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Continuing education in the health professions: a literature review pertinent to North America Nakamoto, June 1972

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CONTINUING EDUCATION I N THE HEALTH PROFESSIONS: A L I T E R A T U R E REVIEW PERTINENT TO NORTH AMERICA  by  JUNE NAKAMOTO R.N. S t . P a u l ' s B.N. M c G i l l  Hospital  University  A T H E S I S SUBMITTED I N P A R T I A L F U L F I L M E N T OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF ARTS _  (Adult  We a c c e p t t h i s  ~-  1  Education)  t h e s i s as conforming  to the required  THE U N I V E R S I T Y OF B R I T I S H COLUMBIA AUGUST, 1 9 7 2  standard  In  presenting  this  an advanced degree the I  Library  further  for  shall  agree  thesis  in p a r t i a l  fulfilment  of  at  University  of  Columbia,  the  make  it  freely  available  that permission for  his  of  this  representatives. thesis  for  It  financial  The  University  ADULT of  gain  shall  D a t e  ^J^V  EDUCATION  B r i t i s h Columbia  Vancouver 8, Canada  / %/p ^  by  the  not  requirements  reference copying of  Head of  i s u n d e r s t o o d that  written permission.  Department o f  for  extensive  s c h o l a r l y p u r p o s e s may be g r a n t e d  by  British  the  I  agree  and this  that  study. thesis  my Department  copying or  for  or  publication  be a l l o w e d w i t h o u t my  ii  ABSTRACT  This  survey of the l i t e r a t u r e  comparative report  on c o n t i n u i n g  provides  education  professions, medicine, d e n t i s t r y , nursing, period  f r o m 1960 t o 1970.  Findings  t h i s report  admits that  implementation.  educators,  adult  education  the  context  pressure  and c l i n i c a l  each o f t h e p r o f e s s i o n s  facilities;  reviewed  although i n d i f f e r i n g qualified  and 3) t h e l i m i t a t i o n o f program g o a l s  education  c a n no l o n g e r  system.  Recent  be r e l e g a t e d  public  advances, i n d i c a t e  that  t o a secondary place i n  Due t o t h e s c a r c i t y o f s u b s t a n t i v e  recommendations were n o t p o s s i b l e .  within  a condition f o rp r a c t i c e , coupled  w i t h a c c e l e r a t i n g t e c h n o l o g i c a l and s c i e n t i f i c  p r o f e s s i o n a l education.  education  2) t h e need f o r more a n d b e t t e r  o f the r a p i d l y changing health care  education  continuing  1) t h e l a c k o f r e s o u r c e s — f u n d s ,  t o make c o n t i n u i n g  continuing  health  and pharmacy, c o v e r i n g t h e  The p r o b l e m s f a c i n g t h e p r o f e s s i o n s ,  research;  senior  i t has been f a rfrom s u c c e s s f u l i n i t s  measure, were found t o be: adult  i n the four  disclose that while  i s g a i n i n g momentum i n t h e h e a l t h f i e l d , in  a comprehensive and  research,  H o w e v e r , i t was s u g g e s t e d t h a t :  specific 1) more  e f f e c t i v e m e t h o d s o f d e f i n i n g l e a r n i n g n e e d s b e d e v e l o p e d a n d t e s t e d ; 2) m o r e s t r e s s be p l a c e d evaluation  on c l i n i c a l l y  oriented  schemes; a n d 3) r e g i o n a l c e n t e r s  development o f ongoing, i n t e r r e l a t e d interprofessional basis. and  programs and t h o s e w i t h b u i l t i n  evaluation  be e s t a b l i s h e d  to f a c i l i t a t e the  programs on b o t h a u n i p r o f e s s i o n a l and  ( D e t a i l e d d e s c r i p t i o n s o f more i n n o v a t i v e  practices are included.)  programs  i i i  ACKNOWLEDGEMENTS  The material  w r i t e r wishes  f o rt h i s review.  