EPM executive editor Mark Plaster sat down with emergency medicine opinion leaders for a candid discussion about continuing medical education – do we need it, who does it best, and what would the ideal methodology look like?
Mark Plaster: Let’s get right into it. Do we really need to be taking CME courses?
Michael Gerardi: The public expects physicians to be up-to-date in their field and there’s really no way to guarantee that. Even though we’re board certified and many of us have a work ethic that drives us to stay current, I think the public and other parties may not be so convinced. There have to be methodologies that drive our behavior and prove to them that they are being taken care of by people who are up to date. The field of medicine is expanding so quickly that I think it really takes a critical number of leaders to say that the core content that you need to know has changed. I think for people to assume that what they learned in residency is going to carry over into 10 or 15 years of practice doesn’t make sense.
Greg Henry: According to Sophocles, “The keenest sorrow is to recognize ourselves as the sole cause of all our adversities.” We’re in charge of us, which means, “Man up.” Before there were state requirements for CME (back when I started) guys who were interested, learned! The CME courses being taught at the university were still full, and nobody required it. I think that with doctors, in general, there are those who are motivated to keep up, and there are those who aren’t. You can’t make someone learn who is stupid or unmotivated. I think if you dropped CME tomorrow, it would have no impact on what people did. The biggest effect would be if you no longer made CME courses tax deductible. Then all of a sudden CME organizers would go broke. CME has done some good things, but to think that states can mandate what you learn is a bunch of crap. It doesn’t make any sense, and I’m one who would explode it tomorrow.
Jerry Hoffman: I don’t know that there is a need for formal CME, in the sense that we all need to take control of what we learn and how we learn it. There are individuals who can do their own continuing education, I am sure. On the other hand, emergency medicine is both complicated and ever changing. So, we do need to have some method by which we can all keep up. Good quality CME is one of the ways to do that.
What are the best ways to learn CME? Let’s start with travel CME and medical conferences:
Gerardi: Let’s say you are a person who works 68 hours a week and you have very little time for CME. When you block off time to go on a ski or beach conference, you are blocking off time to spend three or four hours per day really focusing on your own education. However, the downside is that those courses are not as efficient as you reading at your own pace and picking out the things that you know are important.
HENRY: Going away for education is a lot more than a trip. It puts you in the right psychological environment to learn and it makes it a social event. You get to sit and talk with other physicians and say, “You know that last lecture we heard, do you think that’s a pile of crap?” I think that we highly under rate the value of showing up live. It has to do with putting your brain in a mindset where you’re there to absorb and learn. I think that our brain sends out signals that we’re now in a learning mode. I think that’s important.
Gerardi: What people particularly value are the questions. Many good CME events are firm on the fact that you have to stop talking after 40 minutes and allow five or 10 minutes for questions. That is where the cutting edge stuff, the interesting gray areas, gets discussed more openly, and I think that’s where we learn.
HENRY: There are some brilliant courses out there, which take you heavily, for a week, through a core knowledge base and the shifts in that base. I think that every now and again, that’s good for every one of us. I don’t care if you’re a full professor someplace or whether you’re seeing 40 patients every 12 hours by yourself in Keokuk, Iowa. It’s useful to have a time away to look at where you are in your learning structure.
What is the value of the LLSA?
HENRY: I don’t want to be the first one to start this fight, but LLSA is nothing but a pile of crap. Whoever said that a bunch of pinhead liberals could pick out 20 articles and have you read them and that would constitute what you needed to know to keep up in the field? The articles themselves are not necessarily great quality and not necessarily of great interest. If you are into evidence-based medicine, show me the evidence that reading those 20 articles and taking a little test makes you better. The only thing its proven is that it’s quadrupled the cost of being board certified. It’s also made an industry for people to go through the articles and pick out the answers. Now, there are whole programs where people go to a place, hear the article, then answer the test questions together after paying their 300 bucks. That’s continuing medical education? There is no proof anywhere in the country that that works. All of us went along like lambs to the slaughter, and the only one with a smile on their face is ABEM, raking in the dollars.
HOFFMAN: I don’t think there’s anything about the format of it that’s good or bad. Certainly, there’s no reason why you couldn’t have a program where seminal literature was identified and used to help people try to learn and think about important topics. The devil, as always, is in the details and it’s possible to have a really bad article selection process. There are, in my mind, examples of articles that were put up for LLSA that could be called absurd, and that’s being generous. They seem to suggest to me the possibility that they were chosen for reasons that have nothing to do with education, but may well in fact have to do with competing financial interests. To the extent that LLSA is chosen by smart, thoughtful, dedicated and unconflicted people, there may be some reasonable value in it.
