Wednesday, July 22, 2015

CME, Industry and Outcomes

Recent medical literature describes the challenges of demonstrating the impact of CME on physician learning (with a focus on the lack of impact), and the need to reform the current system.  Writers suggest that it really is not having the impact that it should, given the financial resources provided.  Others have questioned how it is funded, suggesting that it may be biased given the resources provided by industry, and that it should be changed. 

While I admit my own bias as an Associate Dean for CME for a major medical school, I feel that it is important to study the peer-reviewed literature to best understand this important topic.

First, is the industry influence really that significant?  A piece by Cervero discusses this, and found limited evidence of the impact of industry influence on CME.  In the recent ACCME 2014 report (Table 8), only 11% of accredited CME received commercial support from industry.  My interpretation of this is that the commercial support is certainly not an overwhelming part of CME programs (our own institutional data would definitely mirror this finding).

Second, what is the real impact of CME?  The same above author recently published a piece in JCEHP (full disclosure: I am the social media editor for this journal, but was not involved in any way in the creation, revision, or decision to publish this manuscript) that concluded that CME can indeed impact patient outcomes and physician behavior (the former more than the latter).

Third, improvements in how CME is disseminated should occur.  Within this realm, patients should be included, and interprofessional learning should occur in team environments; this is highlighted by the new President and CEO of the ACCME, Dr. Graham McMahon, in a Viewpoint piece in JAMA that came out online earlier this week.


So where should we go from here?  I think there are several things we can consider.  Most importantly, physicians and other healthcare providers should continue to learn in order to provide optimal care of their patients in a changing environment; CME is one way to aid this learning.  Those in the field have been thinking about how to restructure it for many years and have made major strides in focusing on quality improvement.  Second, we should also consider learning healthcare systems as a way to promote learning for those who provide care for patients.  Lastly, we should be diligent about using technology to make our learning more effective.  Examples include online journal clubs and virtual communities of practice.  Given the complexities that abound in medicine in the current environment, anything that can make the process of learning how to "keep up" and best care for our patients easier should be welcomed.  

Tuesday, July 14, 2015

Learning Theory vs Learning Approach

I had the privilege of giving a grand rounds presentation recently on the topic of lifelong learning in healthcare.  In the presentation, I discussed how adults learn within medicine, and reviewed literature on "adult learning theory".  Malcolm Knowles wrote extensively on the topic of Adult Learning, creating "principles of adult learning" also coining the phrase "andragogy" (as opposed to "pedagogy").

Others have questioned the concept of Adult Learning Theory, and have evidence to suggest that having one learning style is a misnomer.  In fact, an article this month suggests that, at the undergraduate medical education level, we should consider a focus on learning approach rather than teaching to a specific learning style.  Learners may not learn optimally with their self-proposed best learning style, and it is hard to say that a learner can learn with only one particular style.  See here http://www.danielwillingham.com/learning-styles-faq.html  for a great review of this.

So what should educators do, given this dichotomy?   Should we focus on the content and a delivery style that "meets the needs of today's learners"?  Should it be about teaching the content to the learners, and nothing more?

In clinical medicine, where I spend most of my time, I do think it is critically important to focus on not just the content, but also the context in which that content is delivered.  Learning environment, sometimes referred to as learning climate, is critical to making the learning process successful.  It is the backbone upon which is built the process where ideal learning can take place.  Given the IOM description of the Learning Healthcare System, this is essential.  After all, where there is a healthy learning environment, there is an opportunity for all to learn with and from each other in order to provide the best care of the patients for whom we are privileged to care.

Thursday, June 25, 2015

Demonstration of "Tweeting the Meeting"

I had the privilege of writing a paper recently with Dr. Janine Zee-Cheng on Live Tweeting in Medicine: 'Tweeting the Meeting', which came out a few months ago (and allows free open access to all articles through the end of June, 2015).  In it, we highlighted the importance of lifelong learning through the use of Twitter at conferences.  I also encourage a quick read of this other great piece giving suggestions on how to live tweet in conferences.

