amee guide no. 4 effective continuing education- the crisis criteria

8/17/2019 AMEE Guide No. 4 Effective Continuing Education- The CRISIS Criteria

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Medical Education Booklet

No. 4

Effective continuing education

:

the

CRISIS

criteria

R . M. H A R D E N J. M. LAI DLAW

Centre o r Medical Educarion,

Univers i ty o Du n de e

Further copies of this booklet are available from the AMEE Office

Level

10

Ninewel ls Hospital and Medical School

Dundee DD19SY. U K


2/16

Effective continuing education: the

CRISIS

criteria

R M H A H I 3 b . N

J

M I A I I I L A W

Centre jor Medical Edircatron, ‘rrivev>ity D ii t idee

Summary. ‘I‘he

11ccd for colitmulng medical

education (C ME) is now well recognized. The

challenge is to make it effective. C R I S I S , an

acronym n, stands for the criteria which must be

met to produce effective CME programmes:

convenience, relevance, individualization, self-

assessment, interest, speculation and systematic.

: I I IS IS is a practical tool, based on 15 years of

experience in the production and evaluation of

C M E programmes at the Centre for Medical

Education, University of Dundee. The appli-

cation of thc

C K I S I S

criteria to a CM E programme

will

highlight any areas iieeding iniprovenicnt

and will guide programme producers in the

creation of new CME materials.

It

will aIso help

those responsible for planning CM E activities to

choose from a range of existing progr ammes.

Key words: education, medical, cuntinuing/

*stand; curricduni; cliriical competence; pro-

gram development; prograrn evaluation

W h o needs

a CRlSlS?

An undergraduace medical qualification IS no

longer regarded

as

a lifelong certificate of

competence: to keep abreast of dcvclopments in

medical practice, a doctor has

to

find some

method of keeping up to date. The need for

continuing medical education (CME) has been

well docuniented and

is

now widely accepted.

C h r r e s p o n d u n i e : Professor It. M. l i a r d e n , Centre

f o r

Medical Educatlon University

of

Dundee,

Nine-

wells Hosp i t a l and Medical School, Dundee DDI

9SY

[ J K .

In response to the recognized need for con-

tinuing education together with financial induce-

ments, provision of CME is iiow

a

growth

industry. In the UK, the postgraduate education

allowance for general practitioners, introduced

in April

1989,

offers an incentive payment for

‘a

balanced programme of continuing training‘.

More doctors now participate in approved

courses and the num ber of prograninies available

from which the doctor can makc

a

choice has

dramatically increased.

The range of approachcs adopred

i n

C M E

varies widely, from formal lecture-based courses

to small-group discussions or practical sessions

and distance-learning prograinnies. Much

discussion relating to the design of continuing

education has focused o comparisons of

different methods (e.g. videotapes versus

lectures), on the use of

new

techriology c.g.

computer-assisted learning, interactive video

disks

or

satellites) and

on

the details of subject

content

However, to maintain arid ericourage quality

i r i all forms of

CME,

a set of educational criteria

is

necessary. Using such criteria, programme

designers, course constructors and teachers can

ensure quality in their products; those respon-

sible for auditing and administering programm es

can check

on

high standards; tutors ( o r others

who select programmes) can choose between

competing products; and participants can assess

what they ‘consume’.

’ In 1982, at the Association for Medical Edu-

cation in Europe/Association for the Study of

Medical Education meeting in Cambridge, the

CRISIS

criteria were first described (Harden

1982).

CRISIS is

an acronym for seven criteria which

contribute to the effectiveness o f CME.


3/16

ect ve cont nu ng e u c on

409

Convenience makes voluntary participation

easy.

Relevance

Individuali-

zation

Self-

assessment

Interest

Speculation

and

Systemat ic

reflects the user’s day-to-day role

in medical practice.

allows learners a say in wha t is

learnt and to adapt the

p r o g r a mme

to

the ir o w n needs .

encourages doctors to evaluate

their understanding of the

subject and

to

remedy an y gaps

identified.

arouses attention and encourages

learners to participate in the

p r o g r a mme .

recognizcs controversial and grey

areas in medicine.

offers a planned programme,

wi th coverage of a w hol e subject

or

an identified part of it.

Since 1982, the CRISIScriteria have been w idely

applied in CME, including the large range

of

continuing-education program mes developed at

the Centre for Medical Education at the Uni-

versity of Dundee. The model has been used,

too, in areas other than medicine. Dunn

Hamilton (1985) applied a modified version of

CRISIS to an assessment o f continuing education

for pharmacists. T he rationale of the CRISIS

criteria has also been explored, and the criteria

related to Brookfield’s (1986) six principles

of

effective practice in facilitating adult learning

(Mulholland 1990).

Th e a i m

of

this paper is

to

give a full descrip-

t ion of the CRISIS criteria together with illustra-

t ions d rawn f rom the work at the Centre for

Medical Education, University

of

Du n d e e .

If

successful, developers and users o f continuing

education should produce and choose better

products.

Convenience

To

suit the user, continuing education must be

available at the right place, a t the r ight t ime and a t

the right pace. Access to resources should be

rapid and easy.

Place

O n occasion, i t m ay be necessary

for

a doctor

to at tend a course some dis tance f rom the h om e

and place

of

work. This is expensive in t ime,

travelling costs and accomm odation. Courses in

the local postgraduate centre have clear advan-

tages. Learning can be based also at ho m e, in the

surgery or elsewhere (e.g. w hile travelling to a nd

from work) . Such learning oppor tuni t ies save

the learner from spending valuable t ime in

non-prmoductive travel to and from a postgra-

duate centre.

A tradition has long existed whereby general

practit ioners educate themselves at h o me

thro ug h books, journals and magazines. paral-

lel tradition has, until recently, put far greater

resources into centralized learning, while com-

munity-based learning was the poor relation.

Th e r e

is

an argument for a mixed economy in

C M E , with centralized courses and courses in

postgra,duate centres con tinuin g their traditional

role alongside distance learn ing. T he centralized

courses should, however, be made m ore conven-

ient and accessible, e.g. by adjusting opening

hours of the postgraduate centre and by provid-

ing general practit ioners with more details of

events and resources. In the past few years the

need for convenience has been reflected in the

rapid expa nsio n o f distance-learning activities,

wh ere the learner is si tuated at a distance f ro m the

teacher but wit h an interaction betwee n the tw o

(H arde n 1988). This tre nd is likely to continue.

Time

To attend a conventional course

at

a postgra-

duate centre or university, the learner must fit in

wi th fixed course schcdules and hours. T his m ay

be difficult for busy doctors with a range of

commitments. Care of patients is any doctor’s

first priority t best, education com es second.

Th e cooperat ion of partners in a gr ou p practice

m ay also be required,

to

provide cover while the

doctor is absent, attending an educational

activity.

An y fixed time, evcn

a

regular comm itmen t a t

a se t hour on a par t icular day of the week, is

a wk wa r d to keep to . I t is not unc om mo n to find a

postgraduate tu tor who, in response to poor

attendance at postgraduate meetings, has


4/16

.

.

ar ew

. .

a r au ~

I

ostgraduate Postgraduate

I

4

Figure 1.

Centred educat~on

(left)

versus distance

learning (right).

changed t he t ime and day o f the sessions to tha t

sugges t ed a s more app rop r i a t e by t he pa r t i c i -

pan t s , on ly t o f i nd t he re is n o imp rov em en t axid

indeed on o c c a s i o n e v e n a d r o p

in

at tendance .

