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Competency of health professionals: an approach for continuing education
OPINION CLEARINGHOUSE T h e issu e s fa c in g d e n tis try to d a y are n u m e ro u s . So are th e n u m b e r o f o p in io n s on a n y g iv e n issue. In th is s e c tio n of
t h e jo u r n a l
w e e n c o u ra g e re s p o n s ib le and w e ll-w ritte n
e x p re s s io n o f o p in io n . A rtic le s are c h o s e n on a c o m p e titiv e basis. A s in o th e r p a rts o f
t h e jo u r n a l ,
o p in io n s e x p re s s e d o r im p lie d
are s tr ic tly th o s e o f th e a u th o rs and d o n o t n e c e s s a rily re fle c t th e o p in io n o r o ffic ia l p o lic ie s o r p o s itio n o f th e A m e ric a n D e n ta l A s s o c ia tio n .
C o m p e te n c y
o f
a n
fo r
a p p ro a c h
h e a lth
p ro fe s s io n a ls :
c o n tin u in g
e d u c a tio n
Paul R. Francis, DDS, C hicago
In N ovem be r o f 1967, the N ational A d viso ry C o m m issio n on Health M a n p o w e r1 recom m ended “ th a t p ro fe ssio n a l socie tie s and state g o v ern m e n ts sh o u ld e x p lo re th e p o s s i b ility of p e rio d ic re lic e n s in g of phys icians and o th e r health p ro fe s s io n als. R e lice n su re sh o u ld be granted e ith e r on c e rtific a tio n of a c ce p ta b le p e rfo rm a n c e in c o n tin u in g e d u ca tio n p ro g ra m s o r on the basis of c h a l lenge e xa m in a tio n s in th e p ra c ti tio n e r's s p e c ia lty .” M ore recently, th e C o m m issio n on M edical M a lp ra c tic e 2 (established in 1972 by E llio t L. R ich a rd so n , then se cretary o f H ealth, E d u ca tio n , and W elfare) re po rted th is re c o m m e n dation- in 1973: “ th a t states revise th e ir lic e n s u re laws, as a p p ro p ria te , to e n able th e ir lice n s in g b o a rd s to re q u ire p e rio d ic re g is tra tio n of phys ician s, d e n tists, nurses and o th e r health p ro fe s s io n a ls based on p ro o f o f p a rtic ip a tio n in approved c o n tin uing e d u c a tio n p ro g ra m s .” A lth o u g h a p ro visio n re co m m e n d ing e sta b lish m e n t of a n ational li censing p ro g ra m u n d e r w h ic h lice n s es w o u ld have to be renewed every six years was rem oved fro m the am ended he alth m a n p o w e r bill
(S 3585), R uhe3 said, ‘‘T h is area is n ow regarded as fa ir gam e by legis la to rs and it is e n tire ly p o ssib le that such p ro v is io n s w ill be re in tro d u ce d in su b se q u e n t le g is la tio n .” The co n ce rn fo r th e p e rio d ic ree va lu a tio n of th e p ra c tic in g health p ro fe s s io n a l’s a b ility to p ro vid e co m p e te n t health care is real. S om e states already have im p le m e n te d le g is la tio n th a t re q u ire s health p ro fe s s io n als to p a rtic ip a te in c o n tin u in g edu c a tio n a c tiv itie s fo r re lice n su re . Leg is la tio n m a n d a tin g p a rtic ip a tio n in c o n tin u in g e d u ca tio n is in e ffe ct fo r d e n tis try in C a lifo rn ia , Kansas, Ken tu c k y , M innesota, N orth Dakota, and S o u th Dakota. These states have im plem ented le g is la tio n fo r c o n tin u in g e d u c a tio n in m e d icin e : A rizo n a , Cal ifo rn ia , Illin o is , M aryland, M ich ig a n , New M exico, O hio, and W a sh in g to n . Kansas, K e n tu cky, and Utah have passed le g is la tio n re g a rd in g re lice n sure in m e d icin e , b u t it is c u rre n tly n o t im p le m e n te d . W isco n sin re q u ire s c o n tin u in g e d u c a tio n fo r mal p ra c tic e in su ra n ce coverage. F or c o n tin u in g e d u c a tio n in pharm acy, 12 states have im p le m e n te d le g isla tio n : C a lifo rn ia , F lorida, Indiana, Kansas, M aine, M innesota, Nevada,
New Jersey, O hio, O klahom a, Ore go n , and W a sh in g to n . K e n tu cky has e n a b lin g le g is la tio n to re q u ire co n tin u in g e d u c a tio n in pharm acy. A lth o u g h le g is la tio n in som e states is m a n d a tin g th e p ra c titio n e r’s par tic ip a tio n in c o n tin u in g e d u ca tio n , th e e ffe cts o f re ce n t c o u rt litig a tio n sh o u ld a le rt th e health p ro fe ssio n a l to th e need fo r m a in ta in in g a sta n dard o f co m p e te n ce . Two la n d m a rk cases, one in m e d icin e in 1968 and a n o th e r in d e n tis try in 1972, ruled th a t th e lo ca l standard of care was no lo n g e r re a lis tic o r a p p ro p ria te fo r th e m o d e rn health p ro fe s s io n a l p ra c tic e . T he lo c a lity ru le was abandoned fo r th e firs t tim e in d e n tis try in the sta te o f W a sh in g to n in S anderson vs M o lin e .4 T h is case involved the fa ilu re o f a general p ra c titio n e r to d ia g n o s e p e rio d o n ta l disease o r p ro v id e hom e-care in s tru c tio n to a pa tie n t. A lth o u g h a lo w e r c o u rt ruled th a t e x p e rt te s tim o n y by a p e rio d o n tis t fro m a n o th e r c ity was in a d m iss ible, because th e d e n tis t is to be ju d g e d by th e sta n d a rd o f his own c o m m u n ity , th e W a sh in g to n State S u p re m e C o u rt o ve rtu rn e d th e lo c a l ity rule. The su p re m e c o u rt s a id 5: “ The ‘lo c a lity ru le ’ has no present day JADA, Vol. 92, June 1976 ■ 1119
vitality except that it may be consid ered as one of the elements to deter mine the degree of care and skill which is to be expected of the aver age pra ctition er of the class to which he belongs.”
