Desarrollo profesional continuo para médicos Continuous professional development for physicians

Resumen Mantener la competencia profesional sigue siendo un Maintenance of professional competence remains an exercise of permament learning and an essential ejercicio de aprendizaje permanente y un requisito esencial requirement for evidence–based medical practice. para la práctica de la medicina basada en la evidencia. Los Physicians attend continuing professional development médicos asisten a programas de educación médica continua (CPD) programs to acquire new knowledge. Often CPD o desarrollo profesional continuo continuing professional programs remain the main source for updates of development ( CPD ) para la adquisición de nuevos information. CPD organizers have a considerable conocimientos. A menudo los programas CPD siguen siendo responsibility in determining appropriate curriculum for their la principal fuente de actualización. Los organizadores de la conferences. Organizing an effective CPD activity often educación médica continua ( CPD ) tienen una gran requires understanding of the principles of adult education. responsabilidad en la determinación de contenidos Prior to deciding on the curriculum for a CPD, course apropiados para sus conferencias. Organizar una actividad organizers should conduct needs assessment of de educación continua ( CPD ) efectiva requiere a menudo la physicians. CPD planners should create activities that would comprensión de los principios de la educación de adultos. consistently improve physician competence. CPD sessions Antes de decidir sobre los contenidos de la ( CPD ) los that are interactive, using multiple methods of instructions organizadores del curso deben llevar a cabo la evaluación de for small groups of physicians from a single specialty are las necesidades de los médicos. Los planificadores de more likely to change physician knowledge and behavior. CPD beyond múltiples métodos de instrucción para pequeños planners should incorporate methods to determine the grupos de médicos de una sola especialidad son más course attendees' improvement of knowledge, skills and propensos a cambiar el conocimiento y la conducta de los attitudes during the CPD activities. Pre and post conference médicos. La eficacia de un ( CPD ) debe ser evaluada en un evaluations of physicians using multiple choice questions nivel más allá de la medición de la satisfacción del médico. may form a useful method of assessment. [Ghosh, AK. Planificadores de ( CPD ) deben incorporar métodos para Continuous professional development for physicians. determinar la mejora de los asistentes al curso de MedUNAB 2013; 16(2):71-76]. [Ghosh, AK. MedUNAB 2013; 16:71-76]. Palabras clave: Educación continua, formación profesional,

Mantener la competencia profesional sigue siendo un Maintenance of professional competence remains an exercise of permament learning and an essential ejercicio de aprendizaje permanente y un requisito esencial requirement for evidence-based medical practice. para la práctica de la medicina basada en la evidencia. Los Physicians attend continuing professional development médicos asisten a programas de educación médica continua (CPD) programs to acquire new knowledge. Often CPD o desarrollo profesional continuo continuing professional programs remain the main source for updates of development (CPD) para la adquisición de nuevos information. CPD organizers have a considerable conocimientos. A menudo los programas CPD siguen siendo responsibility in determining appropriate curriculum for their la principal fuente de actualización. Los organizadores de la conferences. Organizing an effective CPD activity often educación médica continua (CPD) tienen una gran requires understanding of the principles of adult education. responsabilidad en la determinación de contenidos Prior to deciding on the curriculum for a CPD, course apropiados para sus conferencias. Organizar una actividad organizers should conduct needs assessment of de educación continua (CPD) efectiva requiere a menudo la physicians. CPD planners should create activities that would comprensión de los principios de la educación de adultos. consistently improve physician competence. CPD sessions Antes de decidir sobre los contenidos de la (CPD) los that are interactive, using multiple methods of instructions organizadores del curso deben llevar a cabo la evaluación de for small groups of physicians from a single specialty are las necesidades de los médicos. Los planificadores de more likely to change physician knowledge and behavior.