W i th d i s t ance lea rn ing , t he u se r chooses t he t im c

and t he du ra t i on o f each pe r iod o f ac t i v i ty .

P U C f ’

I n

formal co t i rscs , s tudents are t rad i t ional ly

c o n s tr a i ne d t o l ea r n a t t h e s a m e s p e e d. D o c t o r s

w h o a re n e w

to

t h e t o p i c s t r u g g l e to k e e p u p .

Doc tors wi th s on ic previous experiex icc in t he

a rea cou ld lea rn m or e qu i ck ly b u t a re fo rced to

s l o w d o w n a n d th e r e fo r e su ff e r f r o m b o r e d o m .

It

is

possib le , t o an ex t en t , t o ma ke a l l ow ances in

the p l ann ing o fcou rses b u t t h i s is l ikely to tax the

ingenu i ty o f t he cou rse p l anne r . So lu t i ons a re

easi er w i th d i st ance - lea rn ing p ro g ra mm es ,

w h i c h s h o u l d l e t u se rs w o r k a t t h e i r o w n pa c e

repeat ing as necessary or sk imni ing mater ia l i f

a l re a d y k n o w n .

hlakiri‘q edrrcatiori m o w

roriverrirrrt

C o nv en ie nc e o f C M E

is

increased by tak ing

t h e e du c a ti o n p r o g r a m m e t o t h e d o c t o r , r a t h e r

t h a n e x pe c t in g t h e d o c t o r t o c o m e

to

the educa-

to r see Fig.

1) .

T h i s is the basis for d is tance

learn ing ,

a

concept which has achieved increas-

i ng recogn i t i on i n recen t yea rs . T h r ou gh d i s-

tance-learn ing techniques , doctors can s tudy

w hen and w here t hey w i sh and a t a pace bes t

su i t ed to the i r needs.

More t han any th ing else, t h e d e v e l o p m e n t o f

d is tance-learn ing approa ches has helped

to

m a k e

c o n t i n u in g e d u c a ti o n m o r e c o n v e n i e n t f o r t h e

doc to r . D i s t ance l ea rn ing has fou r ma in featu re s

( H a r d e n 1988).

(1)

T h e teacher i s separa ted geogra phica l ly

f ro m thc s t uden t : con in iu t ii ca t i on is w ri t -

ten , audiovisual o r e lec t ronic .

(2)

‘ Th e l e a rn i n g p r o g r a n i m c 1s carefully

planned: the s tudent receives advice and

assistance on h o w b e s t

to

tackle the

subjec t .

3 ) T h e s t u de n t ’s w o r k IS ev i ew ed and reme-

dia l ac t ion prescr ibed wh er e necessary : th i s

i n ip l i e s tw o-w ay commun ica t i on .

(4 ) T h e l ea rner w or ks a lonc o r occas ioua ll y i n

a s m a l l g r o u p .

In d is t ance l ea rn ing , a nu m be r of’ channe ls o f

commun ica t i on a re ava i l ab l e . The l ea rn ing

niatcrial is most f requen t ly d i s t r i bu t ed to the

d o c t o r b y p o s t. F o r e x a m p l e , o n e C e n t r e f o r

M e d i c a l E d u c a t i o n p r o g r a m m e , ‘ IF’ ( In s t an t

Feedback) , c om pris in g a ser ies of pa ticn t-

n ianagenicnt chal lenges and informat ion re la ted

to

the chal lenges (Harden cf a / 1979), w as

d i s tr i b ut e d t o 2 4 0 0 0 d o c t o rs t h r o u g h o u t t h e UK,

in i tia l ly a long w i th

a

medica l j ou rna l and subsc -

q u c n t l y b y d i r ec t m a i l . D o c t o r s w e r e i n v it e d

to

reco rd t he i r managcm cn t o f t he pa ti ent

desc r ibed . Th ey cou ld receive immed ia t e feed-

back , u s ing a l a t en t - imagc p r in t i ng t echn ique

( R o g e r s ef

a / 1Y80),

which a l lowed the i r

r e s p o ns e t o b e c o m p a r e d w i t h t h a t o f t he ir

co ll eagues and w i th exp e r t s in the f ie ld . F urther

infor ma t ion w as avai lab le o n selec ted i tcn is

t h r o u g h r e c o r d e d t e le p h o n e m e s s a g e s o n a tele-

phone -answ er ing m ach ine and

i n

t h e f o r m o f

p r in t ed no t e s

on

t he t op i c .

More recent exam ples o f d is tance-learn ing

p r o g r a m m e s d i s t r i b u t e d

to

doc to rs a rc

a

pro -

g r a m m e o n m a n a g e m e n t f o r g en e ra l p ra c-

t i tioners , ‘ I f O n ly I H a d t h e

Time ’, in

w h i c h

4600 doctors enro l led and part ic ipa ted over a

2-year per io d and a p r o g r a m m e on palliative care

M A C P A C ’

i s t r ibu t ed i n co l l abo ra t i on w i th

Mami i l l an Cance r Re l i e f to ove r 5000 doc to rs .

A s er ie s o f 4 6 p r o g r a n i m e s p u b l is h e d i n t he

j o u r n a l Update, ‘Lea rn ing a t Home’, w as

des igned

to

b e u se d b y d o c t o r s w h e n a n d w h e r e it

bes t su i t ed t hem (H arden

R

S o w d e n

1Y83).

D e v e l o p m e n t s in teleconiniunicatiori tech-

no logy can p rov ide conven i en t oppo r tun i t i e s t o

hea r , and

to

q u e s ti o n , t h e v i e w s o f one e x p e r t o r

an expe r t pane l l oca t ed remo te ly f rom the

learner . Through sa te l l i te te lev is ion and a

supplementa l te lephone l ine , local audiences

in


5/16

many locations can tap into international exper-

tise. Medical Television Network is one example

of this technology in action.

IfCME is to be Convenient

for

doctors, it must

be available where and when they want it . Ifyou

know that someone is lost in the jungle, you do

not send them information about a jungle survi-

val course being held in a nearby village the

following month. To rescue them, you either go

into the jungle and, if required, bring them out,

or

you parachute

a

map, compass and relevant

instructions on map reading.

Convenience of CME can be enhanced by

producing learning materials designed to make

constructive use of otherwise empty time. An

example of this is another Centre for Medical

Education programme ‘Medaymaxims’. This

consisted of short educational messages conveni-

ently located on the doctor’s desk, combined

with telephone mcssages available on demand. It

covered a range of topics and was distributed to

5000

general practitioners. ‘Medaymaxims’

included a desk pad with a page for each day,

containing one important message on

a

medical

topic illustrated by a cartoon

or

diagram. Further

information on the day’s message was sent to the

doctor if requested. Alternatively the doctor

could listen to a recorded telephone message,

which contained additional information about

the topic. An audiotape was also available, in

addition to the printed material and telephone

message, and could be used by the doctor in a car,

or at other times where it suited him

or

her to

listen rather than read. In this way, the doctor

was cncouragcd to use time which might not

otherwise have been available for CME.