Objective of continuing education Such litigation gives rise to this ques tion: Should continuing education merely be an academic exercise or should it be a useful instrum ent for continued professional grow th? If the answer is the latter, then we must ask: Is continued professional growth synonymous w ith professional com petence and have continuing educa tion program s accom plished the ob jective of enhancing the participants’ competence? The conclusion can be drawn that the recom m endations o f the National Advisory Com m ission on Health M anpower and the Commission on Medical M alpractice, as well as the various statutes requiring continuing education as a prerequisite fo r reli censure, address themselves to en hancing competence of health pro fessionals. However, the evidence that follow s suggests that current continuing education has failed to materially im prove competencies and the delivery of health care. M iller6 reported on a com m unity hospital study to determi ne the extent to which physicians would respond to unexpectedly abnormal results on three routine adm ission laboratory tests— hem oglobin, urinalysis, and fasting blood glucose. The charts of patients discharged during a onemonth period were systematically studied to determ ine physicians’ re sponses. Only 35% of the unexpect ed abnorm alities produced any per ceptible action by the physicians. As a result of this startling finding, the education com m ittee of the hos pital initiated an inservice educa tional program. The form at was a sim ple presentation and discussion of the data w ith expert consultation. More than 80% o f the staff members to o k part in the meeting. There was general agreement that something must and would be done prom ptly to correct this unacceptable profes sional performance. One month later, 1120 ■ JADA, Vol. 92, June 1976
a replication of the abnormal routine admission tests was completed. The results, however, were disappointing, to say the least; they were identical to the previous audit, done before the educational exercise.6 In another study, conducted in Kansas, it was found that the matern al and perinatal death rates in vari ous areas were unrelated to the con tin uing education hours in obstetrics and pediatrics taken by local physi cians. It was noted that 57% of the 2,090 practicing physicians in Kan sas participated in continuing educa tion course offerings at the state uni versity from 1956 to 1965.7 These two examples suggest a wide discrepancy between the intent of continuing education programs and actual results. Libby and co w orkers8 criticize the effective worth of existing continuing education pro grams because of the methods, tech niques, and philosophies of tradi tional learning approaches used with adults. They identify these charac teristics as ineffective fo r adult learn ers8: “ 1) The educational purpose is viewed as the transm ittal of inform a tion. 2) The program s reflect techni cal presentation by subject matter experts. 3) The program s are prim ar ily of a lecture or panel discussion form at. 4) Active form alized clientele involvement in the program or in need-determ ination is lim ited.”
Standard setting for evaluation If mandatory participation in contin uing education has not accomplished the intent of legislation—that of pro ducing a more com petent practition er, what can be done? First, we must look at the basic governing principle behind the legislation. The intent of mandatory continuing education fo r relicensure is enhanced competence, not merely ritua listic attendance at scheduled activities. To assess com petence, standards must be set. “ On ly when clearly worded and agreed upon standards exist, can a sound system of assessment of individual competence be constructed.” 9 A responsibility of a profession is to develop and m aintain its own stan dards, and these standards should be continuously upgraded and met
by the profession. Although accred itation agencies evaluate the curric ulum content, learning m ethodology, physical resources, staff qualifica tions, and evaluation tools against a given set of standards fo r an entrylevel professional program , contin uing education program s do not. There are attem pts to evaluate con tin uing education against a set of standards. These standards deal with adm inistrative and financial support and purport goals dealing with im proved health care; they do not deal w ith the issue of defining a standard of competence and measuring the in fluence of the co ntinuing education activity on achievem ent of the stan dard. Needs assessment (the meth ods fo r evaluation o f the potential participant interest to support a given program offering) is identified as necessary fo r developing contin uing education program s, but too often these needs assessments are based on potential program enroll ment and not on an assessment of the discrepancies of knowledge and perform ance of a pra ctition er against a given set of criteria. The American Board o f Pediatrics10 has completed th e ir “ Foundations fo r evaluating the competency of pe dia tricia ns” w hich w ill provide the pediatrician w ith a road map to plan his continuing education activities. It w ill, in all probability, provide course designers in continuing edu cation with a guide by w hich to plan program s and to measure, against an accepted standard, th eir effec tiveness in achieving increased com petence. This type of standard is pre cisely what is needed before we can determ ine whether co ntinuing edu cation is addressing the goal of im proving health care.
Experimental education Second, continuing education should translate knowledge into action-ori ented problems. Dewey suggested that education should be related to experience.11 The very act of th ink ing, he continued, is the process of solving problems. In 1926, U nde m an12 applied Dewey’s concept, stat ing, “ The approach to adult educa tion will be via the route of situations,
not subjects. O ur academic system has grown in reverse order: subjects and teachers constitute the starting point, students are secondary. In con ventional education the student is required to adjust himself to an es tablished curriculum ; in adult educa tion the curriculum is b uilt around the students’ needs and interests.” Knowles13 believes that because adult learners tend to be problem centered in th eir orientation to learn ing, the appropriate approach to or ganizing learning activities is by problem areas, not subjects. He said that in a subject-centered orienta tion the perspective is one of post poned application.14 ‘‘The adult, on the other hand, comes into an edu cational activity largely because he is experiencing some inadequacy in coping with current life problems. He wants to apply tom orrow , what he learns today, so his tim e perspective is one of immediacy of application. Therefore, he enters education with a problem-centered orientation to learning.” 13 M iller6 said, “ The first step in this long process is not to tell them [the learners] w hat they need to know, it is to help them want what they require.” I have discussed the first tw o stages o f this long process and have recommended that a set of guidelines be developed that identi fies an acceptable m inimum level of competency. I have also identified the learner population and the char acteristics that make them different from the educational institution-centered learner.