(CPD) deben crear actividades que mejoren constantemente The effectiveness of a CPD program should be evaluated at la competencia médica. Sesiones de (CPD) interactivas y el a level beyond measuring physician satisfaction. CPD uso de múltiples métodos de instrucción para pequeños planners should incorporate methods to determine the grupos de médicos de una sola especialidad son más course attendees' improvement of knowledge, skills and propensos a cambiar el conocimiento y la conducta de los attitudes during the CPD activities. Pre and post conference médicos. La eficacia de un (CPD) debe ser evaluada en un evaluations of physicians using multiple choice questions nivel más allá de la medición de la satisfacción del médico. may form a useful method of assessment. [Ghosh, AK.
Planificadores de (CPD) deben incorporar métodos para Continuous professional development for physicians. determinar la mejora de los asistentes al curso de MedUNAB 2013; 16 Introduction 4 According to Knowles adult learning is based on the following seven principles, 1) To promote effective environment for learning, adults should feel that the Medical knowledge continues to grow at an enormous pace. environment is safe where all opinions are respected, 2) Physicians often find information taught during their Learners should be self-directed and involved in assessing postgraduate training either obsolete or substantially their gaps in knowledge 3) Learners should be involved in modified with the availability of newer evidence. The planning their curriculum, 4) Learners accept responsibility problems lie wherein after graduation from medical for their own learning and design their own learning institutions most physicians lack a formal method of objectives, 5) Learners need to identify resources and devise acquiring new knowledge. Maintenance of professional strategies for using these sources to achieve their objectives, competence remains an exercise of lifelong learning and an 6) They need to be supported in an informal and personal 1 essential requirement for evidence -based medical practice. environment and 7) Involved in self-reflection and Physicians adopt different methods to update their evaluation of their own learning experience. There are other knowledge including reading journals, attending continuous theories of on how adults learn including social cognitive 6 7 8 medical education (CPD) sessions and participating in theory, reflective practice, transformative learning, self- 9 10 11 hands-on workshops that focuses on updating a skill or directed learning, experiential learning, situated learning 12 learning newer techniques. Physicians traditionally attend and learning in communities of practice. Though many of CPD programs to meet their educational needs, however these principles of adult education would apply in practice CPD lectures alone have not shown to change physician based medicine, for our review we will refer on the 1 5 behavior Medical licensing organizations are increasing principles of Knowles adult learning theory due to its pressure to ensure to the public, payers and media, that widespread applicability. physicians are engaging in meaningful activities of life long learning and self assessment in the field of medical Andragogy assumes that adults are independent learners 2 education that provide competency based education. CPD who have already accumulated a great deal of experience. organizers have considerable responsibility in determining Adults are interested in an immediate problem centered appropriate curriculum for their meeting. approach and are frequently motivated to learn by internal demands to integrate learning to resolve an emerging work In the following review, we summarize essential related problem. Adult learning is often problem centered requirements for organizing CPD activity based on recent rather than subject centered. The difference between the evidence. The current review is not meant to provide an pedagogy and andragogy are summarized in Table 1. exhaustive step by step guideline for developing a CPD program, but meant to serve as a review of the current Prior to embarking on the acquisition of knowledge on a evidence on adult learning behavior and provide direction to topic, adults often have to recognize that they have a 13 enhance physician competence. We present an evidenceknowledge gap . They then strive to find out whether their based summary of 1) the principles of adult learning, 2) knowledge gap is problematic for them to spend time needs assessment of CPD, 3) emerging guidelines for CPD instruction and 4) assessment of CPD programs.

Principles of adult learning
Adult learning presumes that the adult will assess their lifelong learning needs and identify topics for their personal 3 development. Background experience and prior learning are essential components for adults in their assessment and application of new information in their work situations. 4,5 15 addressing it in a manner that would lead to a likely solution. effective in changing physician behavior. The first step in They also have to find out whether they have the necessary identifying lacunae in physicians' knowledge is to conduct a resources available at hand to solve the problem and finally needs assessment. This process identifies the gap between need to be willing to change their behavior based on what what the physician ought to know to practice effective 4,6,7 medicine and what they actually know. they learnt.
