Effective continuing medical education: A challenge for the future

The association between general practitioner participation in joint teleconsultations and rates of referral: a discrete choice experiment

Background

Joint consultations – such as teleconsultations – provide opportunities for continuing education of general practitioners (GPs). It has been reported this form of interactive case-based learning may lead to fewer GP referrals, yet these studies have relied on expert opinion and simple frequencies, without accounting for other factors known to influence referrals. We use a survey-based discrete choice experiment of GPs’ referral preferences to estimate how referral rates are associated with participation in joint teleconsultations, explicitly controlling for a number of potentially confounding variables.

Methods

We distributed questionnaires at two meetings of the Portuguese Association of General Practice. GPs were presented with descriptions of patients with dermatological lesions and asked whether they would refer based on the waiting time, the distance to appointment, and pressure from patients for a referral. We analysed GPs’ responses to multiple combinations of these factors, coupled with information on GP and practice characteristics, using a binary logit model. We estimated the probabilities of referral of different lesions using marginal effects.

Results

Questionnaires were returned by 44 GPs, giving a total of 721 referral choices. The average referral rate for the 11 GPs (25%) who had participated in teleconsultations was 68.1% (range 53-88%), compared to 74.4% (range 47-100%) for the remaining physicians. Participation in teleconsultations was associated with reductions in the probabilities of referral of 17.6% for patients presenting with keratosis (p = 0.02), 42.3% for psoriasis (p < 0.001), 8.4% for melanoma (p = 0.14), and 5.4% for naevus (p = 0.19).

Conclusions

The results indicate that GP participation in teleconsultations is associated with overall reductions in referral rates and in variation across GPs, and that these effects are robust to the inclusion of other factors known to influence referrals. The reduction in range, coupled with different effects for different clinical presentations, may suggest an educational effect. However, more research is needed to establish whether there are causal relationships between participation in teleconsultations, continuing education, and referral rates.

The anatomy of an outstanding CME meeting

Organizing a continuing medical education (CME) meeting should not be a casual undertaking. It requires experience, staff support, and adequate funding. The sponsoring entity should have a thorough grounding in the Accreditation Council for Continuing Medical Education mind-set, and the course should be within the mission of the organization. Needs of the potential attendees should be assessed and objectives developed to meet those needs. An evaluation process should be in place to ensure that the needs were addressed and met. Ideally, a postcourse evaluation should assess the impact of the meeting on the behavior and practice patterns of the registrants. Excellent teachers should be selected as faculty members. These educators should be given advance information about the characteristics of the attendees, their needs, and their expectations. Topics should be chosen for their relevance to the registrants, as opposed to the convenience of the faculty members. This paper deals with these issues and several related topics. It is based on the author's experience and supplemented by relevant peer-reviewed scientific literature. The CME "market" has a "caveat emptor" approach.

Effectiveness of an adult-learning, self-directed model compared with traditional lecture-based teaching methods in out-of-hospital training

Until recently, the U.S. Army Combat Medic School used a traditional teaching model with heavy emphasis on large group lectures. Skills were taught separately with minimal links to didactics.

OBJECTIVES

To evaluate whether the adult learning model improves student learning in terms of cognitive performance and perception of proficiency in military medic training.

METHODS

The study population was two sequential groups of randomly selected junior, enlisted, active duty soldiers with no prior formal emergency medical training who were enrolled in an experimental model of a U.S. Army Combat Medic School. The control population was a similar group of students enrolled in the traditional curriculum. Instructors were drawn from the same pool, with experimental group instructors receiving two weeks of training in adult-learning strategies. The study population was enrolled in the experimental program that emphasized the principles of adult learning, including small-group interactive approach, self-directed study, multimedia didactics, and intensive integrated practice of psychomotor skills. Instructors and students were also surveyed at the end of the course as to their confidence in performing four critical skills. The survey instrument used a five-point scale ranging from "strongly disagree" through "undecided" to "strongly agree." Proficiency for this survey was defined as the sum of the top two ratings of "agree" or "strongly agree" to questions regarding the particular skill. Both experimental and control programs lasted ten weeks and covered the same academic content and nonacademic (e.g., physical fitness) requirements, and the two groups of students had similar duty days. Evaluations included performance on internal and National Registry of Emergency Medical Technicians (NREMT) written examinations and other measures of academic and nonacademic performance.

RESULTS

One hundred fifty students (experimental n = 81, control n = 69) were enrolled in 1999-2000. The scores for internal course grade, NREMT written score, and NREMT written pass rate were, respectively, 86.3, 71.6, and 63% for the experimental group; and 85.8, 69.6, and 49% for the control group. The p-value was </= 0.05 for the comparison between internal course grade and NREMT written score, but p > 0.05 for the comparison between NREMT written pass rates. Students in both the adult-learning and traditional groups rated themselves high in proficiency, whereas instructors in the traditional group were generally much more modest in their rating of student proficiency than instructors of the adult-learning program.

CONCLUSIONS

In this study setting, an adult-learning model offers only a modest improvement in cognitive evaluation scores over traditional teaching when measured at the end of the course. Additionally, students in the traditional teaching model assess themselves as proficient more frequently than instructors, whereas instructor and student perception of proficiency more closely matched in the adult-learning model.