The case for post-training education

In the many countries that have embraced EM, the emphasis has been on specialty training. The majority of current training programs range from 3-8 years in duration. They involve didactic and clinical training that produces graduates with the minimum skills and knowledge required for the independent practice of EM. While each country has somewhat different standards for the independent practice of EM, there is much overlap.Reference Hobgood, Anantharaman and Bandiera ²

The public, payers and regulators have recently become very interested in what happens to physicians after they complete their formal training. The challenge for physicians is to both maintain competence after specialty training and to acquire new knowledge and skills. CME has been defined as “ongoing medical education.” However, CME may not be adequate. The concept of skill development post-specialty-training is known as “continuous professional development” (CPD). Developing robust and meaningful CPD is a challenge that is not unique to EM.

In this manuscript, we describe characteristics of CPD that are applicable to EM around the world.

The case for CME

In most countries with well-developed medical disciplines, physicians are required to undergo CME according to requirements set by national regulatory agencies. CME activities can be divided into broad categories: traditional or sometimes called live (such as lectures and seminars that involve face-to-face meetings); review or group activities and case conferences; written or permanent education materials that sometimes include tests or written assignments;Reference Peck ³ and newer technologies such as audio, video, or the Internet. Much CME is now accomplished with online offerings. CME is typically based on an hour system where one hour of education activity equates to one CME credit.

The amount of time that physicians engage in CME, i.e., the post-formal-training phase of their career, is the longest of any of the educational opportunities. During the post-training career phase, physicians cite a variety of reasons for seeking CME. Most commonly, physicians pursue CME to maintain competence and improve patient care. Physicians feel strongly that participating in CME activities assists them in maintaining competence and gaining new knowledge and skills.Reference Gruppen, Wolf, van Voorhees and Stross ⁴

Whilst formalized CME is one method of maintaining current medical knowledge, a comprehensive review of the literature performed by the Agency for Healthcare Research and Quality (AHRQ) demonstrates that CME is only modestly effective at changing physician knowledge, attitudes, skills, and practice behavior. It is even less successful at changing clinical practice outcomes.Reference Marinopoulos, Dorman and Ratanawongsa ⁵ Two other large meta-analyses of CME demonstrate that CME modalities range in effectiveness depending upon intervention type. In particular, it is rare for lecture-style-only didactics to be effective in changing practice.Reference Davis, Thomson and Oxman ^{6 ,} Reference Oxman, Thomson and Davis ⁷

The case for transition from CME to CPD

In order to practice effectively throughout their professional lives, physicians must remain up-to-date. This entails engaging in some form of continuing education. Many medical educators believe that CME may be the only component necessary for CPD. CME programs can provide needed clinical updates and an opportunity for additional education, training, and sub-specialization. ⁸

To deliver the highest-quality patient care, the content of CME must be directed toward enhancing skills and competencies. Clinical skills, a theoretical knowledge of organizational team building and leadership, communication, medical ethics, teaching, research, and administration are all areas within which the individual physician must learn to remain an effective care provider.

To meet that goal, many educators have suggested that required CME should evolve from the current practice of counting hours of CME participation to recognizing physician achievement in knowledge, competence and performance.Reference Davis, Bordage and Moores ⁹ Medical boards should require valid and reliable assessment of physicians’ learning needs. There should be a collaboration between physicians and CME providers to ensure that legislatively mandated CME achieves the greatest possible benefit for physicians and patients.

Despite the broad range of CME aimed at educating practicing physicians, researchers have found that in actual practice physicians commonly overuse, underuse or misuse therapeutic and diagnostic interventions. CME may therefore not suffice to significantly narrow the gap between clinical practice and current evidence.Reference Miller, Thompson and Mazmanian ¹⁰

The limitations of CME have led to the concept of CPD. New medical knowledge should transform concepts through research into clinical practice. CME alone is no longer enough for the provider to maintain cutting edge proficiency. The medical profession must enter into a program of CPD to be able to incorporate new knowledge into clinical practice.

CPD is a process of lifelong learning. There are several reasons for CPD: to improve skills that provide better patient care, to improve non-clinical skills, and to satisfy employers or regulators. CPD should include an ongoing commitment to continuing professional development as the major component of the process.Reference Peck ³

The critical focus of CPD is to deliver educational materials to practicing physicians, no matter when they completed training, such that they can incorporate new knowledge into their practice. Medical science and technology are always changing. New life-saving ideas are always being sought and disseminated. Successful physicians must incorporate these into their professional development.

In addition to new medical knowledge, new ethical demands and economic developments continually confront the medical profession. This challenges the individual physician to assume new roles for which the doctor’s original training may not have prepared him or her. The evolving role of quality assurance and changes to health care delivery systems are also significant reasons why physicians must transition from CME to the more active educational program of CPD.

