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 Table of Contents  
CHAPTER 4: THE EDUCATION OF THE SPECIALIST OF PHYSICAL AND REHABILITATION MEDICINE
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 65-69

4.3 The education of the specialist of physical and rehabilitation medicine: Continuing medical education


Department of Rehabilitation, USL Umbria 2, Foligno Hospital, Foligno, Perugia, Italy

Date of Web Publication11-Jun-2019

Correspondence Address:
Prof. Mauro Zampolini
Department of Rehabilitation, USL Umbria 2, Foligno Hospital, Foligno, Perugia
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisprm.jisprm_16_19

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How to cite this article:
Zampolini M. 4.3 The education of the specialist of physical and rehabilitation medicine: Continuing medical education. J Int Soc Phys Rehabil Med 2019;2, Suppl S1:65-9

How to cite this URL:
Zampolini M. 4.3 The education of the specialist of physical and rehabilitation medicine: Continuing medical education. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2019 Aug 20];2, Suppl S1:65-9. Available from: http://www.jisprm.org/text.asp?2019/2/2/65/259342




  Introduction Top


From the ancient time of Hippocrates, doctors have promised to keep up-to-date their knowledge and skills. It was the great Greek philosopher Socrates who stated: “If you think that education is expensive, you should consider ignorance.”

However, it has been estimated that about half of all medical knowledge are out of date within 5 years.[1]

To reduce the decline of scientific knowledge over the years, it was necessary to think of a continuous education strategy to maintain the updating and quality of health care.

In the United States early after the foundation of the American Medical Association (AMA) in 1847, the two committees constituted by the new organization were the Committee on Medical Education and the Committee on Ethics, emphasizing the importance the association and the medical profession placed on these two areas. Continuous medical education has to do with ethics as it guarantees the fear of the best possible intervention.

Continuing Medical Education (CME) is defined as any activity useful to maintain, develop, and increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession.[1]

It refers to a specific form of continuing education that helps Medical Doctors to maintain competence and learn about new and developing areas of their field. The activities could be lectured to the Congress, written publications, telelearning programs, audio, video, or other electronic media, including social networking and community of scientists.

Despite the disclosures of conflict of interest, critics complain that drug and device manufacturers often use their financial sponsorship to bias in CMEs toward marketing their own products.

However, CME is a major facilitator of change and improve medical activity which is often disjointed and plagued by doubts about and relatively little evidence for its own effectiveness and efficacy. Similar deficiencies can be found in the adoption of new information and techniques.[2]

In developing countries, the CME is still in the implementation phase. In a recent cross-sectional study done in Pakistan, the idea of attending CME sessions after completion of formal medical education is something new; most of the physicians (32.7%) had never heard of it. This is in contrast to the Western world where physicians are well aware of the idea and importance of regular CME sessions to update their clinical knowledge and skills.[3]

In Haiti, the identified deficiencies in mentorship and specialty training are of great concern, as they further debilitate an already fragile system, failing to keep the workforce engaged, committed, and motivated.[4]

To support the developing countries is necessary that the International Scientific Societies promote the CME in both directly support teaching activities and providing teaching courses using the latest technologies which allow to reach remote regions.


  Certification and Scoring Top


In the world, there is a patching situation on the methods of making CME mandatory for professional activities. In some countries, there is a voluntary activity, in others, there is a specific score necessary to maintain the generic medical activity, in some other, the CME is linked to the maintenance of Specialist certification with subspecialties. The latter condition is in the USA. CME is a cornerstone of the ABPMR Maintenance of Certification Program. Completing an average of 30 Category 1 CME credits every year helps you stay current with the latest research and innovation in the field, as well as demonstrating to your patients that you are keeping up.[5]

In Europe, the CME is still voluntary and medical organizations have adopted charters which state that doctors have an ethical obligation or duty to undertake further education.[1] The certification as well is voluntary, the European Board of PRM established the requirement to obtain the certification and recertification and among them, there is a need to have achieved 250 CME Continuing Professional Development (CME/CPD) credits collected from CME/CPD activities during the 5 years preceding the application[6]

However, the most important issue in CME is the quality of the education programs on offer, not whether they are voluntary or mandatory.[7]


  Quality of Continuing Medical Education Top


In order to guarantee the quality of CME event is necessary to analyze and score the event in order to define the potential interest of the medical doctor, the specificity of the event and avoid the potential bias of conflict of interest.

