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How Many Unjustifiable Lectures Are Worth $2.4 Billion?

2008; Elsevier BV; Volume: 134; Issue: 6 Linguagem: Inglês

10.1378/chest.08-2362

1931-3543

William F. Dunn, Elizabeth Armstrong,

Clinical Reasoning and Diagnostic Skills

A hundred times every day I remind myself that my inner and outer life are based on the labors of other men, living and dead, and that I must exert myself in order to give in the same measure as I have received and am still receiving.Albert Einstein In this issue of CHEST (see page 1299), Leach and Fletcher1Leach D Fletcher S Perspectives on continuing education in the health professions: Improving health care through lifelong learning.Chest. 2008; 134: 1299-1303Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar recognize leaders in postgraduate education and provide an essay on complex issues of concern within the continuing education (CE) processes of the health professions. Their commentary principally is a review of the recommendations emerging from a November 2007 consensus conference convened by the Josiah Macy, Jr. Foundation. Multiple concerning issues are addressed by the authors as well as suggestions for transformative change. As described by Leach and Fletcher,1Leach D Fletcher S Perspectives on continuing education in the health professions: Improving health care through lifelong learning.Chest. 2008; 134: 1299-1303Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar the CE system in the United States is broken and in serious need of reform. Key components of system inadequacies, as described by the authors, are shown in Table 1. Six major recommendations for system reform are proposed in Table 2.Table 1Key Continuing Education System Inadequacies*From Leach and Fletcher.1 Excessive reliance on passive learning techniquesInsufficient focus on facilitating practical, demonstrated competenceInsufficient utilization of Internet technologiesInsufficient utilization of simulation-based learning toolsInappropriate links to commercial support* From Leach and Fletcher.1Leach D Fletcher S Perspectives on continuing education in the health professions: Improving health care through lifelong learning.Chest. 2008; 134: 1299-1303Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar Open table in a new tab Table 2Recommendations for System Reform*From Leach and Fletcher.1 ACCME = Accreditation Council for Continuing Medical Education; ANCC = American Nurses Credentialing Center.Enhance relevance Utilization of methods of experiential learning and reflection (eg, simulations, patient-based learning)Utilization of Internet technologiesEnhanced transparency Utilization of metrics in performance assessmentAccountability to providers and systems of health care toward process improvementRequire lifelong learning Link best-practice standards to CE experiencesElectronic integration of clinical information systems Health system performance dataNational best practice standardsTrain for teamworkFoster education science Creation of a national interprofessional CE instituteEnhance discovery and dissemination of improved methods of CEDiscontinue commercial support of CE Discontinuation of direct and indirect support of CE by accredited organizations from pharmaceutical and medical device commercial sourcesDiscontinuation of pharmaceutical sponsorship of CE via paid spokespersons from academic health centersImprove oversight of CE via ACCME and ANCC collaboration System-integrated, enhancing cross-disciplinary health-care deliveryEnhanced utilization of new technologies InternetPoint-of-care informationSimulation technologies/applications* From Leach and Fletcher.1Leach D Fletcher S Perspectives on continuing education in the health professions: Improving health care through lifelong learning.Chest. 2008; 134: 1299-1303Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar ACCME = Accreditation Council for Continuing Medical Education; ANCC = American Nurses Credentialing Center. Open table in a new tab Implicit in their assertions is the recognition of an evolving technological world, integrated into an active infrastructure of experiential and reflective learning techniques, facilitating (demonstrated and measured) competence and lifelong learning. Let us examine this world further. Market forces affect our lives on a daily basis and provide both incremental and, at times, paradigm changes. Within business, there are many examples in which leading companies fail to stay at the head of their industry and sink into oblivion. Such changes may occur due to many reasons, including bureaucracy, financial indiscretion, arrogance, and resistance to change of processes, among others. According to Christensen2Christensen CM Why great companies can fail.in: The innovator's dilemma: when new technologies cause great firms to fail. Harvard Business School Press, Boston, MA1997: 3-95Google Scholar and Christensen and Armstrong3Christensen CM Armstrong E Disruptive technologies: a credible threat to leading programs in continuing medical education?.J Cont Educ. 1998; 18: 69-80Google Scholar of Harvard Business School, however, there are also examples in which well-managed, seemingly well-run powerhouses of industry succumb to forces that are initially unrecognized or ignored. Such forces he terms disruptive technology. This mechanism— disruptive technologies appearing and