Dr. Zee-Cheng, a pediatric critical care physician from my institution, is giving a presentation on a social media-related project she did as part of her fellowship, at a conference currently going on this week in Chicago.  The hashtag is #smaccUS (to reflect social media and critical care).  I highly encourage those who are reading this blog now to check out the tweets from this conference.  The discussions, on a variety of topics, are truly epic, and range from general content in the management of critically ill patients, to the emotional side of medicine, to introspective reflection about one’s practice, to frank humor.


While I am not at the conference (we are orienting new incoming interns to begin their clinical duties), I have learned so much from reading tweets from participants.  I encourage all interested in this topic, and literally, medicine in general, to check out the #smaccUS hashtag—you will not regret it!

Thursday, May 28, 2015

Social Media in Medicine: Lifelong Learning for All Through Free Open Access

I recently posted about online resources for lifelong learning.  This is a very important topic as emerging technology continues to be a part of medicine.  Just last month, I was privileged to be an author for one article on Live Tweeting in Medicine, within an entire issue of a medical journal focusing on social media.  The guest editor, Dr. Meg Chisolm, has worked with the journal, International Review of Psychiatry, to make the entire issue free open access from now until the end of June 2015.  This is extremely exciting as it makes available to all some wonderful reviews of social media within medicine in a variety of contexts.  I encourage you to take advantage of reviewing these articles, and saving them as resources.  The link to the entire issue of the journal (with free access to all articles full-text through June 2015) is here

In addition, a Twitter chat discussing pertinent issues of social media in medicine, under the hashtag #nephJC will take place on June 16, 2015 at 9 pm EST, and again at 8 pm GMT on June 17, 2015 (as a time more conducive for our colleagues in Europe/Africa).  Many of the authors from this issue will be tweeting in during that discussion.


This is a leading example of sharing materials for lifelong learning for all.  Please share via social media to demonstrate the impact that social media can have!

Saturday, May 23, 2015

Using Technology for Lifelong Learning in Medicine

I think that in the current age of “everything at one’s fingertips”, in the form of mobile devices like smartphones and tablets, the concept of lifelong learning has never been more important.  How does a physician “keep up”?  What are the skills that are important for physicians to have?  Dr. Vartabedian has written extensively on the subject of the digital literacy that is needed for today’s physicians.  Curating, collating, and how to find what one needs are skills that need to be taught, not only to students and residents, but also to practicing clinicians.

Given the plethora of sources available, I am seeing trainees more and more asking “what should I read/study?”  This is interesting, since there never have been more resources available than in today’s age.  I’d like to give just a few examples of tools that I find incredibly helpful.

[Full disclosure, I have no financial conflicts with any of these tools mentioned.  My spouse is an emergency physician in community practice.]

Browzine.  I use this resource on a mobile tablet through my institutional library subscription.  It allows opportunity to get full text articles from most of the journals with which our library has a subscription.  It is also great to review table of contents quickly, with fast linking to the full text if I want to read more.

NEJM Knowledge+. This resource is a way to review content for internal medicine (and family medicine) through adaptive learning, which is very unique.  I think of it as “smart testing”, whereby one inputs both answers to multiple choice questions, as well as her/his confidence in the answer provided.  Here is a link to an explanation on this type of learning.  I have used my own account to choose questions for residents during education conferences, and the engagement from the residents has been quite impressive.  There is also an opportunity to purchase an account for an entire residency program.

ALiEM: this is a compendium by emergency medicine specialists which is an incredible resource for those interested in this field.  It includes posts on staying healthy, links to apps pertinent to caring for patients in an emergency setting, resources for teaching in emergency medicine, as well as learning emergency medicine.    I especially like the videos describing procedures in the ED setting.  For those interested in improving their educator skills, the MEdiC links are incredibly helpful.

