THERE WAS A TIME when CME was catch as catch can. But now, it has a life of its own. Someone figured out how to make money from it, and somebody else figured out how to use CME to ensure that physicians were taught what they needed to maintain hospital privileges. And malpractice insurance carriers discovered that doctors who attend CME activities have fewer claims against them.

Now that CME is formalized, we are concerned about whether the teaching is any good, whether learners take away anything worthwhile, and whether attendees at CME activities are changed by them. Do they treat patients differently and do their patients then do better?

Learning Nothing New?

But why should we be concerned that physicians at our sessions change their practices? I remember asking a family practitioner how he felt when he came out of a session having learned nothing he didn't already know. “Well,” he said, “I learned that what I'm doing is still standard-of-practice.” Nothing new isn't necessarily bad. Finding out he was up-to-date qualifies as a learning success.

But sometimes it's hard to know when not learning something new is a learning failure. This might be the case when doctors attend sessions on managing diabetes or hypertension while there are still millions of such patients whose treatment is inconsistent with evidence-based medicine guidelines. Is CME failing?

I think not. It means we're not looking at the bigger picture — learning in clinical practice. There are many doctors, like the one described above, who benefit even though there is no change in their practices. Those of you familiar with physician learning stages know that it isn't until well into a learning episode that behavior changes.

Day-to-Day Education

Focusing solely on CME misses the fact that most physician learning is of the day-to-day variety. Based on work by researchers like Jackie McClaren and Linda Snell, we know that this is the bread-and-butter learning doctors do. I interviewed a surgeon who summed up day-to-day learning by observing, “That's not learning — that's medicine.”

What resources do doctors use for day-to-day, clinical learning? Medical librarians tell us that doctors talk regularly with consultants, and they use the printed and computer resources available in their offices, as well as CME activities like noon grand rounds or sessions at the medical society annual meeting. The consultants, the printed material, and the CME activities all share three attributes: They are readily accessible, clinically oriented, and familiar.

What does this mean to CME providers? First, it means that we can be of most benefit to doctors when we provide opportunities to learn about problems they have on their minds. This is what researchers Jane Tipping, Jill Donahue, and Eileen Hannah have been telling us for a few years now. Doctors benefit by just talking with other doctors at our meetings about things they're currently facing.

Widen Your View

It also means that if we're really interested in changing the ways doctors practice (if we want them to do a better job with diabetics and hypertensives, for example), then we need to look at CME as one part of the learning mix. We need to ask questions like whether our regularly scheduled CME activity that covers hypertension is coordinated with the materials distributed by the American Heart Association, and whether AHA is coordinating their approach to patients with what we're telling doctors.

Our looking at CME in isolation from how doctors learn daily in clinical practice is kind of like a doctor's being concerned about a patient's hyperlipidemia without considering nutrition over the patient's lifetime.




Henry B. Slotnick, PhD, PhD, visiting professor, CME Office, University of Wisconsin — Madison Medical School, conducts research on how physicians learn. Reach him at hbslotnick@wisc.edu.