In Europe, there UEMS established the European Accreditation Council for CME (EACCME®) in order to give a coordinated system to facilitate such activity, without encroaching on the responsibility of national organizations where they exist. The UEMS-EACCME® has mutual recognition agreements with the AMA for live events and e-learning materials and with the Royal College of Physicians and Surgeons of Canada for live events only.[8]

More and more countries organized the accreditation on CME event in a specific way both from an internal peer reviewing system and through a standardized checklist.

Scientific societies try to improve the quality of the events at the international level such as the International Society of Physical and Rehabilitation Medicine (ISPRM). To obtain the endorsement of ISPRM to an event is necessary to submit the program, goals and objectives of the meeting, learning needs, and the target audience to be peer-reviewed by the Educational Committee of the society.[9] The European UEMS-PRM-Board has created the CME/CPD Committee, which is responsible for the relevant continuing programs within our specialty, for the accreditation of the several scientific events at the European level and the scientific status of the Board Certified PRM physicians. The CME/CPD program organized at European level for accreditation of international PRM congresses and events is based on the provisions of the mutual agreement signed between the EACCME and the UEMS PRM Section and Board.[10]

However, the bias of conflict of interest is present. A 2016 report of pharmaceutical payments to physicians in the UK revealed that up to a third of payments are made for consultancy and service fees, with a large portion going for payments related to educational events, including travel and admission fees to CME events.[11] In order to overcome the potential bias recently it has been proposed a panel with the following point: (1) Transparency regulation should be applied to all CME providers and speakers, including those involving joint provider arrangements, (2) CME faculty should be trained to discern the integrity of the CME content by including a comparison to less expensive treatment alternatives and should declare the payments they receive as potential conflicts of interest at the beginning of their activities, (3) CME providers should recruit academic experts in the activity topics to independently check the presented material for bias in return for CME credits of their own.[12] However, the Accreditation Council for CME oversees a multilayered system that ensures that accredited CME is designed to be independent, free of commercial bias, and based on valid content. Accredited organizations are subject to routine audit, including audits of jointly provided education. The Accreditation Council for CME also investigates complaints and concerns from learners and other stakeholders.[13]


  Impact of Continuing Medical Education Top


Despite many efforts, CME missed the goal to allow pysicians to be up-to-date and to maintain or improve the quality of health care. Studies demonstrated considerable gaps between real and ideal performance and patient outcomes.

A meta-analysis examined 31 studies involving 61 CME interventions have been performed. The results indicate that CME interventions are likely to have a small-to-moderate effect on physician knowledge, physician performance, and patient outcomes.

The use of active and interactive teaching methods versus passive methods, education for a single group versus multiple groups, smaller versus larger groups, longer versus shorter sessions, and increasing the number of sessions all increase the effect size.[7]

Identification of learning needs is the basis for planning of continuing education for individuals, organizations, and the professional organizations responsible for medical training.

Who defines the needs and how they do it is important. Medical audit in its classic form is intended to assess practice against a set of predetermined criteria. It is often carried out as a peer review and is probably more often experienced as a quality control mechanism rather than a basis for defining learning needs. A system of self-assessment is preferable if the emphasis is on education and continuous learning rather than the identification of poor performers.[7]

There is some evidence that interactive CME sessions that enhance participant activity and provide the opportunity to practice skills can effect change in professional practice and in some cases, health-care outcomes. Based on a small number of well-conducted trials, didactic sessions do not appear to be effective in changing physician performance.[14]


  Evolution of Continuing Medical Education Top


CME has traditionally focused on content experts disseminating decontextualized and fragmented clinical content given during the lectures at the congresses. Usually, the topic is established by the expert and not the learner's needs and is not related to a curriculum. On the other hand, there is a need for greater physician accountability, improved patient safety, and better quality of care. We ought to find strategies to enhance physician competence and produce measurable outcomes. In order to reach this goal close to CME, a CPD paradigm has been developed in enhancing competence and performance.[15]

CPD recognizes the broader range of competencies needed to practice high-quality medicine beyond clinical expertise and is individually focused inducing the practitioners to reflect, assess their learning needs, and develop learning cycles based on individual practice learning gaps.[16]

A further progression is competency-based CPD (CBCPD) requiring objective external assessment of performance, patient outcomes, and public health-care evaluation, in addition to self-assessment. Transitioning to CBME-based CPD require a cultural change to increase the popularity from physicians, their collaborators and institutions, CPD providers, professional organizations, and medical regulators. It will require learning to be aligned with professional and workplace standards. Practitioners are required to develop the expertise to systematically examine their own clinical performance data, identify performance.[17]

