aamc.org
www.aamc.org/initiatives/CME/ae4Q
www.rdrb.utoronto.ca