Tiago Villanueva's Discussions
Great resources online
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Started this discussion. Last reply by Baby Jane Aug 28.
Formal training in critical thinking - how to do it?
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Started this discussion. Last reply by Deirdre Bonnycastle Sep. 24, 2008.
Tiago Villanueva's Page
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- Do you think medical education can be reformed? How?
- Yes, through competent and visionary leadership, open mindedness towards the best practices worldwide, mentality change, and evolving from a model of rote learning and knowledge transmission to one of competency based learning. Medical education fails if we know everything about one very rare disease, but don't know how to take a proper history, how to reason and integrate knowledge and emotions, and to be proficient in basic procedural skills.
The top countries in medical education must work closely with the less advanced ones in exporting best practices and fostering adoptions towards the latter, while allowing them to develop their own research and expertise.
- Relation to medical education?
- None
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I've been away for a while, working on a sport medicine project, we have a demonstration next saturday october 4th.
I've seen the websites you posted.
PRIME is a useful and honourable action.
I'd like to have more information about the Virtual Congress of General Practice and Family Medicine. Family Medicine is the field we approach the most.
Ciao
Giancarlo
I'm starting to work for the academic world, with two different universities located in Rome and Florence.
You can visit:
http://www.technicalmedical.com
http://jim.technicalmedical.com (italian only)
http://edu.technicalmedical.com (italian only)
Also check my public profile on LinkedIn network:
http://www.linkedin.com/in/gdmconsulting (yes, I'm also a designer)
Anyway, I agree with you about the practical aspects of med edu, and that's why with my company I wanted simulation to be used in every course provided.
I know personally know the most important italian med edu providers, they're all using simulation and someone is also providing simulation technologies in some edu centers in Spain, of course being sponsored by big pharma companies!
Are you involved in any med edu project?
Ciao
Giancarlo
Your idea for a reform of med edu is interesting.
Can you tell me more about CME programs in your Country?
Giancarlo
Thanks for reading my patient-driven views of transplant.
Catherine
Cite this as: BMJ 2008;337:a973
Analysis
Rethinking continuing medical education
Alfredo Pisacane, director of continuing medical education unit
1 Università di Napoli Federico II, Naples 80131, Italy
pisacane@unina.it
Drug company funding of continuing medical education may affect doctors’ independence. Alfredo Pisacane argues that it can and should be stopped
Continuing medical education has become so heavily dependent on support from drug and medical device companies that the ethical underpinnings and the reputation of the medical profession may be compromised. In industrialised countries, drug companies support more than half of continuing medical education activities, and it has been shown that such support can distort the topic selection, embellish the positive elements as well as play down the adverse effects of some interventions, and influence doctors’ prescribing habits.1 2 3 4
To reduce the risk of conflict of interest in continuing medical education, it has been proposed that sponsors should not have any influence over the choice of speakers and scientific contents; moreover, providers and speakers of educational events should provide a full disclosure of the support received. Such disclosure, however, does not protect against the risks of an invisible influence of drug companies on providers, speakers, and participants.5
Continuing medical education is compulsory in Italy, and the Ministry of Health has recommended that local health authorities spend 1% of their total budget on educational activities. Nevertheless, most authorities spend much less than the recommended amount and up to 60% of the money comes from drug companies.
Because commercial support represents a substantial part of the resources available for educational activities, it may seem essential. However, for the past five years I have organised educational events at an Italian university hospital with no financial support from drug companies. Here, I present seven proposals for limiting the commercial support to continuing medical education.
Concentrate on small groups
One of the reasons for the high costs of continuing medical education is that most is based on conferences, meetings, and workshops. These are expensive and do not have any proved effect on doctors’ behaviour or outcomes of health care. My first proposal is to move away from conferences and instead promote educational events relying on accurate needs assessment, linked to practice, and organised in small groups. Activities such as clinical audit, outreach visits, feedback, and reminders have more effect on doctors’ behaviour and healthcare outcomes than traditional lectures.6 7 8 Such events could be held inside the health institutions and, as a consequence, expenses for trips, meals, and entertainment would be limited.9
In the past five years, over 250 educational events were organised in my hospital; only eight were workshops with more than 100 participants, the others were mainly team based, small group and interdisciplinary meetings aimed at improving clinical practice and quality of care. The cost of such events was low and no extra financial support was needed above the resources that the hospital had provided for continuing education activities.
