Learning for Life

You've just finished eating lunch and are sitting near the back of a crowded, darkened room watching a slide presentation. You had hoped to pick up some pointers on the latest diabetes treatment. Instead, the presenter at the front is only halfway through his 200 illegible slides on cellular function. Is this worth three hours -- or two days -- away from my practice, you wonder?

Is this your vision of continuing medical education (CME)?

For too many physicians it may well be a familiar -- and disheartening -- scenario. But it isn't just a lack of scintillating offerings that can make getting your CME credits a burden. Just as so many presenters fail to come up with interesting approaches to their topics, many physician attendees fail to develop the good lifelong learning habits that can help them get the most out of CME.

It's up to you

When it comes to earning CME credits, the burden of success is on you, the physician. It's physicians who have to find the best offerings, make time to take advantage of them, and constantly evaluate their own aptitude for and receptivity to the process of lifelong learning itself.

For some, lifelong learning may be construed as a treadmill where you forever chase after the newest theories or procedures, regardless of their true relevance to your daily practice. But lifelong learning is not just about earning CME credits. It's about understanding the value of staying on a learning curve. It's about infusing formal education sessions with the knowledge you pick up on the fly every day in your practice, and bringing the learning curve to your practice. And it's about developing strategies for discerning real learning opportunities from among the thousands of invitations to seminars and conferences you receive each year.

Two facts of life hamper physicians' attempts to become good lifelong learners: the demands of their daily practice and their lack of exposure to good lifelong learning habits. The rigors of medical school are partly to blame. Many doctors become hardened crammers who feel that once medical school is over, they've earned a break from studying.

"I think I learned more about lifelong learning when I was an MBA student than when I was in medical school," says John DeMaio, a part-time neonatologist and president of Cadence, LLC, a healthcare consulting firm in King of Prussia, Pa. "One of the things we need to do to improve the education of healthcare professionals is to teach good habits of lifelong learning. During the residency years, you don't hear about it because your existence is education. But the moment you've finished your formal training, that goes away and you're left to your own devices. We don't teach habits that will endure beyond that context."

Once they're past cramming, doctors may do the bare minimum to earn the necessary CME credits, or apply the same frenetic approach to study that can creep in during medical school. But lifelong learning takes time, planning, and dedication -- three things most doctors apply to their daily practices already.

Learning skills 101

So how can a busy physician become a dedicated, engaged learner?

"Making it a habit is the most important thing," says Brian Goldstein, who practices internal medicine at the University of North Carolina School of Medicine in Chapel Hill. "That might be as simple as carving out 20 minutes a day to review journals, or going to a grand rounds once a week, or making time for uninterrupted online or video CME. It has to be part of the fabric of your professional schedule."

DeMaio agrees that discipline is key. "You have to have a mindset in which you are constantly looking at your clinical practice to identify your own educational needs and then meeting them. There's an oversupply of educational programming. The challenge for physicians is knowing what their educational needs really are. How do I know what I don't know? That's the question you need to learn to ask and answer for yourself. I don't think we do a good enough job helping people figure out how to do that."

The good news is you are expanding your knowledge every day as you go from patient to patient.

"It's harder and harder for me to separate CME for credit from the learning we all do every day on the fly," says Goldstein. "Whenever I download information or references on my PDA because I've seen a patient and I need to get data to help them, that's a similar skill to doing lifelong learning through traditional CME activities. It's a time-sensitive version of CME."

DeMaio calls this concept "inline learning." He says an example of this kind of educational opportunity in his own clinical practice as a neonatologist is "when I'm confronted with a patient with dysmorphic features. I go on the Web and I've got the patient in front of me and an educational resource right at my fingertips. I can do my learning and fill the void in my knowledge in that one moment. I think that's the future of education."

"I'd like to see physicians receiving credit for learning what they feel they need to know based on their professional experience, as opposed to learning what someone else thinks they need to know," adds Michael Golub, an emergency room physician and director of CME for Medical Broadcasting Company in Philadelphia.

Some states are taking Golub up on that. "When I went to renew my state medical license recently, the medical board had a category called something like 'reviewing clinical information specifically related to a patient case,'" says Goldstein. "You could tabulate the hours you'd spent doing that and apply it to your credits. I was pleased to see that. I think we need that kind of a broad and progressive definition of CME requirements."