Gerardi: I think LLSA is refreshing, and I feel good knowing that I’ve just reviewed 10 or 14 articles that experts in the field think are important to our specialty. It’s nice being spoon-fed a body of knowledge that could have a major impact on our practice. I don’t see where that’s unfair. We’re all busy. How do we know that we’re keeping up on everything? As our risk manager says, “You don’t know what you don’t know.” The articles I’ve seen have been very reasonable and fair, and I think that they’re appropriate.
Who is doing CME best? Best methods, best venues, best packaging?
HENRY: In general, those people are doing it best who understand what continuing medical education is, which is garnering the interest and excitement of the individual and speaking about relevant matters. And so, the best at show business are also the best at providing CME. Humans want to be entertained.
HOFFMAN: I don’t think it’s so much the venue as the quality of the program itself. In addition, we as individuals are different types of learners. Some of us learn better by studying and reading things, others by listening, still others by interaction. I think personally that interactive learning, particularly when there is the opportunity for small groups, and the opportunity to take part in what is going on, is better. For me personally, I would learn best if I could be in a place where I could engage with other people who both were my teachers and my colleagues.
HENRY: It’s highly individual. There are people who are oral learners and visual learners who enjoy something in front of them sparking the cerebral cortex. I think there are those who could sit in front of a plain monitor and read and watch and do very well. For us to believe we know the exact way to do it is wrong. The other issue is that there are multiple forms of continuing medical education which are right for a certain moment in time. All of those programs that are available on disk, so that you can listen to them in your car, are perfect. Doctors like to multi-task. If they can pick up some education while driving to work, they’ll love it. As soon as they have to sit down at home and watch the computer while their kids want to play, the participation drops. I think CME comes in lots of packages, but it has to fit the lifestyle of the physician involved.
HOFFMAN: As a general rule, if you’re looking for a CME event, you should be asking yourself, “who is paying for it,” and “what are the potential threats to the ability of the presenters to put my interests first at heart.” In my own mind, I would never, ever, under any circumstance, go to a CME program that someone else was paying for, and I would never go to one where the speakers were being paid by some outside proprietary interest that wanted to have me buy things ( i.e. pharmaceutical-sponsored conferences).
If you were in charge, how would you design the ideal CME?
HENRY: You know those piles of magazines and journals you promise yourself you’ll read some day? I call them stacks of guilt. I suggest pick up the pile, and then burn it. That’s not how you’re going to learn. It’s all about small amounts digested frequently, on a regular basis. If you think you’re going to sit with a textbook for three hours and catch up, it won’t happen. It never happened in the history of the world. It needs to be small bites, never more than about a half hour or 40 minutes at a time, and you need to do it on a regular basis. I think the idea of learning during your drive back and forth to work is incredibly successful.
The other thing is that whenever anything can be reduced to four pages, people will look at it. No one is going to read War and Peace when they only have 10 minutes. They are going to look at something short and sweet.
HOFFMAN: I don’t think there is one perfect way, and I doubt that any one way is, by itself, adequate. In order to continue to do well and, in fact, to improve our abilities in a very complicated profession, we have to be lifelong learners. That means gaining experience, and not just alone, but tempered by critical feedback. That often involves the help of others. Another aspect is continuing to learn new things. There is literature out there that it is important to know about and which you might not learn from your own experience. One of the problems is that most emergency physicians practice in isolation. We too frequently fail to see what others are doing, how they are thinking and why they are thinking the way they are. In addition, we too infrequently get the chance to have others look at how we’re thinking and provide us feed back from their observations. To the extent that we could increase both of those behaviors – looking at other’s processes and getting feedback on our own actions – that would be great. That wouldn’t be enough; you’d still need to read, hear from experts, etc... But I think a great part of the benefit would come from observing and being observed.
In other words, in my mind, one of the ideal best ways to continue to learn is to be a resident for the rest of your life. Working at an academic institution, I was blessed to be able to participate in a non-isolated environment where I constantly got to see what others were thinking and doing. And they saw what I was doing and thinking, and I got to have feedback, not just from patients, but from other doctors. Most residencies are in places where there are other doctors beside emergency physicians, some of whom are really experts at certain things. Then, you have a pretty close approximation, at least in my mind, to an ideal learning environment.
The reason that I suggest this is not because we can all do it. I have been very lucky to get to work in academic settings. But I do think it is a sort of model for the type of thing that we should try to encourage if we really want to create ideal learning environments. Periodically, at least, physicians should have the opportunity to watch others and be watched by others, in a less threatening environment.
Gerardi: The ideal learning structure wouldn’t look exactly like what we have now, but we’re certainly evolving to that point. I think with the LLSA and different certification requirements, we’re heading in the right direction. I like the fact that there is some testing to make sure you are paying attention and actually doing the work. I am impressed by the fact that this can be done totally online, with the right set of questions driving the objectives of that learning module, with the article right there that you can access. There’s nothing like going back after you’ve missed a question and having the reinforcement of the content of that particular article.