t o express appreciation Although  shared unpublished reports  contributed  i ti snot possible to s p e c i f i c a l l y  e a c h p e r s o n b y name, s p e c i a l t h a n k s a r e e x t e n d e d willingly  t o a l l t h o s e who  list  t o t h e many n u r s e s who s o  a n d l i t e r a t u r e f r o m t h e i r own p e r s o n a l  files. S p e c i a l t h a n k s a r e a l s o due D r . C o o l i e V e r n e r and a s s i s t a n c e , a n d t o M i s s J a n e C o r c o r a n f o r t y p i n g  f o rh i s continued this  manuscript.  support  iv TABLE OF CONTENTS P a  ABSTRACT ACKNOWLEDGEMENTS LIST OF TABLES . PART  ONE I  INTRODUCTION  1 . . . . . . . . . . . . . . . . .  2  BACKGROUND OF THE HEALTH PROBLEM PURPOSE CLARIFICATION OF TERMS DESIGN AND LIMITATIONS  3 5 5 6  REFERENCES PART  TWO  CHAPTER  8 CONTINUING EDUCATION IN MEDICINE  II  CHAPTER I I I  .  10  THE PROFESSION AND CONTINUING EDUCATION . . . .  11  PHYSICIAN COMPOSITION AND DISTRIBUTION . . Work Patterns Changing Patterns of P r a c t i c e . . . . NEED FOR CONTINUING EDUCATION Early Developments  11 12 13 15 16  PARTICIPATION IN CONTINUING EDUCATION  21  F i e l d of P r a c t i c e .  J . U ^ k i . l . k .  L L A t l ^ ^ l . ^ l I L J  22 .  .  .  .  .  .  .  .  Location of P r a c t i c e Years of P r a c t i c e OPINIONS AND PREFERENCES Deterrents to Attendance Fees and Stipends Scheduling of Programs Sponsors I n s t r u c t i o n a l Processes F e l t Learning Needs Other Information Sources CHAPTER  IV  e  i i i i i ix AN OVERVIEW  CHAPTER  g  24 24 25 25 26 26 27 28 30 31  ORGANIZATION AND ADMINISTRATION ORGANIZATION . . . Numbers of Courses and Sponsors . Course Content and E l i g i b i l i t y . . Patterns of Course Organization . SPONSORSHIP ROLES AND RESPONSIBILITIES Medical Schools Community Hospitals Medical and Specialty Societies . PROGRAM PLANNING AND ADMINISTRATION . Administrative Arrangements Instructors Finances P u b l i c i t y and Promotion Programming  34 . . .. . . . . . . . . . . ..  34 34 36 37 42 43 45 48 50 50 51 53 53 54  V  Page CURRENT AND RECURRING ISSUES AND TRENDS . . Accreditation National Plans Incentives for Learning CHAPTER  V  INSTRUCTIONAL PROCESSES  ;  PATTERNS OF INSTRUCTION SMALL GROUPS P s y c h i a t r i c Case Seminars C l i n i c a l Conferences Demonstrations: Supervised C l i n i c a l Practice . . . LARGE GROUPS MASS MEDIA Radio Conferences Medical Radio Network Telelectures Television Encodes or Scrambled Broadcast TV . . . Slow-Scan TV SUPPORTING DEVICES Motion Pictures Audio Tape Recordings Mediphone Correspondence: Programmed Instruction.. Computer Assisted Instruction ORGANIZATION FOR INSTRUCTIONAL TECHNOLOGY . Regional National CHAPTER  VI  EVALUATION . . ." SUBJECTIVE ASSESSMENT OBJECTIVE EVALUATION Testing f o r the Achievement of Learning Measuring Change i n Performance . . . . Measuring Long Term Results of Care . . Program Models with B u i l t - i n Evaluation PROBLEMS OF EVALUATION The Problem of Objectives Design Problems Costs  CHAPTER VII  SUMMARY AND CONCLUSIONS "  58 58 60 61 65 66 68 68 69 70 73 75 75 77 78 79 85 87 87 88 88 91 92 93 95 96 98 101 101 104 104 110 112 114 118 118 119 120 122  SUMMARY ' 122 Participation 123 Organization and Administration . . . . 124 Instructional Processes 124 Evaluation 125 CONCLUSIONS 126 REFERENCES  129  vi Page PART  T H R E E  CHAPTER VIII  CONTINUING EDUCATION IN DENTISTRY  152  THE PROFESSION AND CONTINUING EDUCATION . . . . COMPOSITION AND DISTRIBUTION Practice Arrangements Patterns of Work NEED FOR CONTINUING EDUCATION  CHAPTER  CHAPTER  153 154 155 156  IX PARTICIPATION IN CONTINUING EDUCATION Location F i e l d of Practice Patterns of Practice Income, Age Use of Information Sources . . . . . . Reasons f o r Attending or Not Sponsors Scheduling of Programs . . . . . . . . . T u i t i o n Fees F e l t Learning Needs Instruction Instructors  CHAPTER  X  XI  160 161 161 162 162 163 164 164 165 165 165 166 167  PROGRAM ADMINISTRATION AND ORGANIZATION . . . .  