Learning activities The third area to be explored is the developm ent of learning activities; this takes into consideration the learner’s style and availability. It is com m only accepted that a variety of learning styles are effective, and some are preferred over others by d ifferent individuals. In the case of a practicing professional, the avail a bility of educational resources should be explored. Current contin uing education program s often re quire that a practitioner must close his office, pay transportation, lodg ing, and a registration fee—on top of lost income—to acquire credit to
ward relicensure requirements. Con tinuing education as a group activity is not the only method of presenting new knowledge. Learning occurs in a variety of ways: by reading journal articles and texts, use of self-instruc tional packages, and exchange of dialogue in small groups or presence at a lecture. Techniques are best learned by observation and participation. If a certain continuing education pro gram addresses a new technique or procedure, a program should be de veloped to maximize on the valuable tim e of the learner. The continuing education activity should be devel oped as a comprehensive package. Participants should not be trans mitted inform ation by a passive lec ture presentation if they can more readily acquire and understand the inform ation by means of distributed literature or appropriate journal ref erences. Not all dem onstrations need be done at a central gathering site. For example, learning packages ac companied by a programmed text can be made available to individ uals or study groups at their conven ience of tim e and place. Expert con sultation should be an integral part of any such learning package to allow the participant to discuss his under standing of the concepts presented and to help evaluate the application of these concepts in the clinical set ting. The only learning activities that would encroach on the delivery of patient care would be the applica tion of the knowledge and skills iden tified in a program offering to en hance mastery of the concepts or the acquisition of advanced consul tation in integrating these concepts into the treatm ent of patients. In the aforem entioned model, the practitioner would be “ buying-into” a program of continuing education w ith the emphasis on a cluster of activities or themes. He would not merely be participating in a one-time passive activity, but would be in volved actively in the learning pro cess. Currently, a few offerings in corporate some of the principles out lined. These offerings require the on site participation of a practitioner w ith a patient one-half day a week fo r several weeks. Although this ac
tivity provides a sign ifican t oppor tunity fo r practitioners to master the concepts and skills of new know l edge and techniques, they lim it prac titio n e r involvem ent because of geo graphic location or appropriate pa tient availability. These programs usually are presented at educational institutions and at tim es convenient to the lecturer. If the p ractitioner lives in a m etropolitan area such as Chi cago, which has three dental schools and seven medical schools, he may not find participation in programs a problem. If, however, he is located a four-hour o r five-hour drive from a teaching institution, w hat may be an afternoon com m itm ent to one prac titio n e r may be a two-day com m it ment to another. Scheduling of offer ings also creates a problem. In the case of a practitioner-patient activ ity, the availability of an appropriate patient fo r the given to p ic may not coincide with tim e scheduled fo r the learning activity. Availability of space is another lim iting factor. In light of recent court cases and legislation, attem pts should be made to make educational resources avail able to practitioners who do not have accessibility to certain lim ited pro grams. Offerings in co ntinuing edu cation should consider a variety of form ats such as lecture, seminar, consultant, videotape, film , clinical exposure, laboratory exercises, and independent learning program s that utilize the slide-lecture, slide-tape, or the videocassette approach.
Self-directed study The fourth area to consider, which is closely associated w ith the third, is the issue of self-directed study. I dis cussed earlier the variety of activities and settings in which learning oc curs. It must be recognized that many health professionals keep abreast of current changes in knowledge and technology through initiatives of th eir own as they meet the needs of their professional practices. Motiva tion fo r this type of self-directed con tinuing education should be instilled in the preparatory stages of a profes sional’s education. Furthermore, evaluation and recognition of self directed study should become an
OPINION CLEARINGHOUSE I JADA, Vol. 92, June 1976 ■ 1121
integral part of any continuing edu cation program. Houle9 asked, “ How does the in dividual (professional) build w ithin his or her value structure the belief that continuous learning should be a way of life and how is that belief carried o u t? ” Knox15 attempted to respond to Houle's question by iden tifying three potential benefits fo r a self-directed approach to continuing education. The first is the “ planning of continuing education programs in a way that encourages the contribu tion of all sponsors and resources. The second is the contribution that it makes to persons who endeavor to facilitate the efforts of health pro fessionals to continually increase th e ir competence and improve pa tient care and health maintenance. The th ird is the basis that it provides fo r the articulation between various disciplines and between preparatory and continuing professional educa tio n .” Knox continued that “ a major challenge to preparatory profes sional education is to increase the p roportion of graduates who are self directed in th e ir continuing profes sional education.” Knox's proposal may be a major undertaking in preparatory profes sional education. When we consider that institutional instruction is most ly subject centered and adult educa tion is person centered, we can be gin to understand the extent of the behavioral changes that are neces sary on the part of professional school faculty. If, however, we iden tify the basic content matter that is offered to students in an institutional setting and develop this content fo r aduft learners in a noninstitutional setting, there is the possibility that these learning activities could then find th e ir way back into the prepar atory professional curriculum . It is not the most direct approach to ini tia ting self-directed study into pre paratory professional curriculum s but it may be the most effective in the long run. In my opinion, there is a resistance on the part of many fac ulty members to tamper with their institutional learning population. If, however, their content expertise can be elicited to provide learning exper 1122 ■ JADA, Vol. 92, June 1976
iences fo r an external (noninstitu tional) target group and it can be shown that quality is not dependent on form at but on measurable out comes of expected perform ance, the new form at may find a place in the curriculum . Most institutional instruction does not nurture self-directed study. Most institutions “ place a premium on reg ularity, punctuality, fo llo w in g direc tions precisely and m em orization.” 16 Independence, however, requires increasing self-direction and some interaction with others. It is this inde pendence and self-direction that is often stifled in our passive, subjectcentered learning situations. Prob lem solving is not a priority; memor ization and the feedback of facts are too often the accepted evaluation of content mastery. To develop the learner’s responsibility fo r self-dir ected study as a continuing educa tion activity, we must seriously con sider the inhibiting forces of prepar atory professional education. Beha vioral patterns and attitudes toward learning that may be d iffic u lt to over come have already been developed.