Doctors were more reluctant than other professionals to accept the shift from traditional lectures to small group work. Continuing medical education records show that over 90% of nurses and other professionals participated in educational events organised by the hospital, compared with less than 20% of doctors, who mostly attended traditional, usually industry supported, conferences held outside the hospital and targeted only at physicians. The Ministry of Health, however, has recently indicated that at least half of continuing medical education activities should be linked to practice, team based, and organised with adequate adult learning techniques.10
The feasibility of a small group approach to continuing medical education has been investigated in several countries. Improvements in clinical practice and healthcare outcomes have been reported when learning was through audit and feedback, outreach visits, and reminders.11 12 13 14 No data are available on the effect of conferences and lectures on doctors’ behaviour and health outcomes.
Agree objectives for educational activities
National or local health authorities, in agreement with professional organisations and scientific societies, should identify a list of essential educational objectives for continuing medical education. Such objectives, based on adequate needs assessment, should be directed at improving practice and outcomes of health care. Educational objectives should also be tailored to each category of health professional. Only those educational events whose objectives are on the essential list will be able to award development credits.
The Italian Ministry of Health has identified a list of educational objectives for continuing medical education.10 Unfortunately, these objectives are too vague and do not specify what health professionals should learn or be able to do at the end of an educational event. As a consequence, clear indicators for evaluating the educational events are not available. I have identified specific objectives for each educational event I have organised, and in most cases it has been possible to evaluate the effect of training activities on competencies and, sometimes, on clinical practice of participants.15
Evaluate providers
Providers of education (medical schools, hospitals, professional organisations, scientific societies, and publishing and education companies) should be carefully evaluated. They should be able to dispense credits only if they organise educational events targeting the agreed essential objectives, the education focuses on small interdisciplinary groups and uses appropriate adult teaching methods,16 and they are able to systematically evaluate the effect of the educational activities on the behaviour of participants and on quality of care.
My experience shows that meeting these criteria is feasible. At present, about 10 doctors (out of over 700 in my hospital) and 40 nurses and other professionals (over 1600) have got experience in organising educational events based on team work and a small group approach and, when teaching a course, are able to identify specific objectives and indicators for the evaluation.15
Health institutions should commit resources
Each health institution should dedicate a percentage of its budget for continuing medical education activities. The budget will cover only the list of essential educational objectives identified by health authorities and will be mainly used for in-service training and small group activities.
Make use of new technology
National health authorities should create a central office for e-learning and should identify the types of educational activities that work with this method. E-learning courses incorporating the essential educational objectives can receive credits and be freely available for all health professionals. In Italy, the Ministry of Health and the National Drug Agency have launched a free online resource,17 based on Clinical Evidence, and have provided continuing education courses for over 26 000 doctors and 56 000 nurses up to the end of 2007. In the United Kingdom, interesting models of e-learning, such as the doctors.net.uk and BMJ Learning, have shown that it is possible to use the web for good quality continuing professional development.18 Moreover, videoconferences can be an affordable way of communicating with colleagues.
Create a central fund
Instead of drug companies supporting specific events or individuals they could be asked to contribute to a central repository of funds or a blind trust for an institution or group of institutions.19 A scientific committee would choose the educational events to support, and the events would include all health professionals, not just doctors. Organisers, speakers, providers, and health professionals would not have any contact with private companies and it could be ensured that the events met the agreed essential educational objectives and used substantiated learning techniques. Although drug companies would not be able to select which activities to support, some of them may agree to support a blind trust because it gives them the opportunity to become leaders, rather than targets, of regulatory initiatives to enforce stronger ethical standards regarding their relationships with doctors.20
Ask doctors to pay
The final proposal is that doctors should pay a modest fee for their continuing education and that such expenses should be taken into account in their tax payments, as happens with professionals in other fields. The "No free lunch" campaign21 and a large debate in the literature4 19 have shown that many doctors are prepared to pay towards their continuing education. I recently organised a 12 hour course for 200 Italian family paediatricians, costing 50 (£40; $79); everybody agreed to pay, and no commercial support was needed.