Frequently, doctors find themselves unable to

schedule long periods for study and the hours

that are available for learning programmes may

be irregular. In these circumstances,

for

the

learner’s convenience, it is sometimes best to

divide

a

programme into a series

of

modules

or

manageable units, each of which may stand

independently. In the

‘CASE’

(Clinical Assess-

mcnt

for

Systematic Education) programme,

which was distributed to 10000 general prac-

titioners, the subject of current trends in medical

practice was divided into

a

series of 24 units

(Adam

et al .

1986). Each topic was succinctly

covered in a small booklet. Of A5 size (about

6”x8“ , he booklets are easily pocketed. Because

they are easy to transport, they can be studied

anywhere and at any time.

On-the-job learning is a convenient form of

CME.

For

its potential to be fulfilled, however,

some organization o r additional resources will

probably be necessary.

A

programme,

developed in the Centre for Medical Education

for dentists, dealt with the common clinical

problems encountered by dentists. On encoun-

tering

.I

problem, the dentist could consult the

programme

as

a focus for further learning

througlh reference sources, audiovisual material,

readings or a discussion with the tutor (Abdel-

Fattah ~t

a /

1991). The ‘SHARING’ programme,

on peptic ulcer disease, was designed to give the

doctor an educational resource which would be

of benefit also to the patient while assisting the

doctor in the management of individual patients

(Strachan

et a l .

1990). Job-aid cards, designed to

assist

a

doctor in decisions about patients with

suspected melanoma, were part of a continuing-

education programme on this topic intended for

general practitioners.

It is :likely that the future will see continuing

efforts to make education more Convenient for

doctors and the further development of distance

learning will be part

of

this

-

ot a replacement

for

other forms of learning, but an adjunct to

them.

Relevance

Why are the poems

of

Robert Burns still read?

Why do they have worldwide appreciation, not

only in the West but also in Central and Eastern

European countries? One reason is that the

message is seen as being relevant to everyone.

People read the poem and can see themselves in

the situation described. Topics addressed in

CME programmes should be seen as being of

practical importance and dealing with everyday

problems rather than just academic interest

(Premi 1974). While the rare Prader-Willi

syndrome (a floppy infant, micro penis and

failure to thrive) may be ofrelevance to paediatri-

cians, it is unlikely to be seen as relevant by busy

general practitioners, unless there are more gen-

eralizable messages for them.

The j~resentationof

a

series of facts is often

seen as the basis of continuing-education pro-

grammes, but by themselves they may not be


6/16

. ar er

.

.

PROGRAbIME CONTENT

DEFICIENCIES

Vdhat

is covered in the

G a p s in

the doctor’s

programme knowledge or competence

Cornpetences required

of

the

doctor for medical practice

Figure 2 .

The relationships between the three

components of relevance:

A)

aspects

of

the pro-

gramme where there is a mismatch between the

educational activity on the one hand a nd

on

the other

the objectives of

CME

and the needs

of

the doctor

using the programme; (B) aspects of the programme

which, though relevant to continuing education i n

general, are not relevant to the doctor using the

programme as he or she

I S

already competent in the

area;

(Cj

aspects of the prog ramme which address areas

where the doctor is not fully competent but whi ch are

not relevant t o his

or

her medical practice;

Dj

deficien-

cies in thc doctor’s compet encein areas where he

or

she

should he competent but which have not been

addressed by the programme;

( E j

a relevant pro-

gra mme he area of competence addressed is

required for medical practice, t he doct or is not already

fully com pet ent in the area and the t opic is addressed

111

the prograniine.

seen as relevant . It is h o w the fact s a re app li ed to

pract ice tha t makes them re levant . Facts them-

selves a re s imp ly i ne r t know lcd gc , o f li tt le u se .

This appl ies par t icu lar ly to rar i t ies such as

the

Prader -W i ll i synd r om e , w h ich thc genera l prac-

t i t i one r migh t see on ly once in a l i fet ime, and

p robab ly no t even t ha t . Con t inu ing -educa t i on

p r o g r a m m e s , t h e r e f o r e , s h o u l d not b e o v e r l y

theoret ical .

N e w t o n N e w t o n

(1991)

r e c o m m e n d t h a t

re l evance shou ld be madc exp l i c i t . In o the r

w o r d s , k n o w l e d g e a l o ne is n o t e n o u g h

he

l e a rne r mus t be show n the u ses

to

w hich t ha t

k n o w l e d g e c a n b e p u t . n e a t c o n n e c t i o n

between re levance and the perce ived nccds of

users

is

p r o v id e d b y S h e e t s H e n r y

(1988).

n a n

e v a l ua t io n o f p r o g r a m m e s f o r f a m i l y d o c t o r s ,

par t ic ipants d id best in

topics

w h i c h t h e y c o u l d

app ly i n imcd ia t e ly

or

i n t he ve ry nea r fu tu re .

Lack o f re leval ice

of

CME

p r o g r a m m e s is a

c o m p l a i n t m a d c f r e q ue n t ly by users. In a su rvey

o f 200 genera l prac t i t ione rs carr ied ou t

b y

t he

C e n t r e f o r M e d i ca l E d u c a t i o n , o v e r 80%

of

Gl’s

regarded lack of relevance

to

t hen i as a p r o b l e m

they associa ted wi th C M E mee t ings i n pos tg ra -

duate cent res . Relevance is related

to

the choice

o f t o p i c a n d a ls o to t h e w a y , o r c o n t e x t ,

i n

w h i c h

tha t con t en t is hand led and p re sen t ed . Pro-

g r a m m e s d e s i g ne d f o r h o s p it a l d o c t o rs often d o

not address adequate ly the i ssues in general

practice. Relevance is as muc h abou t t he pc rcep -

t i on o f t he u se r o r l ea rne r as i t is ab ou t the detai ls

o f the co ntent i tse lf .

F igu re 2 g ives a g raph i c i l l u s t ra ti on o f th c t h ree

i ssues i n C M E w h ich de t e rmine re l evance .

Iiel-

cvance can

be

v iew ed

as

t he ex t en t to w hich t hc rc

is a m a t c h o r m i s m a t c h b e t w e e n t h e c o n t e n t o f

t h e p r o g r a m m e , t h e a i m s a n d o b je c ti v es o f C M L

in the area under considera t ion , and the defi -

c ienci es i n t he doc to r ’ s kno w le dge or

compe tence .

The h ighes t p r i o r i t y l ea rn ing needs i n

coii-

t i nu ing med ica l educa t i on , acco rd ing

to

Laxdal

(1982),

i nvo lve :

(1)

f r e q ue n t , i m p o r t a n t o r s e r i o u s illnesses

a m e n a b l e to med ical care ;

(2)

c o n d i t i o n s f o r w h i c h m a n a g e m e n t

me tho ds have recen tl y improv ed ; and

3 ) c o n d it i on s w h e r e e d u c a t i o n ca n i m p r o v c

p r e v i o u s l y p o o r m a n a g e m e n t .

To

ensure re levance , mater ia l s should be

ain ied a t a par t icu lar audience and carefu l ly

checked fo r app rop r i a t eness w i th a sam p le o f t he

target audience . To ensure cont inued rc lcvancc ,

periodic checks and ,

if

necessary , updates should

b e m a d e .

