CME Associated with Decreased Mortality in Patients with Coronary Heart Disease

Low density lipoprotein

Evidence showing real changes in patient outcomes are rare, even though that's the ultimate goal for most CME programs.  A very nice study, published in the Annals of Family Medicine, showed a change in practice, and a positive change in patient outcomes after a CME program (Kiessling, A.; Lewitt, M.; and Henriksson, P. (2011), Case-based training of evidence-based clinical practice in primary care and decreased mortality in patients with coronary heart diseases.  Annals of Family Medicine, 9:211-218.).   

CME on new Guidelines for Coronary Heart Disease
Practice guidelines in Sweden on the use of lipid lowering drugs were developed after the 1994 publication of the effectiveness of lipid lowering in coronary heart disease.  In order to help general practitioners follow the new guidelines, a series of CME programs were developed. The training was designed to be interactive and to "activate" learners.  They felt that a case-based method was the most effective way to activate the learners and help them improve the sills and attitudes needed for decision making. 

CME Design
All participants were mailed a copy of the new guidelines.  The instruction began with a lecture deliverd by a specialist.  This was followed by a series of seminars, delivered over the next two years.  Physicians participated in 1-2 cases each year, in groups of 4-7 people.  The cases were designed to be simple and well-organized, and presented a problem without an obvious correct answer.  The seminars were one hour each and consisted of the case presentation, followed by interactive problem-solving, with a thorough discussion of the pros and cons of various decisions.  Physicians in the control group only listened to the lecture. 

Results
This seemingly simple design resulted in changes in practice, that at two years, had significantly reduced patient's low-density lipoprotein cholesterol levels compared to a control group. 

Ten years later, the mortality rate of the control group was 44%, while mortality in the intervention group was 22%.  That's right, ten years later, patients whose doctors went through a few interactive cases with an specialist,  had half the mortality of patients whose doctors listened only to a lecture and read the guidelines. 

What Happened?
The results of this study are pretty amazing.  Long -term effects are very hard to find in education studies.  It's very rare to see a study looking at an effect over a few months, let alone years, but there are a few things that we see with other kinds of successful CME that may be giving us a hint about why this worked so well. 

1. Learning over a period of time.  It takes time to learn new skills and new habits.  Physicians in this study had two years of exposure to this material.  This repeated exposure may well have helped these doctors incorporate the new guidelines into their daily practice. 

Interactive and problem focused.  The cases were designed so that they didn't have clear or obvious answers, and participants were given the chance work their way through all of the nuances of these cases, including "defining and valuing the pros and cons, and feasibility of different decisions."  One of the problems with presentations by experts is that they don't let learners work through these important details themselves. 

New Review of Simulation Education

A new article in JAMA looks at the effectiveness of simulations in health education.  The meta-analysis, which looked at over 600 published research papers, found large effects for the use of technology-enhanced simulations for knowledge, skills, and behaviors. 

Many of the papers included in the analysis dealt with surgical procedures, but there were other studies too, including dentistry, communication skills, nursing skills, examination skills, and obstetrics. 

The big limitation with this analysis is that it only looked at studies comparing simulation to no-instruction controls.  It's not surprising that some kind of instructional intervention is better than nothing at all, but this paper can serve as a good resource for those interested in learning more about simulations in medical education. 

Interactive CME Improves Physician Communication Skills

A very nice study, published last year in Patient Education and Counseling, shows that interactive instruction, that's heavily based on practicing skills, can have a positive influence on physician practice.  The study uses several elements that have been shown to influence provider behavior: skills practice, interactivity, and a design that spreads over several different sections (spaced learning). 

The Practice Setting
Physicians in a university health service clinic where there is a strong need to counsel patients on risky behaviors. 

The Instructional Design
The instruction consisted of five 2-hour workshops at 4-6 week intervals, over a span of six months.  the workshops all emphasized communication skills, and each focused on a specific area of need including managing difficult patient encounters, screening and assessment for depression, screening and assessment for alcohol use, taking a sexual history, and behavior change counseling.

Each of the workshops began with a short video or demonstration, to trigger discussion, then there was a brief, highly interactive lecture.  After that, the majority of the time was spent practicing skills with standardized patients and receiving feedback.  After each session, participants were given pocket cards to uses as references, and readings for further information. 

The Measures
This very thorough study, measured four different outcomes - participant satisfaction, learning (measured prior to the intervention and one month afterward), performance (assessed by chart review both before and after the intervention), and the impact on patient satisfaction.

The Results
The results showed positive increases in many important outcomes including knowledge, and more importantly, physicians changed their practice.  The patient satisfaction scores were already very high, and did not increase significantly as a result of the training. 


What it Means
Providers can change their practice.  Often, change requires something more than just education and training, but the elements that can help physicians change practice behavior are not a mystery, we see the same elements over and over again when we find CME that that changes practice:

1. Skills practice with feedback - people need to practice new skills before they can use them
2. Interactive information delivery
3. Practice over time - time is an often overlooked factor, but one of the most powerful

Effective Biology Teaching

We know that people don't necessarily learn much from passive methods like listening to lectures or reading.  People need to actively process the knowledge, practice using it, and get feedback. 