CBCPD is based on public health care needs as part of the needs analysis, and the outcome should be the improvements in public health [Figure 1]. CBCPD is based on five measurable life-long learning (LLL) domain key competencies for clinical practice, which can be organized as a cycle: (1) personal practice self-awareness, in which the professional identifies own learning priorities; (2) scanning the environment to compare and identify gaps through accessing new evidence to integrate in practice; (3) contextually manage knowledge by developing and monitoring a personal development plan; (4) formulate and answer clinical questions, supported on evidence; and (5) assess and enhance practice by measuring performance. The clinical audit is a useful method to objectively measure performance.[4]
Figure 1: Continuing medical education (CME) is integrated with continuing professional development (CPD), and the competency-based CPD (CBCPD). Life-long learning (LLL) as the core of medical profession accountability supports the concepts of CME, CPD and CBCPD

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Moving from a simple demonstration of participation in learning to a competency-based model for physicians that involves feedback and assessment will require new components.[17]

The first one is a broader list of competencies such as Communication skills, Collaboration capacity, Leadership, Health Advocate, Scholarship, and Professional skills. The attention would focus on safety and quality, communication, partnership and teamwork, and maintenance of trust.

Another aspect is the Progression of expertise in practice. A delineation of competencies, milestones, and trustable professional activities (EPAs) for practice will be needed. Trustable Professional Activity is a key task of discipline (i.e., specialty or subspecialty) that an individual can be trusted to perform in given health-care context, once sufficient competence has been demonstrated.

The third one is the alignment with the scope of practice. A CBME approach would require that learning experiences be undertaken in alignment with a physician's scope of practice to demonstrate outcomes of learning for practice, including areas of competence.

The forth is practice-based learning support. Enhanced learning in practice would benefit from assistance such as coaching and peer feedback to develop and implement plans for learning anchored in the physician's work.

The fifth is a multi-level assessment system. The creation of assessment systems of learning will be needed, encompassing the performance of individuals, groups, or teams in the workplace.

The sixth is a reporting structure. The creation of reporting structures such as e-portfolio systems would enable physicians to track and to demonstrate how they are planning and maintaining their competence.


  Future Directions Top


The new concepts of LLL and the growing amount of information need to define new strategies using traditional approach and new technologies including the web resources and artificial intelligence intervention.

Some example can help to underline the new perspectives: hybrid/blended learning (e.g., recorded webinar followed by in-person, small-group problem-solving sessions; live webcast followed by a group quality improvement effort); Bedside case discussions; Review of records and registry data by a physician or group; use of narrative medicine approach to stimulate reflections about personal wellness and facilitate doctor-patient relationship; Online case discussion using social media; Procedural training using virtual reality; Role-play simulation to practice communication skills Interactive game to learn effective practice management.[18]

In a recent meta-analysis, the findings suggest that large-scale online education could contribute to health and social care improvement initiatives and play an increasingly significant role in translating knowledge into practice. The factors contributing to sustainable practice improvement include increased awareness, change in attitudes, improved communication, increased confidence and the actual changes applied in daily practice.[19]

Last but not least, more and more scientific journals are publishing the main contents in the social network such as Facebook, Twitter, LinkedIn, and Instagram. In some case, they enrich the publication with short videos explaining the main data of a specific trial or the publish podcast commenting on the contents of the journals with the authors as well. In this way, there is a further possibility to spread scientific information continuously. The availability of these new ways of disseminating scientific contents useful for LLL raises the question of how to report the effectiveness of the intervention. On the other hand, the use of the web and e-learning can help to reduce the distance on the CME between the developing countries and the rest of the world.


  Summary Top


CME is defined as any activity useful to maintain, develop, and increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession.

The most important issue in CME is the quality of the education programs on offer, not whether they are voluntary or mandatory. Is necessary to analyze and score the event to define the potential interest of the medical doctor, the specificity of the event and avoid the potential bias of conflict of interest. More and more countries organized the accreditation on CME event in a specific way both with an internal peer reviewing system and through a standardized checklist. However, the bias of conflict of interest is present. To improve the quality of a multilayered system that ensures that accredited CME is designed to be independent, free of commercial bias, and based on valid content.

Despite many efforts, CME missed the goal to allow physicians to be up-to-date and to maintaining or improving the quality of health care.