In conclusion, if a more evidence based approach to continuing medical education is achieved, not only would this result in cheaper solutions but financial support from the drug industry would no longer be required. This is a first good reason for a change. But there is another reason, which is probably even more important. Our patients believe in our competence and honesty. What would happen if they suspected that our continuing education was not only directed at improving our clinical competence and their health but also at promoting commercial interests? The rofecoxib affair has shown that a company can sponsor "countless symposiums in an effort to debunk the concern about the adverse effects of a drug."22 People should be confident that marketing and markets will not be allowed to undermine doctors’ commitment to their patients’ best interests or to scientific integrity.
Cite this as: BMJ 2008;337:a973
--------------------------------------------------------------------------------
Contributors and sources: Most of the ideas in this article derive from discussions with several health professionals at my hospital. I thank Armido Rubino, Luciano Vettore, and Isabella Continisio for their support of my work in the last five years.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
References
Steinbrook R. Financial support of continuing medical education. N Engl J Med 2008;299:1060-2.
Wazana A. Physicians and the pharmaceutical industry: is a gift ever just a gift? JAMA 2000;283:373-80.[Abstract/Free Full Text]
Lexchin J. Interactions between physicians and the pharmaceutical industry: what does the literature say? CMAJ 1993;149:1401-7.[Abstract]
Hebert PC. The need for an institute of continuing health education. CMAJ 2008;178:805-6.[Free Full Text]
Moynihan R. Doctors’ education: the invisible influence of drug company sponsorship. BMJ 2008;336:416-7.[Free Full Text]
Davis D, O’Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behaviour or health care outcomes? JAMA 1999;282:867-74.[Abstract/Free Full Text]
Grimshaw JM, Shirran L, Thomas RE, Mowatt G, Fraser C, Bero L, et al. Changing provider behaviour: an overview of systematic reviews of interventions. Med Care 2001;39:112-45.
Mansouri M, Lockyer J. A meta-analysis of continuing medical education effectiveness. J Contin Educ Health Prof 2007;27:6-15.[CrossRef][ISI][Medline]
Moynihan R. Drug company sponsorship of education could be replaced at a fraction of its cost. BMJ 2003;326:1163.[Free Full Text]
Italian Ministry of Health. Educazione continua in medicina. www.ministerosalute.it/ecm.
Armson H, Kinzie S, Hawes D, Roder S, Wakefield J, Elmslie T. Translating learning into practice: lessons from the practice-based small group learning program. Can Fam Physician 2007;53:1477-85.[Abstract/Free Full Text]
Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2006;2:CD000259.[Medline]
Thomson O’Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2000;2:CD000409.[Medline]
Cattaneo A, Buzzetti R. Effect on rates of breastfeeding of training for baby friendly hospital initiative. BMJ 2001;323:1358-62.[Abstract/Free Full Text]
Pisacane A, Continisio GI. Come fare educazione continua in medicina. Roma: Il Pensiero Scientifico, 2007.
Knowles MS, Holton EF, Swanson RA, Holton E. The adult learner: the definitive classic in adult education and human resources development. 5th ed. Houston, TX: Gulf, 1998.
Il progetto ECCE. http://aifa.progettoecce.it.
Sandars J, Lakhani M. e-Learning for GP educators. Abingdon: Radcliffe, 2006.
Rennan TA, Rothman DJ, Blank L, Blumenthal D, Chimonas SC, Cohen JJ, et al. Health industry practices that create conflict of interest: a policy proposal for academic medical centers. JAMA 2006;295:429-33.[Abstract/Free Full Text]
Studdert DM, Mello MM, Brennan TA. Financial conflicts of interest in physicians’ relationships with the pharmaceutical industry: self regulation in the shadow of federal prosecution. N Engl J Med 2004;351:1891-900.[Free Full Text]
No Free Lunch. www.nofreelunch.org.
Topol EJ. Failing the public health: rofecoxib, Merck, and the FDA. N Engl J Med 2004;351:1707-9.[Free Full Text]
Cite this as: BMJ 2008;337:a1023
Feature
Continuing Medical Education
Pharma and CME: View from the US
Suzanne Fletcher, professor emerita
1 department of ambulatory care and prevention, Harvard Medical School and Harvard, Pilgrim Health Care, Boston MA 02215, USA
suzanne_fletcher@hms.harvard.edu
In the United States, commercial support for continuing medical education has grown steadily over the past decade. In 2006 it provided more than half, about $1.5bn (£0.75bn, 0.95bn) or 60%, of the income for educational programmes doctors must take to maintain their medical licences. 1 Evidence shows that commercial support distorts what doctors learn.