Evaluation of competence If the intent of continuing education is to improve a pra ctition er’s ability to provide health care to his patients, we should attem pt to measure this improvement. The fifth area of this process approach to developing continuing competence in the pro fessional practitioner is evaluation. The individuals with vested interests in a program rarely conduct or wel come objective evaluation. Current continuing education activities mere ly evaluate reaction (what the partic ipants like most and least, and what positive or negative feelings they have). U nfortunately future programs are planned based only on reaction evaluation. We must begin looking at other areas of evaluation such as learning effectiveness, behavior, and results. K irkpa trick17 conceived a four-step evaluation system that is most con sistent fo r evaluating the process of developing continuing competence programs. The follow ing steps are outlined:
— Reaction evaluation: Data are gathered about how the participants are responding to a program as it takes place. This is the step at which most evaluation of continuing educa tion programs begins and stops. —Learning evaluation: This in volves acquiring data about the con cepts, facts, and tech niques that were enhanced as a result of the partici pation in a program . Pretests and posttests are necessary so that spe c ific gains resulting from the learning experience can be measured. — Behavior evaluation: This in volves data from an observer’s re ports (self or other) about actual changes in what the learner does af te r the training compared w ith what he did before. The study reported by M iller6 regarding responses to un expectedly abnormal results on three routine admission laboratory tests is an example of behavior evaluation. Other methods could entail self-rat ing scales, diaries, interviews, sched ules, questionnaires, and audits. — Results evaluation: These data are usually contained in routine rec ords of an organization, including costs, efficiency, turnover, frequency of accidents, quality control rejec tions, and so forth. Because of the d ifficu lty in con tro llin g the variables sufficiently to dem onstrate that it was the training that was mainly responsibleforchanges that occurred, K irkpatrick recom mended using control groups when ever possible.
Summary If we consider the responsibility health practitioners have to main tain an acceptable level of compe tence in delivering care to patients, then we must also consider the re sponsibility that continuing educa tion has in providing the kinds of ac tivities that w ill provide fo r and eval uate a practitioner's enhanced com petence. I have outlined a process whereby continuing education can begin to address the issue of con tinued competence. The specific de tails as they apply to a given area must be considered as a process activity. Attem pts to generalize the success of one activity to another area may be
inappropriate. C onscientious fo llo w ing of the steps outlined here w ill enable planners of continuing edu cation to be responsive to the prac titio ne rs’ and patients’ needs fo r en hanced competence and improved health care.
Dr. Francis is associate dean for regional affairs, School of Associated Medical Sciences, College of Medicine and holds an appoint ment as clinical assistant professor of pedodontics in the College of Dentistry, University of Illinois at the Medical Center, 808 S Wood St, Chicago, 60612. 1. Report of the National Advisory Com mission on Health Manpower, voi 1. Govt Print Off, Nov 1967.
2. Report of the Secretary’s Commission on Medical Malpractice. HEW publ no. (OC) 73-88. Govt Print Off, 1973, p 53. 3. Ruhe, C.H. Governmental and societal pressures for programs of continuing medical education. Bull NY Acad Med 51:707 June 1975. 4. Sanderson vs Moline, Wash App 499 P 2d 1281, 1972. 5. Milgrom, P. Continuing education and the prospect for a national standard of dental care. J Dent Educ 38:482 Sept 1974. 6. Miller, G.E. Continuing education for what? J Med Educ 42:320 April 1967. 7. Lewis, C.E., and Hassanein, R.S. Contin uing medical education an epidemiologic eval uation. N Engl J Med 282:254 Jan 29, 1970. 8. Libby, G.N.; Weinswig, M.H.; and Kirk, K.W. Help stamp out mandatory continuing education! JAMA 233:797 Aug 18, 1975. 9. Houle, CO. The nature of continuing professional education. J Am Pharm Assoc NS15:438 Aug 1975. 10. Foundations for evaluating the com
petency of pediatricians. Chicago, American Board of Pediatrics, Inc., 1974. 11. Kilpatrick, W.N. Dewey's influence on education. In Schilpp, P.A., ed. The philosophy of John Dewey. Evanston, III, Northwestern University, 1939, p 454. 12. Lindeman, E.C. The meaning of adult education. New York, New Republic, 1926. 13. Knowles, M. The modern practice of adult education. New York, Association Press, 1970, p 37. 14. Knowles, M. The adult learner: a neg lected species. Houston, Gulf Publishing Co., 1973, p 47. 15. Knox, A.B. Continuing education of pharmacists. J Am Pharm Assoc NS15:442 Aug 1975. 16. Dressei, P.L., and Thompson, M.M. In dependent study. San Francisco, Jossey-Bass Publishers, 1973, p 7. 17. Kirkpatrick, D.L. A practical guide for supervisory training and development. Read ing, Mass, Addison-Wesley, 1971.