R e le v an ce o f a p r o g r a m n i c c a n b e i m p r o v e d

b y e x a m i n i n g t h e n e e ds of t he d o c t o r at w h o m

the p rog ramme i s add ressed . In a s t udy ca r r i ed

o u t a t t h e C e n t r e f o r M e d i ca l E d u c a t i o n 111 the

a rea o f mc lano ma , i t

was

f o u n d t h at m a n y

CME

p r o g r a m m e s on t h i s t op i c d id no t mee t a

gene ra l p rac t i t i one r ’ s needs . They l ooked a t

i ssues such as pa thologica l and microscopic

a p p e a ra n c e , w h il e t h e m o s t i m p o r t a n t t h i n g f o r

a

genera l prac t i t ioner to k n o w w a s w h e n a p a ti en t

w i t h a

mole

should be referred for fur ther

a ssessmen t and w hen t he pa t i en t shou ld be

reassured and no o th e r ac t ion t aken . G u idance on

th is prac t ica l i ssue was of ten lacking . Tackl ing


7/16

this mismatch was the key objective for a pro-

gramme developed in the Centre and funded by

the Cancer Research Campaign. The result was a

programme which has been shown to change

GPs’ management of patients with melanoma

(Laidlaw

eta/.

1992).A feature ofthe programme

was a series of case studies, with colour photo-

graphs, of patients with skin lesions where the

doctor had to decide whether to:

(1)

request a non-urgent appointment with a

hospital specialist;

(2) request an urgent appointment with a

hospital specialist;

3 ) take no action other than to reassure the

patient that there is nothing sinister about

the lesion; or

4) observe and accurately record, follow up

in further month.

The doctor was then given immediate feed-

back through latent-image printing as to the

appropriateness of his or her decision in this

simulated situation.

The first step in the development of the

‘MA C P A C ’ (Macmillan Palliation in Advanced

Cancer) programme, supported by the Mac-

millan Cancer Relief Fund, was to identify the

needs of general practitioners in the area of

palliative care. A critical-incident type study was

undertaken, in which a number of doctors were

interviewed, to establish the issues of concern

to

them. Those topics were then central in the

design of the programme.

A programme on management for general

practitioners was based on a one-year study of

the needs of GPs in this area (Swinfen 1987).The

title of the programme, ‘If Only I Had the

Time ’, reflected the general practitioners’

common perception that their biggest problem is

lack of time.

A

key feature in the development of the

programme ‘Trends in the Management of

Fissure Caries’ was interviews with 16 general

dental practitioners, chosen a t random (Pitts et a /

1992). These interviews produced many helpful

suggestions on omissions from, additions to and

changes of emphasis in the programme outline,

produced by specialists in the field. The inter-

viewees’ opinions also allowed the potential

audience to be divided into three categories:

those already making use of the techniques in

their practice, those interested in introducing the

techniques in thcir practice and those not inter-

ested. The programme was designed to take

account of all three groups.

‘MACPAC’

and ‘Trends in the Management of

Fissure Caries’ demonstrate that the relevance of

an educational activity may be increased by

consuking members ofthe target group as part of

the programme development. We would also

strongly advocate including a member of the

target group in the course-production team.

The

‘CASE’

(Clinical Assessment for Systema-

tic Education) programme, developed in con-

junction with the Royal College of General

Practitiioners, allowed us to look at the benefits of

increased involvement of the potential users in

programme production (Adam e t a / . 1986). Gen-

eral practitioners were closely involved, both in

choosing the topics and in writing the material.

Each

of

the programmes was the responsibility

of one of the Faculties of the Royal College of

General Practitioners, who worked with the

project team from the Centre for Medical Edu-

cation in the production of the programme.

Sincc: relevance depends heavily on meeting

the educational needs of Practitioners, how are

the needs of practitioners to be identified? Dunn

et a l .

(1985) gave a review of the methods

available. This included:

(1) t

isk analysis;

(2) Delphi technique

or

panel of ‘wise men’;

3 ) critical-incident survey;

4) behavioural-event interview;

(5) interviews with recent graduates;

(6)

study

of

recent textbooks and other

7) mortality and morbidity statistics; and

(8)

study of errors in practice.

No single technique provides a total insight as

to educational needs. Dunn et

a /

concluded that

Delphi, critical-incident survey and behavioural-

event interview provide the best guidance in

determining what competences are required.

Relevance can be accentuated by presenting

the subject matter in a context with which the

user can identify. For example, patient-

managcment problems, which feature in many

of the Centre’s programmes, are a vivid way to

show practical and theoretical considerations of a

topic. The concept is extended in ‘If Only

I

Had

the Time ’, a C ME programme for general

practitioners on practice management, and

information on the subject;


8/16

.

.

ar er

. .

a aw

‘Doctor’s Diary’, which covered a range o f topics

of interest to general practitioners. An impo rtant

part of both CME programmes was diary

extracts, where a doctor had recorded the experi-

ences in his practice over a period of days,

commenting on the decisions he had

to

make,

and

on

areas where he found difficulties and

problems as they arose in his practice. These

episodes were then cross-referenced to a resource

book.

Lay-out and design in a printed programme

may also be used to emphasize relevance. Those

sections of a progra mme which contain points of

ininicdiatc importance together with practice

guidelines can be highlightcd in the text. In the

programme for dentists, ‘Trends in the Manage-

ment of Fissure Caries’, trends in dental practice

were highlighted in

a

tinted area at the foot of

many pages (Davis et a l 1992).In the same way,

the ‘MACPAC’ (Macmillan Palliation in Advanced

Cancer) printed programme gives recom-

mendations and action plans in boxed tinted

areas.

Individualization

I n advertising and marketing, specialty maga-

zines are becoming more important to advcr-

tisers: they target and focus the advertisement on

an audience with a particular interest and needs.

Even som e mass-marketing advertisers are fine-

tuning their campaigns, with regional and local

variations. Mass-market magazines, too, offer a

wide array of special demograph ic and regional

editions. This trend towards individualization

should

be

rcflccted also in continuing cducation.

Those following a continuing-education pro-

gramme come from various educational back-

grounds and differing domestic o r professional

circumstances. Their needs will therefore differ.

A recently qualified doctor may be up to date o n a

subject, but lacking in experience: more senior

colleagues may have the expcricncc, but may be

short on up-to-date theory.

The variation in individual’s needs can be

divided into

a t

least 10 areas:

(1) type of medical practice, e.

g .

hospital or

(2)

previous experience and information

communi ty, urban or rural;

about the subject of programme;

degree of interest,

c g some

general

practitioners are particularly interested in

asthma, others i n dermatology;

preferred learning strategies and

methods, e.g. lectures, group work,

problem-based learning;

learning ability and speed;

amount of time willing to spend i n con-

tinuing-education activities;

time of day and

of

week available for

learning;

preferred location for learning, e . g .

home,

work, postgraduatc centre, car;

learning on own or along with other

professional members of the health-care

team; and

teaching responsibilities, e .g. GP trainer,

undergraduate teacher.

first point

to

makc about meeting thc

individual needs and expectations of

CME

parti-

cipants is not to be overly ambitious with the

target audience.

A n

example of the problems

which can arise was a series of videotapes on

cardiology, produced by a commercial organ-

ization at a cost o f over

X500000.

An excellent

film-production company and panel of intcrna-

tionally recognized cardiologists were

used.

The

result was disappointing and the prog ramme less

uscd than had been hoped. The main reason was

that the audience targeted was too broad. While

each videotape contained s ome material of rcl-

evance and interest to general practitioners,

jun ior hospital doctors in training, general physi-

cians, cardiologists and even medical students,

many potential users were not willing to invest

20

minutes in watching a videotapcjust to see the

few minutes relevant

to

them.