In 2007 I chaired the Josiah Macy, Jr conference on Continuing Education in the Health Professions: Improving Healthcare Through Lifelong Learning (www.josiahmacyfoundation.org). A major recommendation emerging from the conference was that organisations providing accredited continuing education should not receive commercial support from drug or medical device companies.
The Macy report, from the conference, summarised the ethical concerns. Commercial support places doctors and nurses who teach continuing education activities in the untenable position of being paid, directly or indirectly, by the manufacturers of healthcare products about which they teach. Commercial entities have an obligation to make a profit for their shareholders and companies with billions of dollars at stake cannot be expected to be neutral or objective when assessing the benefits, harms, and cost effectiveness of their products. But an objective and neutral assessment of clinical management options is precisely what is needed in continuing education. The two responsibilities are fundamentally incompatible and create inescapable conflicts of interest.
Giving up commercial support for continuing education will not be easy; the Macy report suggested the process will take years. It will also take professional leadership. Already, there are stirrings. The Association of American Medical Colleges Task Force on Industry Funding of Medical Education recently proposed that companies be prohibited from offering free food or other gifts to doctors at academic medical centres. 2 Although it is easy to criticise drug and medical device companies, the conflict of interest their support of continuing medical education creates is our problem. It is the responsibility of the health professions, ourselves, to solve it. We need to try to live up to the ideal of a noble profession, to be sure that the care of our patients is not being subverted, even subconsciously, for financial gain.
The Macy conference also concluded that doctors should learn in a way that maximises healthcare quality for patients. Most continuing medical education is conducted with lectures, but we have known for a long time this is not the best way to learn. A 1905 quote succinctly sums up the successful approach.3
"Learning medicine is not fundamentally different from learning anything else. If one had 100 hours in which to learn to ride a horse or to speak in public, one might profitably spend perhaps an hour (in divided doses) in being told how to do it, four hours in watching a teacher do it, and the remaining 95 hours in practice, at first with close supervision, later under general oversight."
Somehow, continuing medical education in the US has ignored this 95 hour "rule" and concentrated on lectures. Systematic reviews show that the results are not impressive 4 5. The Macy conference recommended that continuing medical education move from an emphasis on lectures (learning what to do), to focus on helping healthcare professionals measure and improve what they do in their practices (competence and performance). American specialty boards 3 have begun to move in this direction. They have decided to require doctors who want recertification to complete practice improvement modules in which doctors review the care they deliver in their practices, compare the results with standards of excellence, and create a plan for improvement. The Accreditation Council for Continuing Medical Education in the US also updated its criteria to require that providers of continuing medical education analyse "changes in learners’ competence, performance, or patient outcomes" as a result of continuing medical education programmes.6
Shifting the continuing medical education experience from dimly lit halls, with lectures delivered with numerous, complex Powerpoint slides, to practice based learning and improvement will require a large cultural change in the continuing medical education world.
Cite this as: BMJ 2008;337:a1023
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Competing interests: SF reports potential conflicts of interest related to continuing education in the health professions because Harvard Medical School and Harvard Pilgrim Health Care are accredited continuing medical education providers, and because of honorariums from the American Board of Internal Medicine, Susan G. Komen Foundation, Research Triangle International, Josiah Macy, Jr Foundation, The Lancet, and several medical schools for visiting professorships. She receives royalties from Lippincott Williams & Wilkens, Wolters Kluwer, and UpToDate.
References
Steinbrook R. Financial support of continuing medical education. JAMA;299:1060-62.
Association of American Medical Colleges. Report of the AAMC Task Force on Industry Funding of Medical Education to the AAMC Executive Council. https://services.aamc.org/Publications/showfile.cfm?file=version114.pdf&prd_id=2328prv_id=2818pdf_id=114
Cabot RC, Locke EA. The organization of a department of clinical medicine. Boston Med Surg J. 1905;153:461-5.