Effectiveness of CPD

Although the evidence for CPD effectiveness is limited, where it exists it covers a number of dimensions. There has been a limited focus specifically on CPD in EM;Reference Jones, Smith-Coggins and Meredith ^{11 -} Reference Schrock and Cydulka ¹⁸ however, most medical CPD research is generally applicable to any medical specialty. There is a reasonably strong association between certified assessment of training and future clinical performance.Reference Rhodes, Biesten and Ritchie ^{19 ,} Reference Bordage, Carlin and Mazmanian ²⁰ This mainly relates to certification of specialist training, but could be extrapolated to include certification related to CPD.Reference Lipner, Song and Biester ²¹ There is evidence that emergency physicians in the USA who participate in Maintenance of Certification maintain the same level of performance on their every decade test of medical knowledge.Reference Marco, Counselman and Korte ²² There is a lack of direct evidence on the effect of any particular regulatory regime (certification by examination, records and audit of participation, etc.) on CPD participation or clinical performance.Reference Lowe, Bennett and Aparicio ²³ There is evidence that participation in CPD has a positive effect on knowledge acquisition and retention, though the evidence is weaker in terms of clinical outcomes.Reference Marinopoulos, Dorman and Ratanawongsa ^{5 ,} Reference Davis, Thomson and Oxman ^{6 ,} Reference Wenghofer, Marlow and Campbell ^{24 -} Reference Davis, O'Brien and Freemantle ²⁶ There is evidence of an association between maintenance of certification and some quality of care markers.Reference Holmboe, Wang and Meehan ²⁵

In relation to the question of which CPD formats are more effective, a major review of CPD in the USA and Canadian context recommended the use of multimedia, multiple instructional techniques, and multiple exposures to CPD content.Reference Marinopoulos, Dorman and Ratanawongsa ⁵ Whilst there is evidence that unsolicited print materials are generally ineffective,Reference Davis and Galbraith ²⁷ the use of single live media versus multiple media is not clear, though either is superior to print. Whilst it seems intuitive that multiple exposures versus a single exposure would be superior, the evidence is weak, with either method leading to positive results. Specifically with respect to simulation as an educational tool, simulation has been used widely in undergraduate and graduate medical education (GME) programs, and training of personnel working in inter-professional teams of health care professionals. However, surprisingly, it has not been widely implemented in CPD programs in EM.

There is evidence that medical simulation is an effective learning tool. A best evidence medical education (BEME) systematic review identified 10 conditions that may facilitate learning in high-fidelity medical simulations, including the provision of feedback during the learning experience, learners engaging in repetitive practice, and the integration of simulation into the curriculum.Reference Issenberg, McGaghie and Petrusa ²⁸ Furthermore, the use of simulation is consistent with best practices in CPD, such as mastery learning and deliberate practice,Reference McGaghie, Siddall and Mazmanian ²⁹ although there is very little evidence specific to the CPD context. More recently, in situ simulation has emerged as a feasible educational strategy for facilitating learning in a safe environment in the context of the local environment.Reference Rosen, Hunt and Pronovost ³⁰ It has the potential to improve individual, team, unit, and organizational learning. However, there is little evidence relating to its effectiveness in the transfer of learning into actual improvements in clinical practice, and ultimately, patient outcomes. While the evidence on simulation effectiveness remains lacking in clinical outcomes and skill development, there is at least modest evidence to support its use in teamwork training and critical incident communication, two essential competencies for EM.

Given the current state of knowledge on the effectiveness of CPD, medical specialty organizations should be flexible when developing CPD programs. The programmatic rationale and justification must be transparent. CPD will be most successful when it is linked to needs analyses, assessment, and accreditation. There should be multiple offerings that account for the many differences amongst adult learners. Any CPD program should be designed to meet the needs of physicians and the community they serve.

Continuous Professional Development for Emergency Medicine

Only a small number of countries with EM specialty training programs have developed specific educational requirements for post-training CPD. There is tremendous worldwide variation in EM CPD programs. There are no standard, recognized international curricula for EM CPD.

Once training is complete and an emergency physician (EP) meets criteria for national certification (after completing both his or her undergraduate and graduate curricula), the EP must continue to evolve as a professional. That evolution must be based on individual needs, identified by practice assessment, as well as external needs, e.g., those of the specialty, and the local and national system of care delivery. Globally, external needs must be driven by the appropriate regulatory body. This will differ from country to country. Each EM organization must work with its own regulatory agencies to decide what role EM will play in the country’s health care program. Any EM-specific objective must be delineated and carefully detailed by all stakeholders. The resulting CPD curriculum should reflect these objectives and be designed to accomplish them. The CPD program can then be implemented at the national and local level. For countries where resources are limited, a national approach to high-cost curricular needs is desired. In that way, scant resources can be used to assist all EPs to achieve the goals of CPD.