Which venue for you?

Once you've dedicated yourself to being a lifelong learner and you've begun to see your daily practice as an integral part of CME, you have just one hurdle left -- choosing which formal CME offerings to participate in.

You want to choose events that complement the learning you do in your daily work and that focus on your specific needs. It should be easy to find a half-dozen events that meet these two simple goals out of the hundreds of invitations you receive each month, but that's not always the case.

"Too much CME focuses heavily on the basic science and pathophysiology," says Golub. "The best CME is devoted to practical learning and decision making. If the audience is surgeons, for example, the best CME on a particular procedure might include the fine points that only an experienced surgeon would recognize, like where to stand, how to position yourself, optimal lighting technique, best instruments, etc. Instead, you get courses devoted to the molecular, cellular, anatomic, and pharmacological aspects of medicine, while paying short shrift to the actual behaviors and cognitions involved in being a clinician."

Christopher Crow, a physician at Family Medical Specialists of Texas in Plano, agrees that "CME courses need to be more practical. I've been to some that have been painful because they have nothing to do with my practice. Even though the drug may, they skip over everything that makes sense and go straight to cellular issues. I don't need to listen to someone going over biochemistry and cellular function for two hours."

Presentation skills can matter as much as content. "I got an executive MBA last year and one thing I learned is you have to be a good presenter," says Crow. "Don't speak in a monotone. Interact with the audience. And don't have a million busy slides you just stand there reading aloud."

Virtual learning

A great way to get CME credits without leaving home or your practice is to use the Internet. According to www.cmelist.com, the number of sites offering online CME credit hours jumped from 96 in February 2000 to 250 in July 2003; credit hours offered leapt from 3,000 to 20,300. The site is operated by Bernard Sklar, MD, who also has a graduate degree in Medical Information Science.

But online technology can test the mettle of most would-be e-learners. Participating in an online discussion or seminar means finding time to be in your office on your computer without interruption: no pages, knocks on the door, or phone calls to pull you away.

That's tough, says Goldstein, who has not yet accessed CME online. "It's harder for me to carve out the time to just focus on an Internet course, though in theory it should be more convenient," he says. "The chances of getting interrupted are just too good."

Another hurdle for online CME offerings is living up to the potential of the medium. "With few exceptions, most online CME providers don't really use its unique attributes," says DeMaio. "One of the beauties of this medium is its interactive potential. But when you look at most of what's on the Web now, it's just repurposing of monographs or slide presentations. One reason for that is it gets expensive when you develop interactive programs. And until everyone has broadband capabilities or DSL, it can be a very unsatisfactory experience."

Price does come into the online CME equation, according to Trace Urdan, a principal at ThinkEquity Partners, an institutional investment bank and industry research group in San Francisco. "You need a big investment of people, time, and money to create advanced, interactive technology, so for CME it comes back to the question of who's going to make that investment."

There are many companies that create online CME, but the big player that's missing is the pharmaceutical companies that sponsor most traditional CME events. "Drug manufacturers have high attendance levels at those events," says Urdan. "The events also provide a level of product support for them. So why should they invest a lot of money and effort in creating online technology?"

Still, Urdan points to many technologically rich online offerings -- especially simulations. "Simulations stem from the philosophy that trial and error is the best way for someone to learn," Urdan says. "The common element of simulations is that they require some level of interaction on the part of the learner, and you get different outcomes with different choices. If doctors are actually diagnosing fictional patients, for instance, it makes the whole exercise more engaging."

Rather than reading the results of someone else's efforts, doctors in online simulations can come to their own conclusions by learning from their mistakes without running the risk of harming an actual patient.

Whichever venue you choose for CME, you will get more out of your experience if you develop good learning skills -- which may mean unlearning often-frantic medical school study habits -- and analyze prospective offerings for their relevance and interactivity. In Golub's words, when it comes to CME, "relevant, practical, and timely equal excellent."

Lori Rogers-Stokes can be reached at editor@physicianspractice.com.

This article originally appeared in the October 2003 issue of Physicians Practice.