.Agency for Healthcare Research and Quality. The Effectiveness of Continuing Medical Education (Evidence Report/Technology Assessment; 149). Rockville, MD: US Department of Health and Human Services; 2007. www.ahrq.gov/clinic/tp/cmetp.htm
Davis DA, Thomson MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education. Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 1999;282:867-74.[Abstract/Free Full Text]
Accreditation Council for Continuing Medical Education. Essential areas and their elements. www.accme.org/dir_docs/doc_upload/f4ee5075-9574-4231-8876-Se21723c0c82_uploaddocument.pdf
There's the Merck Manual series which are open and free to anyone, anywhere.
Finally, PLoS (Public Library of Science), BioMedCentral and PubMedCentral are several fine examples of open access journals... available to anyone in the world.
The world's major science-technology-medicine publishers rightly view the open-access movement as a threat to their profitability. However, for researchers, physicians, medical students... credible peer-reviewed resources via open access platforms represent a true democratization of scientific knowledge. Libraries are and will be viewed and used differently because of this knowledge-sharing.
Kathleen
A consortium of major medical schools has announced the World s Largest
Collaborative [OA] Online Encyclopedia of Medicine And Health
, July 23, 2008. Excerpt:
The Medpedia Project today announced the formation of the world s
largest collaborative online encyclopedia of medicine called Medpedia
. Physicians, medical schools,
hospitals, health organizations and public health professionals are now
volunteering to collaboratively build the most comprehensive medical
clearinghouse in the world for information about health, medicine and the
body. This free public site will officially launch at the end of 2008, and a
preview site becomes available today....
Harvard Medical School, Stanford School of Medicine, the University
of California Berkeley School of Public Health, the University of Michigan
Medical School and dozens of health organizations around the world are
contributing to The Medpedia Project in various ways. Many organizations
will contribute seed content free of copyright restrictions. Harvard Medical
School will publish content to uneditable areas that members of their
faculty have created as part of a medical school wide effort. Others
organizations, such as University of Michigan Medical School will encourage
members of their faculty to edit Medpedia as individuals.
Other health and medical organizations that are supporting Medpedia
include the American College of Physicians (ACP), the Oxford Health Alliance
(OxHA.org), the Federation of Clinical Immunology Societies, (FOCIS), and
the European Federation of Neurological Associations (EFNA). These groups
are contributing content and promoting participation in Medpedia to their
members. Medpedia is also receiving content and cooperation from the
National Institutes of Health (NIH), the Centers for Disease Control (CDC),
the Federal Drug Administration (FDA) and many other government research
groups who are eager to have that public domain information distributed to
both the general public and to healthcare professionals.
Medpedia has the potential to become a vital tool for scientists,
researchers and educators, as well as for the general public across the
globe, providing easy access to the latest and best information on medicine,
said Dr. Anthony L. Komaroff, Professor of Medicine at Harvard Medical
School, and Editor-in-Chief of the Harvard Health Publications Division of
Harvard Medical School. Sharing what we know, we can help each other and
help ourselves. ...
Over the next few years, the growing community of Editors on
Medpedia will create and interlink Web pages for the more than 30,000 known
diseases and conditions, the more than 10,000 drugs being prescribed each
year, the thousands of medical procedures being performed and the millions
of medical facilities around the world. These pages will provide insight
into the latest health and medical discoveries along with photographs,
video, sound, and images. The site has been designed so that everything on a
subject will be simple to access. The main topic pages will be written in
language the general public can easily understand, and each topic page will
have with it a "Technical page for professionals to discuss the same topic
in more clinical and scientific language....
Medpedia runs on open source Mediawiki software, and like Wikipedia,
content on the Medpedia site will be available for reuse under GNU Free
Documentation License (GFDL)....In the future, in order to cover operating
costs, non-invasive, text-based advertising will be shown on the Medpedia
website through third-party ad networks such as Google s Ad
Sense....Medpedia.com Inc. is funded and managed by Ooga Labs
a technology greenhouse in San Francisco
developing several for-profit, mission-oriented companies to address
worldwide needs in health, education, and activism.
While the contents of Medpedia will be OA, editing privileges will be
limited to those with an M.D. or biomedical Ph.D. who apply
to become
an editor. For more details, see the FAQ
ns> .
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