Needs assessment planning forms the basis of a successful Adults learn in different educational settings. The efficacy CPD. There are several sources of needs assessment,1) of different modalities of education results in varying 13 inferred need assessment based on current evidence, 2) degree of retention of information. The retention of specific practice needs, 3) proven need assessment based on information is only 10% of what is read, 20% of what is 15 objective external data. Table 2 13 course and objectives of all sessions should reflect topics what is taught. Hence, adults remember best when they that have been selected on the basis of prior needs actively involve themselves in learning, practicing and assessment ( Figure 2). teaching the material.
There is also variability in the learning methods adopted by While designing a strategy to involve adults to gain physicians to meet their individual educational needs. knowledge developers need to design sessions that would 16 McClaren and colleagues studied 366 primary care allow the adults to work in groups or have opportunity to providers who had to use a new knowledge or skill to solve a discuss topics that concern adults in their work [5][6][7][8][10][11][12] recent clinical problems. Physicians used 55 different environment.
CPD organizers have to select the topics 16 learning methods to resolve their issues. Hence multiple based on needs assessment (explained in greater detail in the interventions might be required to target positive change in a next section) and provide documentation of the adult 17 learners participation in the learning process. CPD specific behavior. organizers would therefore require understanding of the principles of adult education to plan an effective scientific program.

Guidelines for continuous professional development activity Needs assessment in continuous
Most medical institutions have a rigorous under and 18 professional development (CPD) postgraduate curriculum for education of medical students and residents respectively. Every step of the medical Continuing professional development strives to improve education is supervised and graded to assess and establish physician behavior with an ultimate goal of improving the competence of the students and their readiness to 14 health outcomes. CPD programs that are designed on the advance into clinical practice. Experts however have been basis of well conducted needs assessments are more concerned about a lack of formal course of study in the last 1 30 to 40 years of a physician's professional career. Most experts agree that lifelong learning constitute the longest 1 phase of medical education.
In the past continuous medical education (CME) activities were felt to be sufficient to meet the learning needs of the physician. CME activities suffer from few drawbacks as they are episodic interventions designed to address the needs of groups of learners, teacher centered and driven, encompass clinical domain, lecture based and conducted in 19 formal settings, e.g., lecture halls and conference rooms. CME lectures alone are insufficient in changing physician 20 behavior. Continuous professional development stresses lifelong learning based on ongoing self-assessments that address individual needs, is learner centered and driven, comprehensive in scope, including clinical domain, practice management, leadership, administration, education and spectrum of professional activities, includes a variety of learning formats and media used in educational activities and can be conducted in a variety of venues, 19 including one's office.

Continuous professional development for physicians
Physicians attend CPD lectures with a goal to update their Modalities of CPD activities would depend on the specific 24 knowledge, learn new skills and obtain CPD credits. Davis domains of education that need to be addressed. For 20 et.al showed that CME activities differ in their ability to example Didactic lectures or seminars would be a good increase physician competence, and performance and have venue to review new medical data. Self-assessment 20 activities like self study or taking maintenance of variable effect on health care outcomes. In a meta-analysis certification modules would apply to answer questions that of 14 studies on the effect of CME on physician arise in clinical practice. CPD activities that involved performance and health care outcomes, it was found that reflection as a group or self would address the domain of interactive CME sessions that included opportunities to judgment, wisdom and improved strategy. Interactive practice and learn new skills, interact with each other sessions like workshops, group discussion and hand-onbrought a change in clinical practice and occasionally activity like simulation or observed structured clinical changed health outcomes. CME sessions that included examination (OSCE) could be used to assess physician lecture format as their chief source of providing instructions 20 competence. Physician performance in practice can be did not appear to change physician performance. studied by audits and quality improvement studies. A more recent meta-analysis included 31 studies on the In order to organize a CPD activity and incorporate the effectiveness of CME suggested a medium increase in ACCME model of enhanced practice-based learning CPD physician knowledge and small increase in physician 21 course organizers have to incorporate different activities performance and patients outcomes. The effectiveness that would implement different learning modalities. was increased when the CME sessions were interactive, Properly selected CPD activities could lead to lifelong using multiple methods of instructions for small groups of 24 21 learning of physicians. physicians from a single discipline. were least skilled and over confident had the worst accuracy in self-assessment. Hence educators who plan CPD activities need to plan a diverse group of education Miller's pyramid of clinical competence is commonly used activities to ensure that they address strategies of improve to assess the knowledge, skills and attitudes of the learner. physician competence and performance in these This tool can be used to assess the cognitive (knows, know educational sessions. how) and behavior (shows and does) competence of the learner. The ability to gather facts (knows) can be assessed by traditional multiple choice questions (MCQ's).