Twitter: there is an incredible community of practice related to medical educators on Twitter.  I learn so much from folks I have met, and also many I have yet to meet in real life.  A Thursday evening, 9 pm EDT Twitter chat on medical education topics is a great opportunity to start learning from others.  For literature on this topic, see these two articles: one on using Twitter as a learning tool, and one on social media for lifelong learning


I am curious what other online resources and technology that others are using for their own lifelong learning.  

Wednesday, May 13, 2015

Lifelong Learning in Medicine

Physicians and other health care providers are incredibly busy.  The administrative burdens have never been greater, they must learn to “keep up” in their respective area of practice, and caring for patients is a complex set of skills that takes time to achieve proficiency.  Recently, there has been a flurry of conversation in medical education about lifelong learning, including this piece on the interplay of social media and lifelong learning.  Most would agree that lifelong learning (whether self-directed or otherwise) is an important skill.  In fact, we teach this early on in medical school, and continue to stress the importance of lifelong learning during residency training and again in practice.

This post by Dr. John Mandrola on the NEJM Knowledge+ blog really hits home with respect to lifelong learning for practicing clinicians.  I really appreciate the last point about finding one’s own strategy for lifelong learning.  I struggle with optimal formats for “teaching” people to have a strategy.  Some excel at this skill, and others really need to work at it.  I think that maybe modeling it to trainees could have an effect (“Someday, I want to be like Dr. X; she is always striving to learn, even after 20 years in practice”). 


I do believe that given the rate of change in medicine, it is paramount that physicians consider the important of lifelong learning.  After all, our patients will ultimately benefit from our efforts to be lifelong learners and to stay current in our practice of medicine.

Sunday, March 1, 2015

Residency (GME) Positions: Addressing the Nation's Healthcare Needs

I’ll start this post with full disclosure: I am a medical educator, and have spent a good portion of my professional life educating trainees (residents) to prepare for independent practice.  My specialty is combined internal medicine-pediatrics, or “Med-Peds” for short, and my personal clinical practice is primary care for the underserved.

I have been very interested in what the future health care environment will look like, and thus follow updates from agencies that comment on the future of health care, as well as the supply of physicians and other health care providers.

There are some facts about which very few disagree, and there are others where interpretations are very different.  We do know that many new medical schools have opened up within the past few years, and also that many existing medical schools have increased matriculation. 

From this, it would seem as if the supply of physicians to care for future generations is being addressed.  But remember that, to be a physician practicing independently, one must graduate medical school, and also complete residency training.  It is this part, the percentage of residency training positions, which has NOT increased as much as the medical school matriculation.  The actual number of positions has increased, but not at the same rate as medical school graduates (see Figure 1).  In short, the “bottleneck” for US students to become practicing physicians is indeed US residency positions, known as GME, or graduate medical education.  The National Residency Match Program (NRMP) does state that there are enough GME positions for all US graduates, but there are other graduates (from international medical schools) applying for these same positions.

This was a busy week for such projections.  The AAMC came out with a roadmap earlier this week describing plans for how to address this situation.  The Commonwealth Fund, however, delivered another interpretation of the situation, stating that the current healthcare situation can handle the influx of new patients as a result of the Affordable Care Act.  This follows on the heels of the IOM report last year addressing the GME issue and recommending no additional funding for new residency positions, among other things. 

So who is correct?  I admit my biases on this topic, in that a) I am an educator, and attend the AAMC meetings, and b) I practice in a state where even the Commonwealth Fund writes that there are fewer primary care docs.  For the record, our Med-Peds residency program is the largest one in the country, and has been for at least 20 years.  About 40-45% of our graduates choose primary care as their ultimate specialty, higher than either hospital medicine or further fellowship subspecialty training.  This percentage of graduates choosing primary care was higher in the 1990s.

I’m curious what readers of this blog think about the situation.  Is there a doctor shortage, and is there a shortage of primary care physicians?  Will patients be able to get access to health care given the influx of new patients into the health care system?  What else should be done besides the roadmap outlined by the AAMC?


Thanks for reading; I’m curious to hear differing opinions.