being used initially in underserved markets and then improving at such a rapid pace that they attack and penetrate mainstream applications from the underside—is the reason that many of the most admired companies of the past have lost their positions of prominence. An example of a disruptive technology that fully changed an industry, undercutting the existing norms of business, occurred in 1876. After inventing and patenting the telephone, Alexander Graham Bell and his partners offered to sell the patent rights to powerhouse organization Western Union for $100,000. The president of Western Union refused, countering that the new technology was a simple toy. Two years later, the same individual lamented that if he were able to purchase the patent for $25 million he would consider it a bargain.4Fenster JM “Inventing the telephone—and triggering all-out patent war.”.Available at: http://www.americanheritage.com/events/articles/web/20060307-alexander-graham-bell-telephone-patent-telegraph-elisha-gray-thomas-watson-gardiner-hubbard-western-union-thomas-edison.shtmlGoogle Scholar Analogous disruptive technologies created entirely new industry sectors such as the mail order catalog (Sears, Roebuck and Company5Sears, Roebuck and Company.Available at: http://en.wikipedia.org/wiki/Sears,_Roebuck_and_CompanyGoogle Scholar), personal computers, steel “mini-mills,” and semiconductors (computing).2Christensen CM Why great companies can fail.in: The innovator's dilemma: when new technologies cause great firms to fail. Harvard Business School Press, Boston, MA1997: 3-95Google Scholar The Internet has proven to be a major disruptive technology. Within the health-care industry, an example of disruptive innovation is the in-store clinic. The “minute clinic” business, instituted in Minnesota and since broadly expanded in geographic scope and impact, provides patients with rapid, efficient assessment at low cost for common disorders. Located in chain stores, these entities strive to capture market share by capitalizing on market weaknesses of conventional medical models of health-care delivery.6Bohmer R The rise of in-store clinics: threat or opportunity?.N Engl J Med. 2007; 356: 765-768Crossref PubMed Scopus (69) Google Scholar The “business” of education has not been untouched by the power of innovation via disruptive technology. An example is that of Phoenix University, pioneer in the applications of online learning. Their World Wide Web site7University of Phoenix.Available at: http://www.phoenix.edu/about_us/about_us.aspxGoogle Scholar states: Founded in 1976 on an innovative idea: make higher education highly accessible for working students. Still guided by this idea, University of Phoenix has helped transform the landscape of higher education in widely recognized ways. Many of the conveniences that twenty-first-century students now take for granted— … a student-centered environment, practitioner faculty, online classes, online library, ebooks, computer simulations—were pioneered or made acceptable through University of Phoenix's efforts. The practices imposed into the preexistent higher education community by innovations of University of Phoenix disrupted traditional university programs. Starting initially with the provision of rather humble employee training courses, progressive expansions have made this entity one of the leading providers of online education and one of the largest educational institutions in the United States.8The innovator's solution: creating and sustaining successful growth. Harvard Business School Publishing Corporation, Boston, MA2003Google Scholar Today, CE is a highly regulated market. One might expect that disruptive technology is less possible in such a domain. However, examples from other industries suggest that advances in CE delivery via disruptive technologies will indeed increase and succeed. Typically, disruption in such a climate occurs first within a commercial system outside the regulated market. Rarely has revised regulation preceded disruptive revolutions.9Christensen CM Johnson CW Horn MB Disrupting class: how disruptive innovation will change the way the world learns. McGraw-Hill Companies, New York, NY2008Google Scholar Unfortunately, existing CE regulation has facilitated a system of passive experience; typically, lectures are provided to seated audiences. Such an instructional paradigm is inconsistent with long-established education theory models that have been published and accepted as foundational in modern education,10Merriam SB Caffarella RS Learning in adulthood: a comprehensive guide. 2nd ed. John Wiley and Sons, San Francisco, CA1999: 248-266Google Scholar, 11Kolb DA Experiential learning: experience as the source of learning and development. Prentice Hall, Englewood Cliffs, NJ1984Google Scholar, 12Maslow AH Toward a psychology of being. 2nd ed. Van Nostrand Reinhold, New York, NY1968Google Scholar, 13Dewey J Democracy and education: an introduction to the philosophy of education. Macmillan, New York, NY1916Available at: http://www.ilt.columbia.edu/publications/dewey.htmlGoogle Scholar, 14Dunn WF Education theory: does simulation really fit?.Simulators in critical care and beyond. SCCM Press, Des Plaines, IL2004Google Scholar including those currently advocated by most undergraduate medical education curricular reforms.15Armstrong E Parsa-Parsi R How can physicians' learning styles drive educational planning?.Acad Med. 2005; 80: 680-684Crossref PubMed Scopus (136) Google Scholar If the goal of CE is truly to modify behavior, such passive experiences are insufficient for the future because they are without either pedagogic or scientific merit. In examining the impact of active vs passive mechanisms of CE delivery, Davis et al16Davis D O'Brien MAT Freemantle N et al.