The

mor e closely

defined is the target audience for a CME pro-

gra mme , the fewer problems arc likely to result

with individualizing the pr ogramme to meet thc

needs of each participant.

What can be done to individualize continuing

education and increase the likelihood of success

for all? A number of strategies can help a

programme meet the individual needs of the

users. Here are some examples.

To cope with the requirements for different

lcvels of detail, a learning programme

on

rheu-

matology Joint Studies in Rheumatology’

presented three parallel text streams, with

information summarized in the left column, the


9/16

ec ve

co nt nu ng e um o n

main body of information in the middle column

and further information on the right column.

Alternative paths through parallel tracks allow

doctors to choose the depth

to

which they study

the subject. Once chosen, this is not fixed and can

be varied as the doctors work through the

programme, depending on prior knowledge and

interest.

The need of some participants for additional

information can be identified and built into the

design of the programme. A further feature of

the rheumatology programme was a resource

book which was designed to allow the user to add

further information sheets, supplied with self-

adhesive backing strips, to sections of the book.

In the ‘IF’ programme (Hardenet

a / .

1979) further

information was made available as an option, in

the form of recorded messages on the telephone

or

as further study booklets on aspects of the

subject. In the same way, the ‘Medaymaxims’

offered more detailed explanations on the tele-

phone or in writing of the shorter messages

presented in the programme.

Page lay-out and design, the use of headings

and summary lists can all help readers match the

programme to their learning needs. The doctor

can scan the programme, stopping to study

aspects of interest in more depth. In ‘Trends in

the Management

of

Fissure Caries’ for dentists,

carefully chosen headings and a short question

relating to the subject matter were printed at the

top of each page. This allowed the reader to scan

through the resource book, stopping at pages of

particular interest.

A carefully designed contents page and a quick

reference guide,

as

used in the

‘CASE’

programme

described above, may help a reader find parts of

the programme that are of particular interest.

The ‘Malignant Melanoma’ programme for gen-

eral practitioners included a resource book, with

each of the

11

pages (including covers) of a

different size. The margin exposed in this way

contained subject descriptions of each page,

encouraging quick access to the information

contained in

the

book. Spiral binding or loose

leaf binding of a book makes it possible for the

user to arrange the sections in his

or

her preferred

order. This approach was adopted in

a

pro-

gramme on the cardiac dysrhythmias, where the

user could choose to have as the first section

background information, clinical features

or

managment.

Feedback and self-assessment provide a

powerful method of individualizing a pro-

gramme. ‘Joint Studies in Rheumatology’ and

the mmagement programme ‘If Only I Had the

Time ’ both featured individualized computer-

generated feedback (Walker et a l . 1989). Partici-

pants returned their responses to patient-

management problems

or

clinical situations to

the Centre for Medical Education, University of

Dundce. In turn they received feedback. The

form of that feedback and the amount of

information sent depended on the doctors’

response to the problems. If their responses

indicated that they were competent in the area,

they were simply given

a brief reinforcement.

If,

on the other hand, their responses demonstrated

a failure to understand the area,

a

more detailed

explanation was given, with reference back to the

resource book and other sources of information

on the topic. Information was also given which

let doctors see how their decisions compared not

only with experts in the area but also with

col1ca;gues.

Programmes can also be designed to take

account

of

different learning strategies. A pro-

gramme produced in the Centre for Medical

Education on cardiac dysrhythmias comprised

two volumes. The first volume, ‘What Every

Doctor Should Know About Cardiac Dysrhyth-

mia’, contained the basic information for general

practitioners on the topic. A second volume

contained patient-management challenges with

cross-references back to the resource volume.

Doctors could choose whether they first studied

the subject in the resource manual

or

instead

went directly

to

tackle the patient-management

problems, referring to the resource manual only

when they ran into difficulties. Information from

a sample of 500 users suggested that about 85%

of domctors preferred to get into the programme

through the patient-management challenges and

15% through the resource manual. The user was

free to choose between a problem-based

or

an

information-oriented approach: that choice was

not imposed on the user by the programme

producer.

Programmes can be produced in different

versions to take into account the time doctors

have available to study the topic. For example,


10/16

.

-ar er

.

n l ~ -a~

two di fferen t vers ions

of

a p r o g r a m m e o n m e la -

noma w e r e p r o d u c e d . One, p a r t o f t h e ‘CASE’

s er ie s, c o m p r i s e d k e y s u m m a r y p o i n t s o n t h e

subjec t and a se t o f sho r t pa t i en t -managemen t

challenges in a br i e f24 -page A 5 book le t . A m o r e

i n - d e p t h p r o g r a m m e w a s

also

p r o d u c e d , w h i c h

included an ex tended ser ies of case s tudies , and

in fo rm a t ion abo u t d i f fe ren t a spec t s o f d i agnos i s

a n d m a n a g e m e n t o f m e l a n o m a .

S o m e d o c t o r s c h o o s e

to

sha re con t i nu ing -edu -

c a ti o n p r o g r a m m e s w i t h o t h e r m e m b e r s o f t h e

health-care team. To mee t t h i s need , p ro -

g r a m m e s c a n

be

designed for use by d i fferen t

discipl ines. A ser ies ofpa t ien t -m anag em ent chal -

lenges was developed part icu lar ly for th i s pur-

pose a t t he Cen t re fo r Med ica l Educa t i on , i n a

s t u d y f u n d e d

by

the S c o t t i s h O f f i c e ( T h o m a s

1990).A fu r t he r p ro g ra mm e, be ing deve loped a s

pa r t o f the ‘ M A C P A C ’ (Macmil lan Pal l ia t ion in

A dvanced Cance r ) se r ie s , is des igned fo r

use

b y

the health-care tea m arid has

as

i t s t it l e ‘Un i te the

T e a m ’ .

Self-assessment

A feature tha t of ten d is t inguishes successfu l f ro m

unsuccessful CME is t h e i n c o r p o r a t i o n o f a

se lf-assessment com pon ent . Indee d cont in uing

educa t i on has been equa t ed w i th con t i nu ing

self-assessment, cri t ical self-appraisal be ing the

ha l lmark o f t he goo d p ro fe ss iona l.

‘T he exam inat io n o f c lin ica l prac tice’ , asser ted

t h e N e w L e c u w e nh o rs t G r o u p (1986), ‘ m u s t

be

t he key c l emen t i n c on t i nu ing med ical educa t i on ,

w h ich o the rw i se becomes an i n t e l l ec tua l o r

sc i cn t i f i c game w i thou t a clear consequcncc’ .

Even excel len t doc to rs can d eve lop bad h ab i t s

a n d b e c o m e o u t - d a te d . T h e s e w i ll s h o w u p i n t h e

m irr or of se l f-assessment ,

h y

self-assess?

Se lf -asscssmcn t can con t r i bu t e i n a num be r o f

(1)

I t can se rve as a d iagnost ic tes t

to see

w h e the r readers need t o pa r t i c i pa te in t he

l e a rn i n g a c t i v i t y / p r o g r a m m e a n d , i f so, to

s el ec t pa rt s o f t h e p r o g r a m m e f r o m w h i c h

they w ou l d bene f it .

w a y s

to

C M E .

(2) I t can assess wheth er learners h ave

the

necessary competence or prerequis i tes to

u n d e r ta k e t h e p r o g r a m m e .