OPINION CLEARINGHOUSE / JADA, Vol. 92, June 1976 ■ 1123
t h e jo u r n a l
w e e n c o u ra g e re s p o n s ib le and w e ll-w ritte n
e x p re s s io n o f o p in io n . A rtic le s are c h o s e n on a c o m p e titiv e basis. A s in o th e r p a rts o f
t h e jo u r n a l ,
o p in io n s e x p re s s e d o r im p lie d
are s tr ic tly th o s e o f th e a u th o rs and d o n o t n e c e s s a rily re fle c t th e o p in io n o r o ffic ia l p o lic ie s o r p o s itio n o f th e A m e ric a n D e n ta l A s s o c ia tio n .
C o m p e te n c y
o f
a n
fo r
a p p ro a c h
h e a lth
p ro fe s s io n a ls :
c o n tin u in g
e d u c a tio n
Paul R. Francis, DDS, C hicago
In N ovem be r o f 1967, the N ational A d viso ry C o m m issio n on Health M a n p o w e r1 recom m ended “ th a t p ro fe ssio n a l socie tie s and state g o v ern m e n ts sh o u ld e x p lo re th e p o s s i b ility of p e rio d ic re lic e n s in g of phys icians and o th e r health p ro fe s s io n als. R e lice n su re sh o u ld be granted e ith e r on c e rtific a tio n of a c ce p ta b le p e rfo rm a n c e in c o n tin u in g e d u ca tio n p ro g ra m s o r on the basis of c h a l lenge e xa m in a tio n s in th e p ra c ti tio n e r's s p e c ia lty .” M ore recently, th e C o m m issio n on M edical M a lp ra c tic e 2 (established in 1972 by E llio t L. R ich a rd so n , then se cretary o f H ealth, E d u ca tio n , and W elfare) re po rted th is re c o m m e n dation- in 1973: “ th a t states revise th e ir lic e n s u re laws, as a p p ro p ria te , to e n able th e ir lice n s in g b o a rd s to re q u ire p e rio d ic re g is tra tio n of phys ician s, d e n tists, nurses and o th e r health p ro fe s s io n a ls based on p ro o f o f p a rtic ip a tio n in approved c o n tin uing e d u c a tio n p ro g ra m s .” A lth o u g h a p ro visio n re co m m e n d ing e sta b lish m e n t of a n ational li censing p ro g ra m u n d e r w h ic h lice n s es w o u ld have to be renewed every six years was rem oved fro m the am ended he alth m a n p o w e r bill
(S 3585), R uhe3 said, ‘‘T h is area is n ow regarded as fa ir gam e by legis la to rs and it is e n tire ly p o ssib le that such p ro v is io n s w ill be re in tro d u ce d in su b se q u e n t le g is la tio n .” The co n ce rn fo r th e p e rio d ic ree va lu a tio n of th e p ra c tic in g health p ro fe s s io n a l’s a b ility to p ro vid e co m p e te n t health care is real. S om e states already have im p le m e n te d le g is la tio n th a t re q u ire s health p ro fe s s io n als to p a rtic ip a te in c o n tin u in g edu c a tio n a c tiv itie s fo r re lice n su re . Leg is la tio n m a n d a tin g p a rtic ip a tio n in c o n tin u in g e d u ca tio n is in e ffe ct fo r d e n tis try in C a lifo rn ia , Kansas, Ken tu c k y , M innesota, N orth Dakota, and S o u th Dakota. These states have im plem ented le g is la tio n fo r c o n tin u in g e d u c a tio n in m e d icin e : A rizo n a , Cal ifo rn ia , Illin o is , M aryland, M ich ig a n , New M exico, O hio, and W a sh in g to n . Kansas, K e n tu cky, and Utah have passed le g is la tio n re g a rd in g re lice n sure in m e d icin e , b u t it is c u rre n tly n o t im p le m e n te d . W isco n sin re q u ire s c o n tin u in g e d u c a tio n fo r mal p ra c tic e in su ra n ce coverage. F or c o n tin u in g e d u c a tio n in pharm acy, 12 states have im p le m e n te d le g isla tio n : C a lifo rn ia , F lorida, Indiana, Kansas, M aine, M innesota, Nevada,
New Jersey, O hio, O klahom a, Ore go n , and W a sh in g to n . K e n tu cky has e n a b lin g le g is la tio n to re q u ire co n tin u in g e d u c a tio n in pharm acy. A lth o u g h le g is la tio n in som e states is m a n d a tin g th e p ra c titio n e r’s par tic ip a tio n in c o n tin u in g e d u ca tio n , th e e ffe cts o f re ce n t c o u rt litig a tio n sh o u ld a le rt th e health p ro fe ssio n a l to th e need fo r m a in ta in in g a sta n dard o f co m p e te n ce . Two la n d m a rk cases, one in m e d icin e in 1968 and a n o th e r in d e n tis try in 1972, ruled th a t th e lo ca l standard of care was no lo n g e r re a lis tic o r a p p ro p ria te fo r th e m o d e rn health p ro fe s s io n a l p ra c tic e . T he lo c a lity ru le was abandoned fo r th e firs t tim e in d e n tis try in the sta te o f W a sh in g to n in S anderson vs M o lin e .4 T h is case involved the fa ilu re o f a general p ra c titio n e r to d ia g n o s e p e rio d o n ta l disease o r p ro v id e hom e-care in s tru c tio n to a pa tie n t. A lth o u g h a lo w e r c o u rt ruled th a t e x p e rt te s tim o n y by a p e rio d o n tis t fro m a n o th e r c ity was in a d m iss ible, because th e d e n tis t is to be ju d g e d by th e sta n d a rd o f his own c o m m u n ity , th e W a sh in g to n State S u p re m e C o u rt o ve rtu rn e d th e lo c a l ity rule. The su p re m e c o u rt s a id 5: “ The ‘lo c a lity ru le ’ has no present day JADA, Vol. 92, June 1976 ■ 1119
vitality except that it may be consid ered as one of the elements to deter mine the degree of care and skill which is to be expected of the aver age pra ctition er of the class to which he belongs.”