There is some evidence that interactive CME sessions that enhance participant activity and provide the opportunity to practice skills can effect change in professional practice and in some cases, health-care outcomes.

The evolution of CME needs: a broder list of competencies, the progression of expertise in practice, implementation in practice, practice-based learning support, multi-level assessment system, and reporting structure.

New concepts of LLL and the growing amount of information need to define new strategies using traditional approach and new technologies including the web resources and artificial intelligence intervention.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
European Union of Medical Specialists – CME – CPD. European Union of Medical Specialists; 2013. Available from: https://www.uems.eu/areas-of-expertise/cme-cpd. [Last accessed on 2018 Jun 30].  Back to cited text no. 1
    
2.
Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA 1995;274:700-5.  Back to cited text no. 2
    
3.
Ali SA, Hamiz Ul Fawwad S, Ahmed G, Naz S, Waqar SA, Hareem A, et al. Continuing medical education: A cross sectional study on a developing country's perspective. Sci Eng Ethics 2018;24:251-60.  Back to cited text no. 3
    
4.
Nádas M, Bedenbaugh R, Morse M, McMahon GT, Curry CL. A needs and resource assessment of continuing medical education in Haiti. Ann Glob Health 2015;81:248-54.  Back to cited text no. 4
    
5.
American Board of Physical Medicine and Rehabilitation – Continuing Medical Education; 2018. Available from: https://www.abpmr.org/MOC/PartII/CME. [Last accessed on 2018 Jul 01].  Back to cited text no. 5
    
6.
PRM Section & Board of UEMS – By Equivalence. Available from: http://www.euro-prm.org/index.php?option=com_content&view=article& id=19&Itemid=297&lang=en. [Last accessed on 2018 Jul 02].  Back to cited text no. 6
    
7.
Holm HA. Quality issues in continuing medical education. BMJ 1998;316:621-4.  Back to cited text no. 7
    
8.
UEMS-EACCME®; 2017. Available from: https://www.uems.eu/areas-of-expertise/cme-cpd/eaccme. [Last accessed on 2018 Jul 02].  Back to cited text no. 8
    
9.
ISPMR-EC. ISPRM Endorsement of Events. International Society of Physical and Rehabilitation Medicine; 2018. Available from: http://www.isprm.org/meet/endorsement-events/. [Last accessed on 2018 Jul 02].  Back to cited text no. 9
    
10.
European Physical and Rehabilitation Medicine Bodies Alliance. White book on physical and rehabilitation medicine (PRM) in Europe. Chapter 9. Education and continuous professional development: Shaping the future of PRM. Eur J Phys Rehabil Med 2018;54:279-86.  Back to cited text no. 10
    
11.
Cookson C. Database Shines Light on Pharma Payments to UK Doctors. Financial Times; 2016. Available from: https://www.ft.com/content/b3e42806-3ec7-11e6-8716-a4a71e8140b0. [Last accessed on 2018 Jul 02].  Back to cited text no. 11
    
12.
Golestaneh L, Cowan E. Hidden conflicts of interest in continuing medical education. Lancet 2017;390:2128-30.  Back to cited text no. 12
    
13.
McMahon G. Transparency in continuing medical education. Lancet 2018;391:2323-4.  Back to cited text no. 13
    
14.
Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A, et al. Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 1999;282:867-74.  Back to cited text no. 14
    
15.
Campbell C, Silver I, Sherbino J, Cate OT, Holmboe ES. Competency-based continuing professional development. Med Teach 2010;32:657-62.  Back to cited text no. 15
    
16.
Filipe HP, Golnik KC, Mack HG. CPD? What happened to CME? CME and beyond. Med Teach 2018;40:914-6.  Back to cited text no. 16
    
17.
Lockyer J, Bursey F, Richardson D, Frank JR, Snell L, Campbell C, et al. Competency-based medical education and continuing professional development: A conceptualization for change. Med Teach 2017;39:617-22.  Back to cited text no. 17
    
18.
McMahon GT, Skochelak SE. Evolution of continuing medical education: Promoting innovation through regulatory alignment. JAMA 2018;319:545-6.  Back to cited text no. 18
    
19.
Zubala A, Lyszkiewicz K, Lee E, Underwood LL, Renfrew MJ, Gray NM. Large-scale online education programmes and their potential to effect change in behaviour and practice of health and social care professionals: A rapid systematic review. Interact Learn Environ 2018:1-16. Available from: https://doi.org/10.1080/10494820.2018.1465438.  Back to cited text no. 19
    


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