3 ) I t c an check w he the r t hey have mas t e red

the t op i c s cove red in t h e p r o g r a m m e .

(4) I t can demon s t ra t e t o d oc to rs t ha t t hey can

g o b e y o n d t h e c o n te n ts o f t he p r o g r a m m e

and app ly i t in the i r

o w n

con t ex t .

Self-assessment is no t exclusively fo un d in

se lf -l ea rning p ro g ra m me s bu t may

be

iricorpo-

ra ted i n fo rma l pos tg radua t e -cen t re p rog ram me s

as w e ll . O n e w e e k p r i o r to a pos tg radua t e

l u n c h t im e m e e t i n g o n ‘ T h e e n m o s t u s ef ul d r u g s

in cl inical practice’, do cto rs \ \’ere as kcd to w ri t e

d ow n the i r pe rsona l cho i ce. T he fo l l ow ing

w eek , t hey cou ld co mp are l is ts w i th t he i r col -

leagues.

W h a t

5 h O U l d

be sel f assessed?

Too

often, self-assessment is presented

as

a

ser ies of mul t ip le-choice quest ions , to

be

tackled

be fo re , du r ing o r a f t e r a l ec tu re o r a d i s t ancc -

l ea rn ing p rog ram m e, w i t h reca ll o f fact s as a

low - l eve l ob j ec t i ve . Much to

be

pre fe r red I S a n

a p p r o a c h to se l f-assessment which tes t s whether

reade rs can solve prob l em s i n t he a rea conce rned

and app ly t he kno w le dge t o t he i r prac ti ce. Th i s

m a y t a k e t h e f o r m o f a pa t i en t -managemen t

p r o b l e m ( H a r d e n

1983).

S e l f a s s u s s m e r i t :

-a

t h re e - s t qr

process

It is useful

to

th ink of se l f-assessment as a

three-stage process.

1 ) T h e question. I n the f i rs t s tage , a ques t ion is

p u t to t h e l e a rn e r . T h i s m a y b e i n t h e f o r m o f a n

i l lus t ra ted descr ip t ion of a pat ien t , as in the

me lano ma di s tance- l ea rn ing p rog ram me

descr ibed above , w i th a cho i ce o f va r ious man-

agcmcn t op t i ons . A l t e rna t i ve ly , i t may be prc-

sented as

a

desc r ip t ion o fo ne d oc to r ’ s p rac ti ce, a s

in t he ‘D oc to r ’ s D ia ry ’ and ‘ I f O n ly

1

H a d t h e

T i m c ’ p r o g r a m m e s , w i t h a n i n v i t at i on

to

readers

to

com par c t he i r p rac t ice w i th t ha t o f the

doc to r w ho se d i a ry i s p re sen t ed . In a c o m p u t e r -

ized

CME

p r o g r a m m e , p a t i e n t - m a n a g e m e n t

p r o b l e m s c a n

be

presen t ed

as

evolv ing cases ,

w i th deve lopm en t s a f fec ted by p r io r dec i s ions .


11/16

2) The response. The question having been

asked, some mechanism has to be provided

where the doctor can respond. In

a

printed

programme, this may be in writing brief

note as to a diagnosis, an explanation

or

a

management approach. The response may be to

make one

or

more selections from a range of

options available or

it

may be to score various

choices on a 5-point scale, where 1

=

wrong

or

certainly do not do,

2

= probably wrong or

probably not do, 3

=

uncertain, 4 = probably

correct or probably do, and 5

=

certainly correct

or certainly do.

This format was used successfully in the

‘IF’

distance-learning programme and was rated as

attractive by users (Harden et al. 1979).

In patient-management problems, the doctor’s

response may influence the further development

of the problem. This is more commonly

encountered in computer-based programmes.

O u r computer program for

‘ M A C P A C ’

(Mac-

millan Palliation in Advanced Cancer) allows

a

group of doctors to explore issues in managing

patients. Each computerized ‘patient’ responds

to treatment or advice: doctors face the con-

sequences of their actions (and mistakes).

Standardized patients can also be programmed to

give similar responses in a more life-like way.

The self-assessment component of a pro-

gramme need not be overt, demanding a written

response or a discussion with colleagues. Instead,

the programme can be designed so that , as users

work through it, their view on the topic or

knowledge of the area is challenged. This tech-

nique was used in the ‘Doctor’s Diary’ pro-

gramme, where the reader’s response to

comments in the diary, such as ‘I wonder what I

should do next?’or ‘I cannot believe that this is a

characteristic feature o f . .’, stimulates readers

into deciding where they stand on the issue or

forces readers to consider their own knowledge

of the topic.

If the learning programme

is

being used in a

group, the required response to the question may

be a discussion by the group.

3) Th e feed b a ck . The key part of self-assess-

ment is the feedback to the learner. In its simplest

form, this can be

a

‘Yes/No’ or ‘Correct/Incor-

rect’ response. In almost every instance,

however, it

is

of value to expand the feedback

beyond this. Feedback should include an expla-

nation why the correct answer is correct and why

the in’correct answers are incorrect. In this way,

any common misconceptions are addressed. The

doctor should be referred back to the learning

programme or to additional reading material

where appropriate. In the Centre for Medical

Education we have pioneered the use of individ-

ualized feedback, using

a

microcomputer

(Walker

e t a / .

1989). Each doctor participating in

a number of our continuing-education pro-

grammes receives individualized feedback in the

form of a personal letter: the letter reinforces

correct responses and discusses inappropriate

responses at length, with references back to the

learning programme.

If the feedback is too readily available in a

printd programme, the reader may consult this

before making a choice or decision. Conversely,

if the feedback is too difficult to get at, e.g. in

some remote page in a book or available only in a

subsequent instalment

or

programme, it may be

little used. Feedback can be hidden yet immedi-

ately available on demand through two tech-

niques: latent-image printing (Rogers et

a /

1980)

or scraimbled text (Cairncross Harden 1983).

Standards

Implicit in any self-assessment exercise is the

notion that there

is

a standard against which

doctors are assessing themselves. That standard

may be derived from the views ofan expert in the

field or the consensus view of a panel of experts.

We have found it very valuable to allow doctors,

as part of the self-assessment exercise, to

compare responses with those oftheir peers. This

can bc

a

pre-selected panel of doctors, the

selection of whom should be identified in the

programme, or the responses of other doctors

taking part in the programme. These peer

responses can be commented upon by the

authors of the programme and by experts in the

field.

Examples

The management programme, ‘If Only I Had

the Time ’, invited doctors to make, in each of 18

months, a set of management decisions. In

return, they received computer-generated, indi-


12/16

.

M .

Har en

.

.

Lai aw

vidualized letters giving comparisons with peer-

group and expert responses.

For the ‘Malignant Melanoma’ programme,

latent-image printing allowed immediate fecd-

back on a series ofdecis ions abou t skin lesions. In

the computer ‘ M A C P A C ’ (Macmillan Palliation in

Advanced Cancer), feedback was not only

immediate , but also influenced the ‘progress’ of

‘patients’ whose alternative futures were built

into the computer program.

Tirriin‘p

The feedback componen t of a self-assessment

activity may be made available immediately or

subsequently. Immediate feedback, e.g . through

latent-image printing or scrambled text, is

studied by the doctors when they are perhaps

most ready to receive the message, either having

jus t finished or being in the process o f worki ng

through the programme. In contrast, feedback

provided later can be more sophisticated, more

individualized and may contain information

about the responses of other doctors completing

the programme.