168  ADMINISTRATION . . . Administrative Arrangements Instructors and F a c i l i t i e s Finances P u b l i c i t y and Promotion . . . . . . . . PROGRAM PLANNING Study Clubs Regional Programs . Hospital Programs . Professional Meetings T e l e v i s i o n Programs Correspondence, Programmed Instruction Information R e t r i e v a l CURRENT AND RECURRING ISSUES AND TRENDS. .  168 169 170 171 172 173 174 176 177 178 178 181 182 183  SUMMARY PARTICIPATION ADMINISTRATION AND ORGANIZATION  REFERENCES  153  . . . . . .  186 . . . . . .  186 187 188  vii  Page PART  FOUR  CHAPTER  CONTINUING EDUCATION IN NURSING .  XII THE PROFESSION AND CONTINUING EDUCATION . . . .  196  NURSE COMPOSITION AND DISTRIBUTION . . . . Trends i n Composition and ; Distribution Changing Patterns of Practice . . . . CONCERN FOR CONTINUING EDUCATION . . . . . Research Interests . . . . . . . . . .  196  CHAPTER XIII  PARTICIPATION IN CONTINUING EDUCATION CHARACTERISTICS OF PARTICIPANTS . . ... . Location of Practice P o s i t i o n i n Nursing Service M a r i t a l Status and Age Educational Achievement . Use of Other Information Sources . . . REASONS FOR PARTICIPATION OR NOT Scheduling . . . Cost F e l t Learning Needs . . . . . . . Methods and Techniques . . . . . . . .  CHAPTER  CHAPTER  195  XIV  XV  REFERENCES  PROGRAM,ORGANIZATION  197 199 202 205 208 208 208 209 209 210 210 212 213 213 215 218  AND ADMINISTRATION . . . .  220  SPONSORS AND PROGRAMS Nursing Associations Hospitals U n i v e r s i t i e s and t h e i r Schools of Nursing ADMINISTRATION . . Instructors Finances P u b l i c i t y and Promotion . Program Planning SOME SAMPLE PROGRAMS Regional and Sub-Regional Programs . . Inservice Education . . . . Mass Media and S e l f - I n s t r u c t i o n a l Methods RECURRING ISSUES AND TRENDS  220 220 222  SUMMARY  225 227 228 228 229 229 232 233 240 244 249 251 254  viii  Page PART  F I V E  CHAPTER  CONTINUING EDUCATION IN PHARMACY  264  XVI THE PROFESSION AND CONTINUING EDUCATION . . . .  265  COMPOSITION AND DISTRIBUTION . . . . . . . The Changing Nature of Practice . . . Need f o r Continuing Education . . . .  265 268 269  CHAPTER XVII  PARTICIPATION IN CONTINUING EDUCATION REASONS FOR ATTENDING OR NOT Scheduling of Programs Fees F e l t Learning Needs I n s t r u c t i o n a l Processes  272 274 275 275 275 276  CHAPTER XVIII PROGRAM ORGANIZATION AND ADMINISTRATION . . . .  277  CURRENT COURSE OFFERINGS . . . . . . . . . ADMINISTRATION . . . . . Finances and Faculty Promotion and P u b l i c i t y SOME SAMPLE PROGRAMS Regional Programs Mass Media Home Study ISSUES AND TRENDS  277 282 282 283 284 284 284 285 28o  CHAPTER  XIX SUMMARY  REFERENCES PART  S I X  CHAPTER  XX  . . .  290  CONTINUING EDUCATION IN THE HEALTH PROFESSIONS: MAJOR CONCLUSIONS • • •  293  MAJOR CONCLUSIONS  294  T  REFERENCES  287  COMMON FINDINGS AND IMPLICATIONS EDUCATIONAL PLANNING . . . . Relevant Programs . . . . A Health Team Approach ORGANIZATION AND ADMINISTRATION The Role of the University The Role of the Hospital Services. . . Coordination of Programs Financing and Promoting Continuing Education . The Educator i n Continuing Education. . METHOD AND TECHNIQUES EVALUATION SUMMARY .  294 294 295 296 297 298 298 299 300 301 302 303 304 306  ix  L I S T OF  TABLES Page  TABLE TABLE  I II  QUALITY OF CARE PROCEDURE I N GROUPS (CANADA, 1967) ' CONTINUING  MEDICAL EDUCATION  23  COURSES L I S T E D  1961-1962 TO 1970-1971 TABLE I I I TABLE TABLE TABLE  IV V VI  TABLE V I I TABLE V I I I TABLE  TABLE TABLE  IX  X XI  TABLE X I I  35  PERCENTAGE D I S T R I B U T I O N OF CONTINUING COURSES BY TYPE OF COURSE 1964-65 TO  EDUCATION  1969-70 . .  