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 (8674): 8678Crossref Scopus (1874) Google Scholar concluded that interactive CE experiences based on active engagement of the learner, providing opportunities to practice skills, can effect change in professional practice and health-care outcomes. No parallel data exist for passive didactic sessions. Thus, the investing of billions of health-care dollars into such methods in not justifiable. In contrast to passive learning, increasing numbers of scientific studies17Wayne DB Didwania A Feinglass J et al.Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study.Chest. 2008; 133: 56-61Abstract Full Text Full Text PDF PubMed Scopus (480) Google Scholar, 18Swanstrom LL Fried GM Hoffman KI et al.Beta test results of a new system assessing competence in laparoscopic surgery.J Am Coll Surg. 2006; 202: 62-69Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar, 19Fried GM Feldman LS Vassiliou MC et al.Proving the value of simulation in laparoscopic surgery.Ann Surg. 2004; 240: 518-525Crossref PubMed Scopus (657) Google Scholar, 20Gallagher AG Lederman AB McGlade K et al.Discriminative validity of the minimally invasive surgical trainer in virtual reality (MIST-VR) using criteria levels based on expert performance.Surg Endosc. 2004; 18: 660-665Crossref PubMed Scopus (120) Google Scholar, 21Seymour NE Gallagher AG Roman SA et al.Virtual reality training improves operating room performance: results of a randomized, double-blinded study.Ann Surg. 2002; 236: 458-463Crossref PubMed Scopus (2095) Google Scholar, 22Sedlack RE Kolars JC Computer simulator training enhances the competency of gastroenterology fellows at colonoscopy: results of a pilot study.Am J Gastroenterol. 2004; 99: 33-37Crossref PubMed Scopus (226) Google Scholar, 23Ritter EM McClusky III, DA Lederman AB et al.Objective psychomotor skills assessment of experienced and novice flexible endoscopists with a virtual reality simulator.J Gastrointest Surg. 2003; 7: 871-877Crossref PubMed Google Scholar, 24Sedlack RE Kolars JC Validation of a computer-based colonoscopy simulator.Gastrointest Endosc. 2003; 57: 214-218Abstract Full Text PDF PubMed Scopus (92) Google Scholar, 25Mayo PH Hackney JE Mueck JT et al.Achieving house staff competence in emergency airway management: results of a teaching program using a computerized patient simulator.Crit Care Med. 2004; 32: 2422-2427Crossref PubMed Scopus (148) Google Scholar, 26Blum MG Powers TW Sundaresan S Bronchoscopy simulator effectively prepares junior residents to competently perform basic clinical bronchoscopy.Ann Thorac Surg. 2004; 78: 287-291Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar, 27Colt HG Crawford SW Galbraith III, O Virtual reality bronchoscopy simulation: a revolution in procedural training.Chest. 2001; 120: 1333-1339Abstract Full Text Full Text PDF PubMed Scopus (212) Google Scholar, 28Patel AD Gallagher AG Nicholson WJ et al.Learning curves and reliability measures for virtual reality simulation in the performance assessment of carotid angiography.J Am Coll Cardiol. 2006; 47: 1796-1802Crossref PubMed Scopus (118) Google Scholar, 29Edmond Jr, CV Impact of the endoscopic sinus surgical simulator on operating room performance.Laryngoscope. 2002; 112: 1148-1158Crossref PubMed Scopus (81) Google Scholar, 30Berkenstadt H Haviv Y Tuval A et al.Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk.Chest. 2008; 134: 158-162Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 31Devitt JH Kurrek MM Cohen MM et al.The validity of performance assessments using simulation.Anesthesiology. 2001; 95: 36-42Crossref PubMed Scopus (124) Google Scholar validating efficacy of simulation-based learning, outside the domain of CE, suggest that simulation-based techniques may qualify as truly disruptive innovation in CE. Similarly, online education techniques are dramatically altering methods of educational content delivery in many markets outside of health care. Online technology improves convenience and accessibility, while providing learner-centric flexibility in terms of the rate of information acquisition by the user. Economically, it often represents a cheaper method of content delivery, with a reduced cost per unit for the learner. Factors that may impact and accelerate implementation within health-care CE are as follows: (1) technological improvements, (2) improved learner centricity of applications, (3) instructor shortages, and (4) efficiency associated with increasing scale of use.9Christensen CM Johnson CW Horn MB Disrupting class: how disruptive innovation will change the way the world learns. McGraw-Hill Companies, New York, NY2008Google Scholar If consistent with the Christensen model, disruptors will creep into the CE market competing largely against nonconsumption. An example would be large numbers of rural Chinese physicians obtaining CE they could never get before through videotape classes delivered in many remote areas, or CE via UptoDate (or similar online products), answering questions at the end of