Many accreditation organizations like the Accreditation
Interpretation and application of the knowledge (knows Council for Continuing Medical Education (ACCME) in how) can be assessed by case presentations, essay type United States mandate that CPD providers need to provide questions and MCQ's that assess for deeper understanding physicians with learning activities that update their existing 24 of subject. Demonstration of learning (shows) can be skills and lead to continuous professional development.
accessed via simulations and OSCE's and integrating The ACCME suggested that CPD activities should include knowledge and skills in practice (does) can be assessed by Miller's framework of clinical assessment ( knowledge, 25 direct observation and work place based assessment. competence, performance and action). The ACCME model suggests that physicians should start by asking a 26 question that they encounter in practice and seek relevant The four levels of Kirkpatrick's evaluation model is often 24 information. Through analysis, synthesis and reflection , used to evaluate learning. Level 1 reaction to learning and it the information is processed to new knowledge. Physicians measures participants satisfaction with the program. Most then use their best judgment to process this knowledge into CPD programs incorporate a post course survey to assess for wisdom and use the new strategy to enhance their satisfaction and use the data for post hoc program competence. This competence when put into practice could assessment. The problem with Level 1 evaluation is that a enhance physician performance.
positive reaction by the attendee does not guarantee learning. Level 2 assesses learning and goes beyond learners course organizers construct programs that would measure 24 satisfaction and attempts to measure the students change in learning (Level 2). Hence, CPD sessions should have some skills, knowledge and attitude as a result of CPD activity. form pre and post self assessment using MCQ's or evaluation Examples for this kind of activity would be a pre and post of a skill or task in their program to ensure learning. test multiple choice question (MCQ) test to determine knowledge and its application in real life simulated In conclusion, CPD activity requires insight on how adults situations. Level 3 measures the change in behavior that learn and knowledge of needs assessment of physician's occurred as a result of the CPD course and is a post-learning based on information gathered from various sources. CPD event. Individuals would need to answer if any of the new planners need to be organize activities that would acquired skills, knowledge and attitudes were being used in consistently improve physician competence. There is their work environment. This form of measurement is mounting pressure to assess the effectiveness of a CPD difficult due to the inherent uncertainty in determining when program beyond a measure of physician satisfaction and the change in behavior occurred and appropriate timings of incorporate some measure in the program to assess that conducting the follow up evaluation studies. Level 4 physicians have learnt the information discussed during the evaluation is a measure of outcome evaluation and is highest CPD activities. Pre and post course test of physicians using achievement of a learning session. A level 4 evaluation seeks MCQs form a useful method of assessment, though the to determine whether a change in behavior of the physicians course organizers would need to ensure that the questions as a result to the CPD session improved patient outcomes. are appropriately constructed to assess the ability to use Examples of improved patient outcomes could be reduced knowledge in real life situations. frequency of adverse effects, and improved quality of life.
Though evaluation of experienced physicians is complex as most practice in dynamic environment that are influenced by many factors, recent recommendations suggest that CPD