I think that in the future, you’re going to see online maintenance of certification. But you’re also going to see this being combined with being asked to come in to a simulation center to, “Show us what you got.” I think that’s what the resuscitation courses have done, which has annoyed some people. But you have to give them credit for knowing that there is extinction of skills.
HOFFMAN: What I’ve found works best in my own career is a discussion that is based on tangible cases. Those are fabulous educational opportunities. They are very difficult to come by because they are very labor and cost intensive; You can’t have actors and multiple players for every five, ten, or even 15 students. But that’s sort of my ideal. To the extent that a conference offers the opportunity for registrants to participate and not merely listen, I think that’s also better.
What role will simulation play in the future of CME?
Gerardi: We know, as educators, that people’s skills diminish if they are not rehearsed or used on a regular basis. I think that moving forward there will be an important place for real-time scenarios, simulation in continuing medical education. I think that we all have to be put in an environment where we can watch our behavior, confidentially, and see where we fall short, just like airline pilots. It is so important to practice so that when you get into the high-pressure situation, it is practically reflex. We know that unless you practice certain things every six months to a year, you lose the reflex. Some things are like riding a bike, but we’re not all the same. If we took something like floating a pacemaker wire, I’m not sure we’d all perform as well as we did when we were just out of residency.
HENRY: This is not an offense to the airline industry or pilots, but they have a very specific and narrow list of things that they do and situations to respond to. You can always set up a storm landing in a simulator, but our knowledge base is much more diffuse, much broader. I think that a simulator would not be near as good as having someone look at your charts every two years – pick 20 of your charts, read them and see how you’re doing.
HOFFMAN: I think that simulation is a potentially wonderful tool, but I don’t think we should fool ourselves into thinking that it can do everything. As we practice more and more, we come to realize that the most important issues are often human and interpersonal, having to do more with communication and ethics than simple medical decisions. Simulators tend to be least effective for that realm. They are very effective for procedures, though still not perfect. Simulators may also have the potential to do reasonably well for some types of decision-making. That said, poor simulation will actually be counter productive. When you try to intubate on an intubating model and there’s no resemblance to a real patient, you’re going to learn the wrong things. So, it has to be a good model. When you start to deal with more complex things, like how to talk to the patient, how to deliver bad news, how do I tease out the real history, that’s very hard to get from a simulation. Though, if it’s done extraordinarily well, even those finer elements can be teased out to some extent. There is a great potential there, particularly because, compared with the other options, one could do this at markedly less cost. To do it well, it won’t be cheap and will require continual flexibility. If we’ve learned anything from computers it’s that a simple model without flexibility doesn’t work and makes us all crazy.
What are some Innovative Ideas for continuing education?
Gerardi: I’m also board certified in pediatric emergency medicine, and the American Board of Pediatrics has a program for their maintenance of certification where they give you the articles online, in PDF, and you can access them before and after you take the test. If you get an answer wrong, you may go back to the article and have three shots at it. I found that interactivity to be very positive. If I made a mistake I knew exactly where to go to find the article. I didn’t have to go take a course somewhere; I could do it on my computer. It was totally secure, and I could do it while on vacation. The fact that you could access your article, go back to it and take the test again was a very positive-reinforcing way to learn.
HENRY: I suggest physicians have someone review their charts, taking the five most common chief complaints in emergency medicine and evaluate what you did. For many, the only chart reviews we currently have are all non-elective. The state of New York is the worst. As a punitive measure, they will ask for a review of your performance to be done by people that we do not agree are experts in emergency medicine. But what if the physician showed some intelligence and asked to be reviewed in order to make sure he/she is keeping up with the standard of care? We’re going to have a huge manpower surge to handle this soon because EPs are beginning to retire. There are people who are going to be around who would love to spend one or two days a week reviewing someone’s performance. By the way, that would be no more expensive than what we’re doing now with LLSA.
HOFFMAN: As an academic attending, I was very proactive and involved with all the patients and would often follow the residents into the room and watch exactly what they did and try to provide feed back to them. But I also, towards the last few years, have done much more of the opposite. I walk into the room with the resident and have them watch me take care of the patient. Neither, in isolation, is the whole answer. We would all benefit from being observed on a somewhat regular basis, but there is also a role for learning and teaching by demonstrating. If I had a really good mentor, I would not only want that person to watch me work, but I’d also want to watch them work.
Jerry Hoffman, MD
Professor at the UCLA School of Medicine; Associate medical editor for Emergency Medical Abstracts.
Greg Henry, MD
Founder and CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP.
ACEP Board of Directors, Former President of New Jersey ACEP