Review: Interactive, but not didactic, continuing medical education is effective in changing physician performance
Davis D, Thomson 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 behavior or health care outcomes?
JAMA 1999;282 (September):867-74.
Question
How effective are formal continuing medical education (CME)
interventions in changing physician performance and healthcare
outcomes?
Data sources
Studies were identified by using the Research and Development
Resource Base in CME at the University of Toronto, the Specialised
Register of the Cochrane Effective Practice and Organisation of Care
Group, Medline (1993 to January 1999), CINAHL, ERIC, EMBASE/Excerpta
Medica, and PsycINFO and by searching bibliographies of relevant
papers.
Study selection
Studies were selected if they were randomised controlled
trials; if they used formal CME interventions of a didactic, an
interactive, or a mixed didactic and interactive nature; if they
objectively determined either physician performance in the
workplace or healthcare outcomes, or both; and if >=50% of the
participants were practising physicians. Didactic interventions were
those that offered minimal participant interaction (eg lectures or
presentations); interactive interventions were those that encouraged
participant activity and provided the opportunity to practise skills
(eg role playing, discussion groups, hands-on training, or problem
or case solving). Studies were excluded if they used coercive
educational activities or provided incentives for learning.
Data extraction
Methodological quality, participant characteristics, nature of
intervention (didactic, interactive, or mixed), occurrence of
intervention (one time or series), educational content and format,
intervention group size, physician performance, and healthcare
outcomes.
Main results
Sixty-four studies were identified. Fourteen studies (17
interventions) met the selection criteria. Nine of 17 interventions
that assessed physician performance and three of four interventions
that assessed healthcare outcomes showed positive changes in >=1
measure. Meta-analysis of seven studies showed no overall effect of CME
interventions (standardised weighted mean difference [WMD] 0.34, 95%
CI —0.22 to 0.97). A meta-analysis that included only interactive and
mixed CME interventions showed an effect on physician performance
(standardised WMD 0.67, CI 0.01 to 1.45). None of the four didactic CME
interventions altered physician performance. No association between
intervention group size and positive outcomes was shown.
Conclusion
Formal interactive, but not didactic, continuing medical education
interventions are effective in changing physician performance.
Notes
Funding: National Institutes of Health Fogarty
EBM-Commentary
The conclusions drawn by Davis and colleagues in this
review are similar to those in their previous
publications.1,2 All are high quality reviews that
examined difficult and important issues. They provide evidence of a
redirection of formal CME towards the practice place as a learning
arena, the empowering of the learner, and the value of learning that
occurs in day to day patient encounters. Furthermore, the broader
concept of continuous quality improvement reminds us that other areas
of competence (eg managerial, social, and personal) also need to be
nurtured.
The implications are that CME providers need to re-examine their role
and be more supportive of practice based learning and that any
monitoring system must be tuned to support and document activities that
have been shown to promote learning and change.
Hans A Holm MD, PhD, Norwegian Medical Association, Oslo, Norway
- Davis DA, Thomson MA, Oxman
AD, Haynes RB. Evidence for the effectiveness of CME. A review of
50 randomized controlled trials. JAMA
1992;268:1111-17.
- Davis DA, Thomson MA, Oxman AD, Haynes
RB. Changing physician performance. A systematic review of the
effect of continuing medical education strategies. JAMA
1995;274:700-5.
studentBMJ 2000;08:259-302 August ISSN 0966-6494