O f all the features, w e have found self-assess-

mcnt to be one of the most impo rtant in predic-

ting the effectiveness of a continuing-education

programme.

I t

can clarify

or

even change the

doctor’s educational objectives and it can pro mpt

reflective deep processing of information rather

than surface learning. Sowden Harden (1985)

have shown that, for instructional text in medi-

cine, the use of questions as an adjunct aid can

enhance learning and understanding o f the text.

Th e inclusion of a self-assessment element in a

continuing-education programme

is

important,

even if it has only a minor place in the pro-

gra mme. Alternatively it may be the major basis

for the programme or focus for the programm e.

Interesting

Any continuing-education programme has to

compete for time in the lives of very busy people,

whether patients or health-care professionals.

Uptake of the programme is seldom compul-

sory. Surrounded by expensively produced tele-

vision advertisements and progr amme s, faced by

high-quality print in free magazines and coffee-

table books , the potential user

is

unlikely t o look

twice a t a stapled collection of dull typescript

pages shoddily duplicated. Even such

a

simplc

little thing as the title of

a

program me, course

or

lecture might sway

a

doctor’s decision on

whether to take part. Would the successful

programme, ‘If Only

I

Had the Time ’, have

been

of

less interest to doctors if dully labelled

‘Management for General Practitioners: A n

Introductory Guide’?

How

the programmc

for a

postgraduate centre is presented, or how a dis-

tance-learning prog ramme

is

packaged, may also

determine the doctor’s participation. Indeed, the

packaging may determine whether the doctor

or

the doctor’s receptionist opens the envelope

or

deems it jun k mail and consigns it to the bin.

For three main reasons, cont inuing education

must be interesting to be successful:

1 ) to gain the attention of the potential user;

(2)

to encourage potential users to become

actual users, and to invest time, effort (and

possibly mone y); and

(3)

to hold attention and sustain the user’s

motivation to complete the material.

Educators have debated whether the stick or

the carrot provides the better motivation. Both

give little lasting interest and enthusiasm. The

best reason for studying is the inherent satisfac-

tion

of

finding out new things and developing

new talents.

A s

Kohn

(1991)

says, ‘Rewards have

been described as the “cncmics of explorat ion” ’.

The first large-scale distance-learning pro-

gramme produced in the Centre for Medical

Education went to both hospital doctors and

general practitioners. Programme completion

was encouraged by offering a limited-edition

print of

a

McIntosh Patrick watercolour to every

doctor who returned all their responses for the

patient-management problems to Dundcc. W e

have no evidence whether this affected doctors’

responses but som e later programmes ,

offering no such rewards, have had equally high

response rates.

Personal contact with doctors can help to

stimulate their interest in a lecture or

a

pro-

gramme. Tutor-initiated telephone calls he

‘friendly reminder’ to continue stud y ay be

of considerable value in encouraging distance

learners who are not in a ‘learning milieu’

(Harden

et

a / 1980).

Some subjects are of intrinsic interest

meetings on a sex-related topic or OIK with


13/16

financial implications usually attract

a

largc

audience hereas others may be perccived as

boring. For each continuing-education pro-

gramme, there will be an appropriate combin-

ation of at least six factors to maximize

attractiveness and interest.

(1 ) Relevance

Relevance is

so

important that it merits treat-

ment as

a C R I S I S

criterion and has been discussed

in a previous section. Anything that makes a

programme more relevant will also make it more

interesting.

As

part of the ‘Malignant Melanoma’

programme, doctors were sent the number of

new cases of melanoma reported in their area

since the programme had been initiated. This

helped to relate the programme to their own

practice and was picked out by users as both

relevant and interesting. Doctors have to appre-

ciate how they will benefit from attending the

meeting or studying thc programme.

2)Presentation

of

materials

How the meeting

or

programme is packaged

will also affect the doctor’s level of interest. For

example, the ‘CASE’ booklet ‘HIV and AIDS in

General Practice’ carried

a

slip wrapper with a

question designed to grab attention: ‘What is the

connection between AIDS, cabbages and

caterpillars?’ The answer, given on the other side

of the wrapper, was potential vaccines. The

intention was that the doctors’ curiosity, once

aroused, would lead them on to read also the

inside of the booklet.

A

book may not always be the most interesting

way to put across ideas in words and pictures.

Audiotapes, videotapes and computer disks have

all been used successfully. Novelty can attract

curiosity and interest may stimulate doctors to

use

computer-assisted learning programmes. A

mixed-media approach is often attractive.

However, by itself, a new medium

or

new

approach is not automatically better. Some ofthe

dullest programmes in recent years run on

computers o r are delivered via satellite.

3 )

T ex t des kn and lay-our

With printed material, well designed and laid-

out pages can help to scduce readers into

studyiing the material. The design can help them

to steer a path and find any chosen material. Text

should be tightly edited and presented in ‘bite-

sized’ chunks. Generous white space allows

room lor easy navigation and encourages readers

to annotate the text where necessary. Spot colour

can also help by differentiating, for example,

summ,iries

or

crucial guidelines. In trained

hands, an in-house desktop-publishing system

can reveal and enhance the interest in any subject

material. The ‘SHARING’ (Self-Help Resource in

Gastroenterology) programme, published in

1988, and the programme for dentists on fissure

caries provide examples of what can be achieved

through desktop publishing.

4) Visuals and

colour

The use of illustrations, in the form of over-

head projection transparencies, slides or video-

tape ex tracts, can add to the interest of a lecture.

Similarly, the use of illustrations and colour can

add to the interest of, and enhance, the printed

page. Illustrations, which played a large part in

the ‘Learning

a t

Home’ series, published in

Update ,

not only added to its interest but also

may have increased its learning effectiveness

(Sowdcn Harden

1985).

5)

Cartoons and huq our

Cartoons and humour have a role, too, in

arousing the interest of the doctor, whether in a

lecture or in a printed programme. Learning can

be fun ut this message

is

often not recog-

nized. Humour, however, is notoriously diffi-

cult to handle: it may backfire on the user. A

feature of the ‘Medaymaxims’ desk pad was

a

cartoon illustrating the message of the day. This

was overwhelmingly voted

a

great success by

doctors. who received the programme.

However, a small minority felt that thc cartoons

trivialized medicine. When cartoons were

applied in such areas as cancer or palliative care,

that disapproving minority felt that, at best, they

trivialized the subject and, at worst, were in bad


14/16

t as tc . Noncthclcss , used w i t h c a r e a nd n o t

ovcr-

d o n e , h u n i o u r c a n b e a p o w e r f u l w e a p o n .

If

t he users a r c amused by t he ma te r i a l , t hey

w i ll no t becom e bo red and m ay be t t e r re ta in

the

po in t s made .

16) Arriile irivolvrwicwt

Audien ce part ic ipa tion i s well recognized in

t he en t e r t a inn ie i i t i ndus t ry a s a means o f m a in -

t a in ing aud ience n i t c re s t. In the same w ay , m an y

peop le sh ow a su rp r is i ng w i ll ingness t o w ork fo r

no th ing ( i n t e rms

of

cash and educa t i on ) a t

so lv ing puzzles pr in ted in news papers and n iaga-

zincs.