certain content sections. Thus, these examples of disruptive innovation in CE can be less expensive, available, efficient, and extremely convenient by comparison with traditional methods of passive educational content delivery. Passive learning methods of CE may assess learning goals (ie, cognition) but are typically incapable of adequate assessment of competency or demonstrated proficiency, particularly in complex tasks. Additionally, they may underemphasize some important domains of professional medical practice, including interpersonal skills, lifelong learning, professionalism, and integration of core knowledge into clinical practice. In an extensive MEDLINE database review from 1966 to 2001 and reference list review of relevant articles for English-language studies of reliability or validity of measures of competence of physicians, medical students, and residents, Epstein and Hundert32Epstein RM Hundert EM Defining and assessing professional competence.JAMA. 2002; 287: 226-235Crossref PubMed Scopus (1816) Google Scholar found that in addition to assessments of basic skills, new formats that assess clinical reasoning, expert judgment, management of ambiguity, professionalism, time management, learning strategies, and teamwork promise a multidimensional assessment while maintaining adequate reliability and validity. All six areas of competence defined by the Accreditation Council for Graduate Medical Education (patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice) can be addressed in a single simulation tool. Such new methods of assessment have been selectively utilized in high-stakes assessment.33Berkenstadt H Ziv A Gafni N et al.The validation process of incorporating simulation-based accreditation into the anesthesiology Israeli national board exams.Israel Med Assoc J. 2006; 8: 728-733PubMed Google Scholar, 34Chambers KA Boulet JR Gary NE The management of patient encounter time in a high-stakes assessment using standardized patients.Med Educ. 2000; 34: 813-817Crossref PubMed Scopus (14) Google Scholar, 35Cregan P Watterson L High stakes assessment using simulation: an Australian experience.Stud Health Technol Inform. 2005; 111: 99-104PubMed Google Scholar, 36Ziv A Rubin O Sidi A et al.Credentialing and certifying with simulation.Anesthesiol Clin. 2007; 25: 261-269Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Polanyi37Polanyi M Personal knowledge: towards a post-critical philosophy. University of Chicago Press, Chicago, IL1974Google Scholar describes that competence is defined by tacit rather than explicit knowledge. Tacit knowledge is that which we know but normally do not explain easily, including the informed use of heuristics (rules of thumb), intuition, and pattern recognition.32Epstein RM Hundert EM Defining and assessing professional competence.JAMA. 2002; 287: 226-235Crossref PubMed Scopus (1816) Google Scholar Because clinical competency is of a higher complexity than simply knowledge, this may be more difficult, or impossible, to define, short of using experiential techniques, such as simulation. This fact is an important driver behind the rapid growth of an international multidisciplinary organization, the Society for Simulation in Healthcare, which has seen an over-tenfold growth in membership, to > 2,000 members, within the first 4 years of existence.38Society for Simulation in Healthcare.Available at: http:www.ssih.orgGoogle Scholar In conclusion, due to a combination of factors including educational theory, scientific inquiry, and disruptive technologies driving market forces, it is highly likely that the landscape of CE will change rapidly in the upcoming years. The impact of the Josiah Macy, Jr. Foundation report is creating a broad-based reflection on the motivations and operations of CE, which is certainly in flux. How will these changes, representing innovative disruptive technologies, change the CE landscape? Perhaps the past can provide us the window to the future. Once again, Christensen et al,39Christensen M Roth EA Anthony SD Seeing what's next: using theories of innovation to predict industry change. Harvard Business Press, Boston, MA2004Google Scholar by intense study and reporting on the history of disruptive technologies creating transformational changes in the business and educational arenas, can help us perhaps predict changes in CE. He relates that within the “industry” of education, nonconsumption exists even in contexts within which everyone seems to be consuming. The mechanism for transformational improvement of CE therefore is dependent on making it easier for “nonconsumers”—those empty seats at your last CE event—to learn in new ways that matter to them, creating relevance. Modular computerized interactive education and simulation-based technologies will be expected to increasingly emerge within the scene of health-care CE processes, and can be utilized in creative ways of dynamic improvement. Christensen et al39Christensen M Roth EA Anthony SD Seeing what's next: using theories of innovation to predict industry change. Harvard Business Press, Boston, MA2004Google Scholar further relate that “companies can start at the fringes and then move to the core to avoid being snared in … regulation. All organizations—even nonprofit ones—have skills and motivation that drive what they can and cannot do.” The authors thank Rachel Dunn for technical assistance in preparation of this article.