Objective of continuing education Such litigation gives rise to this ques tion: Should continuing education merely be an academic exercise or should it be a useful instrum ent for continued professional grow th? If the answer is the latter, then we must ask: Is continued professional growth synonymous w ith professional com petence and have continuing educa tion program s accom plished the ob jective of enhancing the participants’ competence? The conclusion can be drawn that the recom m endations o f the National Advisory Com m ission on Health M anpower and the Commission on Medical M alpractice, as well as the various statutes requiring continuing education as a prerequisite fo r reli censure, address themselves to en hancing competence of health pro fessionals. However, the evidence that follow s suggests that current continuing education has failed to materially im prove competencies and the delivery of health care. M iller6 reported on a com m unity hospital study to determi ne the extent to which physicians would respond to unexpectedly abnormal results on three routine adm ission laboratory tests— hem oglobin, urinalysis, and fasting blood glucose. The charts of patients discharged during a onemonth period were systematically studied to determ ine physicians’ re sponses. Only 35% of the unexpect ed abnorm alities produced any per ceptible action by the physicians. As a result of this startling finding, the education com m ittee of the hos pital initiated an inservice educa tional program. The form at was a sim ple presentation and discussion of the data w ith expert consultation. More than 80% o f the staff members to o k part in the meeting. There was general agreement that something must and would be done prom ptly to correct this unacceptable profes sional performance. One month later, 1120 ■ JADA, Vol. 92, June 1976
a replication of the abnormal routine admission tests was completed. The results, however, were disappointing, to say the least; they were identical to the previous audit, done before the educational exercise.6 In another study, conducted in Kansas, it was found that the matern al and perinatal death rates in vari ous areas were unrelated to the con tin uing education hours in obstetrics and pediatrics taken by local physi cians. It was noted that 57% of the 2,090 practicing physicians in Kan sas participated in continuing educa tion course offerings at the state uni versity from 1956 to 1965.7 These two examples suggest a wide discrepancy between the intent of continuing education programs and actual results. Libby and co w orkers8 criticize the effective worth of existing continuing education pro grams because of the methods, tech niques, and philosophies of tradi tional learning approaches used with adults. They identify these charac teristics as ineffective fo r adult learn ers8: “ 1) The educational purpose is viewed as the transm ittal of inform a tion. 2) The program s reflect techni cal presentation by subject matter experts. 3) The program s are prim ar ily of a lecture or panel discussion form at. 4) Active form alized clientele involvement in the program or in need-determ ination is lim ited.”
Standard setting for evaluation If mandatory participation in contin uing education has not accomplished the intent of legislation—that of pro ducing a more com petent practition er, what can be done? First, we must look at the basic governing principle behind the legislation. The intent of mandatory continuing education fo r relicensure is enhanced competence, not merely ritua listic attendance at scheduled activities. To assess com petence, standards must be set. “ On ly when clearly worded and agreed upon standards exist, can a sound system of assessment of individual competence be constructed.” 9 A responsibility of a profession is to develop and m aintain its own stan dards, and these standards should be continuously upgraded and met
by the profession. Although accred itation agencies evaluate the curric ulum content, learning m ethodology, physical resources, staff qualifica tions, and evaluation tools against a given set of standards fo r an entrylevel professional program , contin uing education program s do not. There are attem pts to evaluate con tin uing education against a set of standards. These standards deal with adm inistrative and financial support and purport goals dealing with im proved health care; they do not deal w ith the issue of defining a standard of competence and measuring the in fluence of the co ntinuing education activity on achievem ent of the stan dard. Needs assessment (the meth ods fo r evaluation o f the potential participant interest to support a given program offering) is identified as necessary fo r developing contin uing education program s, but too often these needs assessments are based on potential program enroll ment and not on an assessment of the discrepancies of knowledge and perform ance of a pra ctition er against a given set of criteria. The American Board o f Pediatrics10 has completed th e ir “ Foundations fo r evaluating the competency of pe dia tricia ns” w hich w ill provide the pediatrician w ith a road map to plan his continuing education activities. It w ill, in all probability, provide course designers in continuing edu cation with a guide by w hich to plan program s and to measure, against an accepted standard, th eir effec tiveness in achieving increased com petence. This type of standard is pre cisely what is needed before we can determ ine whether co ntinuing edu cation is addressing the goal of im proving health care.
Experimental education Second, continuing education should translate knowledge into action-ori ented problems. Dewey suggested that education should be related to experience.11 The very act of th ink ing, he continued, is the process of solving problems. In 1926, U nde m an12 applied Dewey’s concept, stat ing, “ The approach to adult educa tion will be via the route of situations,
not subjects. O ur academic system has grown in reverse order: subjects and teachers constitute the starting point, students are secondary. In con ventional education the student is required to adjust himself to an es tablished curriculum ; in adult educa tion the curriculum is b uilt around the students’ needs and interests.” Knowles13 believes that because adult learners tend to be problem centered in th eir orientation to learn ing, the appropriate approach to or ganizing learning activities is by problem areas, not subjects. He said that in a subject-centered orienta tion the perspective is one of post poned application.14 ‘‘The adult, on the other hand, comes into an edu cational activity largely because he is experiencing some inadequacy in coping with current life problems. He wants to apply tom orrow , what he learns today, so his tim e perspective is one of immediacy of application. Therefore, he enters education with a problem-centered orientation to learning.” 13 M iller6 said, “ The first step in this long process is not to tell them [the learners] w hat they need to know, it is to help them want what they require.” I have discussed the first tw o stages o f this long process and have recommended that a set of guidelines be developed that identi fies an acceptable m inimum level of competency. I have also identified the learner population and the char acteristics that make them different from the educational institution-centered learner.