THE B I - C Y C L E : R E L A T I O N OF PATIENT-CARE EDUCATION CYCLES  39  AND 116  ESTIMATED COST OF D I F F E R E N T EVALUATION TECHNIQUES FOR A HYPOTHETICAL ONE-WEEK SHORT COURSE . . . .  121  PERCENTAGE D I S T R I B U T I O N OF EMPLOYED NURSES BY F I E L D OF EMPLOYMENT I N CANADA 1930, 1960, 1968  198  .  THE FREQUENCY WITH WHICH RN's WOULD BE W I L L I N G TO ATTEND SHORT TERM REGIONAL PROGRAMS  214  PERCENTAGE D I S T R I B U T I O N OF PHARMACISTS AND CURRENT EMPLOYMENT, 1962  266  BY F I R S T  A COMPARISON OF P A R T I C I P A N T S I N AND THE PROMOTION OF COURSES OFFERED BY PHARMACY SCHOOLS I N 1967 AND 1968 BY S P E C I A L T Y OF THE P A R T I C I P A N T S  273  COURSES SPONSORED BY SCHOOLS OF PHARMACY 1966-1968 C L A S S I F I E D BY LOCATION AND CONTACT HOURS . . . .  278  COURSES SPONSORED J O I N T L Y BY SCHOOLS OF PHARMACY AND PROFESSIONAL ASSOCIATIONS 1966-1968 BY LOCATION AND CONTACT HOURS  280  NUMBER OF COURSES OFFERED AND 1968  BY SUBJECTS I N  1967  281  PART ONE AN  OVERVIEW  1  2  CHAPTER  I  INTRODUCTION  L i f e l o n g l e a r n i n g i s p r o b a b l y t h e most i m p o r t a n t e d u c a t i o n a l i m p l i c a t i o n of our automated world b e c a u s e i t g i v e s m e a n i n g a n d c o n t e n t t o t h e human resources of the nation. L a u r e n e E. G i l m o r e , Everywhere across of  life  not  are continuing  their  a v a i l a b l e , estimates  some k i n d  the country  adults  education.  are that  o f a l l ages and i n a l l w a l k s  Although r e l i a b l e  some 35 t o 50 m i l l i o n  of a planned l e a r n i n g experience annually  i n s t i t u t i o n and agency i s i n v o l v e d many a n d d i v e r s e  educational  R.N.  statistics are  adults  engage i n  and a l m o s t e v e r y  social  i n o n e way o r a n o t h e r i n m e e t i n g t h e  requirements of these m i l l i o n s of adult  learners (7). De C r o w ( 6 ) s t a t e s  that:  Much o f t h i s a c t i v i t y i s h a p p e n i n g u n i n t e n t i o n a l l y , l a r g e l y unobserved, and w i t h o u t t h e s l i g h t e s t c o n s c i o u s d i r e c t i o n . I t i s happening of n e c e s s i t y , almost as a r e f l e x motion of a s o c i e t y grappling with s o c i a l forces which are remoulding a nation to confront the challenges of a r a p i d l y changing world. Cotton  (4) n o t e s t h a t  t h e d o m i n e n t theme i n r e c e n t  years i s related  to the " a c c e l e r a t i n g r a t e of s o c i a l change...the knowledge the  f a c t that  rapidly  scientific  and t e c h n o l o g i c a l knowledge i s a c c u m u l a t i n g s o  t h a t we m u s t c o n t i n u e  t o l e a r n o r we w i l l  In defining the r o l e of adult Hallenbeck this  explosion...and  education  become  obsolete."  i n this era of rapid  change,  ( 8 ) s e t s f o r t h a r a t i o n a l e w h i c h seems p a r t i c u l a r l y p e r t i n e n t t o  survey.  He  says:  3  I t i s q u i t e as p o s s i b l e t o l e a r n t o l i v e i n a c h a n g i n g w o r l d as i t i s to learn to l i v e i n a s t a t i c world. When o n e comes t o a d u l t h o o d a n d f i n d s t h a t h e i s p r e p a r e d t o l i v e i n one k i n d o f w o r l d , b u t must l i v e i n a n o t h e r k i n d o f w o r l d , he l e a r n s , o f c o u r s e , b u t a s we s a y , " t h e h a r d way." B u t o u r k i n d o f s o c i e t y c a n f a l l t o p i e c e s w h i l e i t s i n d i v i d u a l members a r e l e a r n i n g " t h e h a r d way" t o cope w i t h i t , keep i t i n o p e r a t i o n , and g u i d e i t s d e s t i n y . I n t e l l i g e n c e h a s t o l e a r n " t h e h a r d w a y " o n l y o n c e . The j o b o f adult education i s to help people to understand t h e i r problems, d i s c o v e r t h e r e s o u r c e s w h i c h a r e a v a i l a b l e t o them, and f i n d t h e way t o s o l v e t h e i r p r o b l e m s a n d t o r e a c h t h e i r g o a l s u n d e r c u r r e n t circumstances.  