It's not always clear how to do that though.  What can people do to increase the kinds of activities that lead to better learning outcomes?  We can look to some of the work being done that looks at learning in other disciplines.  I've been very excited by some of the work that's being done in science, technology, engineering, and mathematics (STEM) teaching.  There have been a lot of recent developments in STEM teaching, based on what we know about the science of learning. 

I recently came across an excellent review from the Annual Review of Cell and Developmental Biology (2009, W.B.Wood, Innovations in teaching undergraduate biology and why we need them.  Ann, Rev. Cell Dev. Biol., 25:93-112).  This article very nicely lays out the argument for better teaching methods, and gives some very practical advice on how to implement them. 

Some Key points are:

Recent research in educational psychology, cognitive science, and neurobiology has yielded important new insights into how people learn and the optimal conditions for learning.

Discipline-based educational research (DBER) has led to the development of teaching approaches based on these insights (promising practices) and has provided extensive evidence that these approaches can be substantially more effective than traditional lecturing even in large classes.

These promising practices vary in their ease of implementation but even their partial adoption can lead to significant gains in student learning.

The recommendations would work well for teaching in many different settings, including continuing medical education.  Teaching recommendations include:

Effective instruction must build on students’ prior knowledge (which may include misconceptions that require correction).

Instructors should be aware of the student diversity in their classrooms and use a variety of teaching modes to optimize learning for all students.

Classes should include frequent formative assessment to provide feedback to both instructors and students.

Students should be encouraged to examine and monitor their own understanding of new concepts, for example, by explaining these concepts to their peers.

Students should be encouraged to work cooperatively and collaboratively in small groups.

In order to bring about the neurological changes that constitute learning, students should spend time actively engaged with the subject matter, for example, discussing, diagramming, solving problems, working on a research project, etc., in addition to or in place of listening passively to a lecture, reading the textbook, or consulting Web sites.

This paper is highly recommended for anyone trying to learn more about how learning science is being applied today. 

ACCME Interviews

ACCME has been producing series of video interviews about continuing medical education.  The interviewees are experienced practitioners who share some of the things they've learned while producing CMEs. 

In June, they interviewed Rick Kennison of Peer-Point Medical Education Institute.  He's doing a lot of work integrating the CME process into an improvement framework that impacts patient outcomes.  Sometimes people think of education as the "solution," but a lot of times, education works best if it's part of an overall improvement effort. 

Internet-Based Learning Doesn't Take less Time than Classroom Learning

Does internet-based learning take less time than classroom learning, as claimed by many authors?   Probably not.

Cook, Levison and Garside, (2010, Advances in Health Sciences Education, 15(5):755-70), looked at studies that compared the amount of time spent learning a topic in the classroom and over the internet.  They found that internet-based methods not necessarily any more efficient than classroom-based  In fact, if you use methods that increase learning, like interactivity, internet-based learning may take longer. 

"... our data suggest that there are few shortcuts to learning.  In this review, nearly all of the modifications of IBL [internet-based learning] to improve learning outcomes (interactivity, feedback, audio, video, etc.) required more time on task."  

Internet-based methods can be great time savers if you're at the cost of getting to a classroom, but learning takes time,  no matter how it is delivered.  

Active Learning Beats Lectures in a College Physics Class

CME presented as didactic lectures don't change practice behavior, and most of the time, they do little to improve knowledge.  So why are they used so often?  I think people use lectures partly because that's the way they learned in college, so they think it must work.  The problem though, is that college is a completely different situation because college students have to recall information on tests.  This means that they often use a variety of techniques to help them remember the information in a lecture.  Professionals don't have to pas high stakes tests (at least not for most CME), so they won't go through that extra work. 

Lectures aren't always the best way to learn, even in college.  A recent article in Science (hat tip to Donald Clark) compared learning in a physics class sections taught in two different ways.  The first was taught by an experienced, highly-rated lecturer, and the second, was used methods developed from learning theory, and was taught by a graduate assistant with no teaching experience.   This class used a variety of interactive methods based on the idea of deliberate practice.

"Deliberate practice takes the form of a series of challenging questions and tasks, that require the students to practice physicist-like reasoning and problem-solving during class time while provided with frequent feedback." 

The goal was to have students spend their time learning to reason and think like scientists, rather than simply being given facts.  It's important to note that both classes used clickers, and even used many of the same clicker questions, but the lecture-based class used them more like a post instruction assessment, rather than a way to start discussion and keep it going. 

The graduate assistant didn't lecture, he presented the problems, and gave guidance and explanations.  He also responded to student's answers for the clicker questions and to things that he heard during the student discussions. 

The results were uniformly positive.  The active learning group had higher attendance, higher levels of engagement, and most importantly, twice the learning of the group that received the lectures. 



Active learning, centered around problems can easily be incorporated into CME activities.  In fact, given the fact that these active learning experiments are more enjoyable for students, and more likely to result in better learning outcomes, it's hard to come up with reasons not to at least try them. 

Louis Deslauriers, Ellen Schelew, and Carl Wiemann (2011), Improved Learning in a Large-Enrollment Physics Class, Science 332:862-864.  http://www.sciencemag.org/content/332/6031/862.abstract