Learning activities The third area to be explored is the developm ent of learning activities; this takes into consideration the learner’s style and availability. It is com m only accepted that a variety of learning styles are effective, and some are preferred over others by d ifferent individuals. In the case of a practicing professional, the avail a bility of educational resources should be explored. Current contin uing education program s often re quire that a practitioner must close his office, pay transportation, lodg ing, and a registration fee—on top of lost income—to acquire credit to
ward relicensure requirements. Con tinuing education as a group activity is not the only method of presenting new knowledge. Learning occurs in a variety of ways: by reading journal articles and texts, use of self-instruc tional packages, and exchange of dialogue in small groups or presence at a lecture. Techniques are best learned by observation and participation. If a certain continuing education pro gram addresses a new technique or procedure, a program should be de veloped to maximize on the valuable tim e of the learner. The continuing education activity should be devel oped as a comprehensive package. Participants should not be trans mitted inform ation by a passive lec ture presentation if they can more readily acquire and understand the inform ation by means of distributed literature or appropriate journal ref erences. Not all dem onstrations need be done at a central gathering site. For example, learning packages ac companied by a programmed text can be made available to individ uals or study groups at their conven ience of tim e and place. Expert con sultation should be an integral part of any such learning package to allow the participant to discuss his under standing of the concepts presented and to help evaluate the application of these concepts in the clinical set ting. The only learning activities that would encroach on the delivery of patient care would be the applica tion of the knowledge and skills iden tified in a program offering to en hance mastery of the concepts or the acquisition of advanced consul tation in integrating these concepts into the treatm ent of patients. In the aforem entioned model, the practitioner would be “ buying-into” a program of continuing education w ith the emphasis on a cluster of activities or themes. He would not merely be participating in a one-time passive activity, but would be in volved actively in the learning pro cess. Currently, a few offerings in corporate some of the principles out lined. These offerings require the on site participation of a practitioner w ith a patient one-half day a week fo r several weeks. Although this ac
tivity provides a sign ifican t oppor tunity fo r practitioners to master the concepts and skills of new know l edge and techniques, they lim it prac titio n e r involvem ent because of geo graphic location or appropriate pa tient availability. These programs usually are presented at educational institutions and at tim es convenient to the lecturer. If the p ractitioner lives in a m etropolitan area such as Chi cago, which has three dental schools and seven medical schools, he may not find participation in programs a problem. If, however, he is located a four-hour o r five-hour drive from a teaching institution, w hat may be an afternoon com m itm ent to one prac titio n e r may be a two-day com m it ment to another. Scheduling of offer ings also creates a problem. In the case of a practitioner-patient activ ity, the availability of an appropriate patient fo r the given to p ic may not coincide with tim e scheduled fo r the learning activity. Availability of space is another lim iting factor. In light of recent court cases and legislation, attem pts should be made to make educational resources avail able to practitioners who do not have accessibility to certain lim ited pro grams. Offerings in co ntinuing edu cation should consider a variety of form ats such as lecture, seminar, consultant, videotape, film , clinical exposure, laboratory exercises, and independent learning program s that utilize the slide-lecture, slide-tape, or the videocassette approach.
Self-directed study The fourth area to consider, which is closely associated w ith the third, is the issue of self-directed study. I dis cussed earlier the variety of activities and settings in which learning oc curs. It must be recognized that many health professionals keep abreast of current changes in knowledge and technology through initiatives of th eir own as they meet the needs of their professional practices. Motiva tion fo r this type of self-directed con tinuing education should be instilled in the preparatory stages of a profes sional’s education. Furthermore, evaluation and recognition of self directed study should become an
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integral part of any continuing edu cation program. Houle9 asked, “ How does the in dividual (professional) build w ithin his or her value structure the belief that continuous learning should be a way of life and how is that belief carried o u t? ” Knox15 attempted to respond to Houle's question by iden tifying three potential benefits fo r a self-directed approach to continuing education. The first is the “ planning of continuing education programs in a way that encourages the contribu tion of all sponsors and resources. The second is the contribution that it makes to persons who endeavor to facilitate the efforts of health pro fessionals to continually increase th e ir competence and improve pa tient care and health maintenance. The th ird is the basis that it provides fo r the articulation between various disciplines and between preparatory and continuing professional educa tio n .” Knox continued that “ a major challenge to preparatory profes sional education is to increase the p roportion of graduates who are self directed in th e ir continuing profes sional education.” Knox's proposal may be a major undertaking in preparatory profes sional education. When we consider that institutional instruction is most ly subject centered and adult educa tion is person centered, we can be gin to understand the extent of the behavioral changes that are neces sary on the part of professional school faculty. If, however, we iden tify the basic content matter that is offered to students in an institutional setting and develop this content fo r aduft learners in a noninstitutional setting, there is the possibility that these learning activities could then find th e ir way back into the prepar atory professional curriculum . It is not the most direct approach to ini tia ting self-directed study into pre paratory professional curriculum s but it may be the most effective in the long run. In my opinion, there is a resistance on the part of many fac ulty members to tamper with their institutional learning population. If, however, their content expertise can be elicited to provide learning exper 1122 ■ JADA, Vol. 92, June 1976
iences fo r an external (noninstitu tional) target group and it can be shown that quality is not dependent on form at but on measurable out comes of expected perform ance, the new form at may find a place in the curriculum . Most institutional instruction does not nurture self-directed study. Most institutions “ place a premium on reg ularity, punctuality, fo llo w in g direc tions precisely and m em orization.” 16 Independence, however, requires increasing self-direction and some interaction with others. It is this inde pendence and self-direction that is often stifled in our passive, subjectcentered learning situations. Prob lem solving is not a priority; memor ization and the feedback of facts are too often the accepted evaluation of content mastery. To develop the learner’s responsibility fo r self-dir ected study as a continuing educa tion activity, we must seriously con sider the inhibiting forces of prepar atory professional education. Beha vioral patterns and attitudes toward learning that may be d iffic u lt to over come have already been developed.