The

same princip les apply in educa t i on .

Act ive i i ivo lvenicnt

is

essential for effect ive

learn ing . No one w h o has fa ll cn a s leep in a

lecture

or

a t a n after-d inner speech wo uld

disagree.

Active part icipation is

a

key con t r i bu to r to

nia in ta in ing do ctors’ in teres t in computer-assi s-

t ed lea rning p rog ran in i c s and s imu la t i ons . Tha t

enhanced in teres t is part icu lar ly ev ident when

p r o g r a m m e s a r c u se d b y g r o u p s o f d o c to r s .

Pa t i en t -managemen t p rob l ems i n distancc-

l e a r n i n g p r o g r a m m e s also, b y i n v o l v i n g t h e

doctors , seek to mainta in the i r in teres t .

Speculation and systematic

S p

cii la t io i

All too f requen t ly CME concen t ra t e s on aspects

of medicine which are es tab l i shed fac ts and

igno res a reas w here there is con t rove rsy or n o

s ing l e co r rec t an sw er . I t is i m p o r t a n t

to

i nc lude

areas

of con t rove rsy and specu l a t i on in

CME

prog ram mes . Reasons fo r t hi s i nc lude :

(1) I t will add to the interest

of

t he pro-

g r a m m e , w h i c h m a y o t h e r w i s e b e b o r in g

and du l l .

(2)

I t makes t he p ro g ra mm e c red ibl e . N eg lec t

of such issues may result in a programme

seen as irrelevant t o day-to-day practice,

wh er e i ssues are se ldo m clcar-cu t and

w h e r e u n c e rt a in t y

is

c o m m o n .

(3) Confron t i ng such i s sues i n a p r o g r a m m e

m a y he lp t h e d o c t o r to t a ck l e t hem in

practice.

I t is i m p o r t a n t t o d i s t i n gu i s h for t h e d o c t o r

a spec t s w h ich sho u ld

be

ob jec t s

of

m a s t e r y , a n d

w h e r e

a

clear-cut coursc of ac t i on is ind ica ted ,

f r o m a re a s w h i c h a r e

a focus

for speculat ion and

w h e r e t h e r e is n o c l ear cou rsc o f ac t i on . A reas

w h ere specu l a t i on ma y ex i s t i nc lude :

(1) t opi c s w he re t he re is mo re t han one

‘co r rec t ’ so lu t i on ;

(2) reccnt advances which

m a y

n o t h a v e been

gcnera l ly adopted or about xvhich thcrc is

son i c unce r t a in ty ; and

(3) subjec ts tha t a re soci‘illy sensitive and have

di fferen t in tcrprc ta t ions ,

c g

H I V a n d

A I D S .

Such grey areas arc of ten neglec ted as be ing

too ha rd t o pu t ac ro ss

to

t he

l e a r n e r .

I t need no t

be

so wo v iew s on a subject n iay o ccup y l i t tl e

n io rc space t han one ove rs imp l i f i ca t i on . Fo r

example , t he

‘CAS E’

b o o k l e t o n H I V a n d

AIDS

al lows the reader

to

rate various reactions in a

se ri es o f case st ud i e s . A po s t c xd w i th t hose

ra t ings marked

is

then processed

to

p r o v i d e

a

‘pe rsonal ’ com pu te r i zed con im en ta ry .

Som et im es a cont rovers ia l issue is presented as

an e s t abl ished fac t. T h i s sho u ld b e avo ided . T h e

l earner wi l l benefi t by d is t inguish ing between

the genu ine ly au tho r i t a t i ve and

the

s t rong ly

expressed i nd iv idua l v i ew .

The

‘ IF’

prog ran in i e demo ns t ra t e s t he de li bcr -

ate use of specu l a t ion (Roge rs r t a/ 980). F o r a

series of pa t i en t -managemen t p rob l ems ,

there

w ere , i n

some

instances, no abso lu t e ly co r rec t

answ ers . T he doc to r ra ted poss ib l e cou rses

of

act ion 11a

1-5

scale, 1 being reject ion, 3 m e a n i n g

unce r t a in and 5 f o r a g r e e m e n t . S o m e t i m e s , 3 w a s

t h c m o s t a p p r o p r i a te a n s w e r . F o r e x a m p l e , t h e r e

w a s s o m e a g re e m e n t on dru g trea tmen t a f t e r a

myocard i a l i n fa rc t ion : admiss ion to hospi ta l

of

t he pa t i en t desc r ibed w as m or e con t rove rs i al and

mer i t ed a

3.

The d ia ry app roach , adop t ed in ‘ D o c t o r ’ s

’ D i a ry ’ a n d ‘ If O n l y I H a d t h e T i m e ’ . a lso

a l l ow ed areas of unce r t a in ty and con t rove rs y to

be t ack l ed , some t imes t h rough t he v i ew s of

different memb ers

of

the practice team .

Systematic

M u c h ofCME is h a p h a z a r d . A doc to r can read

med ica l j ou r na l s and a t t end a ll m ee t i ngs i n t he

loca l pos tg radua t e cen t re fo r a y e a r b u t n o t b e

sure a t t h e c n d

of

t ha t t imc w ha t has been

cove red .


15/16

EJective continuing education

42

1

Although some learning proceeds happily on

an ad hoc, opportunistic basis, this is not a

satisfactory basis if doctors are to keep up to date

in all aspects of practice.

To be systematic, a continuing-education pro-

gramme should let the consumers know how and

why aspects ofthc subject will be covered over a

planned period. The benchmark for systematic

coverage is that a course provides all that the

learners need to know about a particular topic. I t

need not include all there is to know or even all

that it is nice to know. We should be looking

towards a curriculum for continuing medical

education: a curriculum planned with the same or

greater rigour than the current undergraduate

curriculum.

Several of the Centre for Medical Education’s

programmes offered Systematic coverage of one

area of medicine:

Pro‘qramme Coverage

‘Joint Studies i n Rheurnatology’ One area of medicine

heumatology

‘MACPAC’ O n e area of medicine

-palliative care

‘If Only

I

Had the Time ’ One aspect

of

medical practice

management

‘CASE’ series Current important

trends in medical

practice

Knowledge that doctors can thoroughly

update themselves in one area of medical practice

may increase motivation, by encouraging

completion ofthe programme

or

attendance at all

lectures in a series.

The future

C R I S I S

is of considerable value as a practical tool.

In this booklet, we have described it in somc

detail, illustrated with examples from

a

wide

range of CME materials produced in the Centre

for Medical Education at the University of

Dundee.

If we examine the cutting edge

of

that tool

closely, it may look ragged. Any taxonomy is

artificial and interferes with reality. For example,

if a subject is re levant to

a

doctor’s day-to-day

work it is likely also to be

interesting.

Thus CRISIS

shows a fuzzy junction between two criteria.

Real life is always complex,

CRISIS

is

a

simplifi-

cation .- but if it does identify the characteristics

of successful CME, i t does work and deserves to

be used.

Acknowledgements

We are grateful to all who have contributed to the

development of CME programmes in the Centre

for M’edical Education at the University

of

Dundee. Our thanks go also to those who have

supplied financial backing for our work in this

area. We gratefully acknowledge the feedback

from practitioners who have used our pro-

grammes. These three groups allowed our

C R I S I S

to develop. We also wish

to

acknowledge Neil

Stamper’s assistance with the preparation of this

publication.

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