Lifelong Learning in the 21st Century

For people who choose to become physicians, continually improving their knowledge is a hallmark of their profession and essential to improving patient care.

Like almost all working adults, doctors learn most, and most effectively, through informal (incidental) learning opportunities: knowledge gained on the job (1). Unlike most other working adults, physicians must regularly, and formally, demonstrate their knowledge to retain their ability to practice, admit patients, receive payor reimbursements, and hold academic positions.

The physician’s focus on learning

Physicians have long focused on the value of improving their knowledge to improve treatment. The 13th-century Oath of Maimonides noted “Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today”—an approach echoed by Sir William Osler: “…you will draw from your errors the very lessons which may enable you to avoid their repetition.”

In 1935, the Philadelphia County Medical Society formed the Anesthesia Mortality Committee, a precursor to the now-familiar Morbidity and Mortality (M&M) Conference, “to facilitate discussion and to share knowledge about fatalities secondary to anesthesia, and other interesting anesthetic situations” (2). M&M conferences still constitute a potentially valuable teaching tool, although they vary considerably in structure and effectiveness.

The Accreditation Council for Continuing Medical Education (ACCME), established in 1981, was designed to develop a national system for providing continuing education to physicians in the United States. In 1982, the ACCME issued its first set of accreditation requirements, the Seven Essentials, and it now accredits 2000 organizations that offer 138,000 learning opportunities to 24 million health care professionals worldwide.

For many years, continuing medical education focused on didactic learning. However, didactic learning fails to incorporate some of the methods that have proved most effective in improving physician knowledge and, ultimately, patient care. In addition, many of these single-meeting lectures triggered skepticism among physicians regarding vested interests involved in disseminating what might—or might not—be advances in treatment. In 2004, the ACCME implemented stronger limitations on commercial interests, but presenting bias-free material in a complex and ever-changing industry like medicine will remain a perpetual challenge.

In recent years, accreditors have shifted somewhat to competency-based professional education, but how does one effectively gauge a physician’s competency? As described in the article beginning on page 1 of this issue, current debate centers on how to accurately and fairly evaluate a physician’s knowledge and performance over the course of a career.

The commitment to evolving care

The debate over physician recertification sometimes overshadows the reality that most physicians possess innate curiosity and a strong commitment to contributing to the evolution of patient care.

Physicians, like other adults, learn best when they are self-directed and can plan and evaluate their own learning; moreover, their learning increases based on the need to know (3). Interactive education that involves physicians in its planning and execution, and engages them as active learners, is more likely to influence changes in physicians’ practice and performance that will exert a significant and positive effect on improving practice.

Recently some medical centers have developed new approaches to the M&M conference. The New Mexico Veterans Administration Health Center recently developed a “revised morbidity and mortality format” that involves interdisciplinary teams (4). The Agency for Healthcare Research and Quality now offers access to online M&M rounds at http://webmm.ahrq.gov/.

Technology may provide avenues to address two common complaints: that many recertification requirements do not reflect knowledge relevant to a physician’s practice, and that they drain valuable time from a doctor’s practice and personal life. The applied use of the electronic health record (EHR) may be potentially transformative: “The EHR should be explored as an aggregation point for professional development, a space in which physicians can continuously transfer questions and observations from practice and obtain answers to mature their expertise” (5). Similarly, the strategic use of data gleaned from registries and other emerging technologies may provide a wealth of patient data that is credible and useful to physicians in improving their treatment of patients.

The challenge to educators, accrediting organizations, and professional societies like the American Society of Nephrology is to evolve the provision and use of educational tools and assessment in ways that most support and advance physicians’ desire to develop and improve patient care.

References

1. 

Dobbs K. Simple moments of learning. Training 2000; 35:52–58.

2. 

Orlander JD, Barber TW, Fincke BG. The morbidity and mortality conference: the delicate nature of learning from error. Acad Med 2002; 77:1001–1006.

3. 

Knowles MS. The Modern Practice of Adult Education, New York, Cambridge, The Adult Education Company, 1980.

4. 

Gerstein WH, et al. Interdisciplinary quality improvement conference: using a revised morbidity and mortality format to focus on systems-based patient safety issues in a VA hospital: design and outcomes. Am J Med Qual 2014 Oct 20. doi 1062860614555430.

5. 

Moja L, Kwag KH. Point of care information services: a platform for self-directed continuing medical education for front line decision makers. Postgrad Med J 2015; 91:83–91.