Evaluation of competence If the intent of continuing education is to improve a pra ctition er’s ability to provide health care to his patients, we should attem pt to measure this improvement. The fifth area of this process approach to developing continuing competence in the pro fessional practitioner is evaluation. The individuals with vested interests in a program rarely conduct or wel come objective evaluation. Current continuing education activities mere ly evaluate reaction (what the partic ipants like most and least, and what positive or negative feelings they have). U nfortunately future programs are planned based only on reaction evaluation. We must begin looking at other areas of evaluation such as learning effectiveness, behavior, and results. K irkpa trick17 conceived a four-step evaluation system that is most con sistent fo r evaluating the process of developing continuing competence programs. The follow ing steps are outlined:
— Reaction evaluation: Data are gathered about how the participants are responding to a program as it takes place. This is the step at which most evaluation of continuing educa tion programs begins and stops. —Learning evaluation: This in volves acquiring data about the con cepts, facts, and tech niques that were enhanced as a result of the partici pation in a program . Pretests and posttests are necessary so that spe c ific gains resulting from the learning experience can be measured. — Behavior evaluation: This in volves data from an observer’s re ports (self or other) about actual changes in what the learner does af te r the training compared w ith what he did before. The study reported by M iller6 regarding responses to un expectedly abnormal results on three routine admission laboratory tests is an example of behavior evaluation. Other methods could entail self-rat ing scales, diaries, interviews, sched ules, questionnaires, and audits. — Results evaluation: These data are usually contained in routine rec ords of an organization, including costs, efficiency, turnover, frequency of accidents, quality control rejec tions, and so forth. Because of the d ifficu lty in con tro llin g the variables sufficiently to dem onstrate that it was the training that was mainly responsibleforchanges that occurred, K irkpatrick recom mended using control groups when ever possible.
Summary If we consider the responsibility health practitioners have to main tain an acceptable level of compe tence in delivering care to patients, then we must also consider the re sponsibility that continuing educa tion has in providing the kinds of ac tivities that w ill provide fo r and eval uate a practitioner's enhanced com petence. I have outlined a process whereby continuing education can begin to address the issue of con tinued competence. The specific de tails as they apply to a given area must be considered as a process activity. Attem pts to generalize the success of one activity to another area may be
inappropriate. C onscientious fo llo w ing of the steps outlined here w ill enable planners of continuing edu cation to be responsive to the prac titio ne rs’ and patients’ needs fo r en hanced competence and improved health care.
Dr. Francis is associate dean for regional affairs, School of Associated Medical Sciences, College of Medicine and holds an appoint ment as clinical assistant professor of pedodontics in the College of Dentistry, University of Illinois at the Medical Center, 808 S Wood St, Chicago, 60612. 1. Report of the National Advisory Com mission on Health Manpower, voi 1. Govt Print Off, Nov 1967.
2. Report of the Secretary’s Commission on Medical Malpractice. HEW publ no. (OC) 73-88. Govt Print Off, 1973, p 53. 3. Ruhe, C.H. Governmental and societal pressures for programs of continuing medical education. Bull NY Acad Med 51:707 June 1975. 4. Sanderson vs Moline, Wash App 499 P 2d 1281, 1972. 5. Milgrom, P. Continuing education and the prospect for a national standard of dental care. J Dent Educ 38:482 Sept 1974. 6. Miller, G.E. Continuing education for what? J Med Educ 42:320 April 1967. 7. Lewis, C.E., and Hassanein, R.S. Contin uing medical education an epidemiologic eval uation. N Engl J Med 282:254 Jan 29, 1970. 8. Libby, G.N.; Weinswig, M.H.; and Kirk, K.W. Help stamp out mandatory continuing education! JAMA 233:797 Aug 18, 1975. 9. Houle, CO. The nature of continuing professional education. J Am Pharm Assoc NS15:438 Aug 1975. 10. Foundations for evaluating the com
petency of pediatricians. Chicago, American Board of Pediatrics, Inc., 1974. 11. Kilpatrick, W.N. Dewey's influence on education. In Schilpp, P.A., ed. The philosophy of John Dewey. Evanston, III, Northwestern University, 1939, p 454. 12. Lindeman, E.C. The meaning of adult education. New York, New Republic, 1926. 13. Knowles, M. The modern practice of adult education. New York, Association Press, 1970, p 37. 14. Knowles, M. The adult learner: a neg lected species. Houston, Gulf Publishing Co., 1973, p 47. 15. Knox, A.B. Continuing education of pharmacists. J Am Pharm Assoc NS15:442 Aug 1975. 16. Dressei, P.L., and Thompson, M.M. In dependent study. San Francisco, Jossey-Bass Publishers, 1973, p 7. 17. Kirkpatrick, D.L. A practical guide for supervisory training and development. Read ing, Mass, Addison-Wesley, 1971.
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