CPD is important for the career evolution of all EPs. For academic-based EPs, the metrics used to judge success are set by the institution (usually the university or equivalent), and should be transparent and readily accessible. Issues such as teaching time, teaching evaluations, scholarly publications, funding, and national and international presentations are typically important, but may not represent all items needed to achieve institutional advancement. Within this milieu, the exact value of each component varies by university and across countries. A successful professional development plan involves matching one’s personal goals and achievements with those valued by the university or institution for which one works. Successful professional development in an academic practice is measured by promotion and tenure. Recognition is based on the candidate’s record of performance in the areas of teaching, research, and service. Most universities highly value scholarship. The number of scholarly publications is counted and each manuscript is judged by how frequently it is cited by other authors. Extramural funding is frequently recognized as an external validation of quality. Faculty members must also maintain a list of all courses, the number of students taught, and an estimate of total student contact hours. Teaching quality is documented through student feedback and peer evaluation. Evidence of teaching awards or publications related to educational efforts constitutes excellent evidence of activity worthy of academic promotion. If one meets the criteria, this is recognized with academic titles demonstrating advancing rank: assistant, associate, then full professor.

In non-academic careers, the criteria for success are not as clear as in academia. They may include personal, employer, hospital or community goals. Career development in this arena is focused on an adaptation to an ever-changing practice environment. Successful EPs are constantly acquiring new skills. To facilitate this growth, a program of professional development must be planned. Attention should be paid to both short-term and long-term needs. Knowledge and skills can be acquired by self-instruction, short courses, attending seminars given by professional organizations, or by enrolling in formal courses of instruction sponsored by universities or business schools. A large amount of information is always available at a library or on the Internet. Areas of development might include becoming a clinical content expert (e.g., airway, wound care, ultrasound), a sub-specialty (e.g., toxicology, pediatric, emergency medical services, hyperbaric, palliative care, critical care), administrative (e.g., business, regulatory, leadership, professional societies), and research.

Mentors are also important in helping physicians develop their professional skills. A mentor could be a more experienced colleague, someone who has successfully traversed the same political, university or employment environment, a coach, or someone who opens doors when needed. It is true that successful people, including EPs, have much to learn from others.

IFEM and EM CPD

It is the desire of the IFEM that this manuscript be used to help develop EM CPD programs throughout the world.

The development of a robust CPD program requires the emergency physicians of a country to be actively involved in the process. The initial establishment of a program requires a needs assessment to identify post-training development gaps and opportunities. This must include both physician and regulatory input. Representative emergency physicians should meet with the regulatory body and discuss national needs. A working group could take the agreed-upon objectives and develop a CPD curriculum. This plan would be easiest to implement if ratified by all parties involved. EM educators could then develop a step-by-step curriculum to accomplish the educational goals. Whether they are called objectives, milestones, competencies, or proficiencies, the desired outcome would be a series of continuing educational activities and training experiences that would help the nation’s emergency physicians evolve and continue to provide the best possible care for the nation’s patients. The IFEM supports the integration of medical simulation into a CPD program for specialists in EM. As a learning tool within a CPD program, it may have the potential to facilitate learning in complex environments, such as the ED setting.

A CPD program should build on a physician’s training. Ideally there should be integration with medical school and specialty training. Lifelong learning across such disparate elements is called “vertical integration.” To vertically integrate, all three educational phases must cooperate and ideally achieve agreement on a longitudinal, integrated curriculum. This would then become a road map for specialty training, physician education, and performance across an entire career. Currently, we are aware of a few countries that have a common theme and easy transitions between the three educational phases. At this time, no country has achieved complete vertical integration. A partial listing of national CPD programs is presented in Table 1.

Table 1

Comparison of Current National CME/CPD Programs

A number of nations have some form of mandatory requirements for CME. The process of CPD should include CME and every effort should be made to align the requirements to the needs of the practicing physician. CPD should be part of a continuum of training, building on GME in a vertically integrated fashion. There should be a clear relationship between the GME and CPD curricula. There should also be a clear relationship between patient care needs and CPD. A comprehensive IFEM curriculum framework is provided in Table 2.

Table 2

IFEM curriculum framework for Continuing Professional Development in Emergency Medicine

* Cathy Peck, Martha McCall, Belinda McLaren, Tai Rotem. “Continuing medical education and continuing professional development: international comparisons.” BMJ 2000;320:432–5.

CPD challenges and opportunities

The CME/CPD world is more heterogeneous and less structured in most jurisdictions than either undergraduate or graduate medical education. Undergraduate and graduate medical education focus primarily on medical knowledge and the development of the fundamentals of practice skills. A successful CPD program will integrate medical school, GME, and CPD into a continuum of lifelong learning on a diverse range of topics more expansive than medical knowledge. In addition to medical knowledge, CPD must encompass other topics into the curricula, such as ethics, technology, organizational change management and knowledge translation. This may prove to be especially difficult since most physicians have rudimentary--if any--training in business or management. Since most EM faculty are not experts nor prepared to teach these subjects, the learner must seek this content elsewhere. Teaching resources may not be easily available in the local environment. Organizations such as the IFEM may provide support in this domain.

Whilst IFEM does not mandate CPD, there are core principles that IFEM endorses: every EP should evolve in the multiple domains that are required for practice advancement; patient care should evolve according to the best available evidence; and there is a set of basic core EM knowledge, skills, and attitudes that define the discipline regardless of the location of practice. There is individual and national practice variation and every country should establish its own longitudinal EM curriculum that integrates content from the undergraduate (medical school) and graduate (formal specialty training) as well as professional development (post-training education) career phases.