BACKGROUND OF THE HEALTH PROBLEM As a p a r t  o f t h e l a r g e r changes i n s o c i e t y ,  has w i t n e s s e d an i n c r e a s e d health professions.  emphasis on c o n t i n u i n g  the in  the forces  field.  Modern  understanding, prevention, expectancy two-fold.  accentuating  leaders  this  reports  i n the health  field  r e f e r r e d t o , t h e most d r a m a t i c and u n r e l e n t i n g i s  tremendous r a t e a t w h i c h b i o - m e d i c a l the health  i n a l l of the  i n many g o v e r n m e n t h e a l t h manpower  (21) (24) ( 1 9 ) , and as w e l l , by numerous  Among  education  The s c i e n t i f i c - s o c i o - e c o n o m i c f o r c e s  need have been w e l l documented (22)  t h e decade of t h e s i x t i e s  science  research  i s p r o d u c i n g new k n o w l e d g e  h a s made m a s s i v e b r e a k t h r o u g h s i n t h e  and c u r e o f i l l h e a l t h , and has i n c r e a s e d  A t t h e same t i m e ,  life  i t h a s become i n c r e a s i n g l y a p p a r e n t  t h a t new a n d b e t t e r means m u s t b e f o u n d t o h a s t e n t h e a p p l i c a t i o n o f t h e s e new d i s c o v e r i e s t o t h e i m p r o v e m e n t o f h e a l t h The n e e d t o c o p e w i t h  t h i s problem has been h e i g h t e n e d  y e a r s as an i n c r e a s i n g l y i n f o r m e d p u b l i c l e a r n s e r i e s a n d demands t h e m . and expanded h e a l t h consumer  Furthermore, higher  insurance  care. i n recent  o f t h e s e new m e d i c a l  education,  higher  coverage a r e r a p i d l y s h i f t i n g  discov-  earnings,  the r o l e of  as " p a t i e n t " t o consumer as " b u y e r " t h e r e b y s t r e n g t h e n i n g h i s  4  position  t o demand more and  e g a l i t a r i a n philosophy be  t o pay.  The  services.  v i e w s h e a l t h as  a v a i l a b l e to a l l people w i t h  ability and  now  better health  e q u a l q u a l i t y and  services reflects  I n r e s p o n s e t o t h e s e new  by  agencies,  increasing their  without reference  have attempted  commitment  have taken a v a r i e t y of  this  circumstances,  s i o n a l a s s o c i a t i o n s , j o i n e d i n c r e a s i n g l y by health  growing  a b a s i c human r i g h t w h i c h  ever expanding r o l e of government i n the  s u r v e i l l a n c e of h e a l t h  voluntary  In addition, a  to  provision  view.  the  u n i v e r s i t i e s and  profes-  employing i n s t i t u t i o n s  to prevent p r o f e s s i o n a l  to continuing  forms, nevertheless,  should  education.  These  and obsolescence  activities  everywhere apparent i s  the  growing concern that  continuing  education  i s a r e s p o n s i b i l i t y which i s  being  discharged  (14)  (19)  satisfactorily  n o t e d by  Houle  (10)  (12)  (20).  Moreover,  not  as  (11):  Even more d i s c o n c e r t i n g i s the e x p r e s s i o n o f a g r o w i n g p u b l i c h o s t i l i t y toward the s e v e r a l p r o f e s s i o n s b e c a u s e of the a l l e g e d i n c o m p e t e n c e o r s e l f - s a t i s f a c t i o n of t h e i r i n d i v i d u a l members, f a u l t s which b e t t e r c o n t i n u i n g p r o f e s s i o n a l education might have h e l p e d to p r e v e n t . Although the continuing  case i s not  education  i n the h e a l t h  purpose, l i m i t a t i o n s of is are  also widespread not  the  "continuing"  model designed  teachers, impression  but  f o r the  whatever the  c r e a r , the view i s w i d e l y  and  of  the  recommend t h a t ing education  found.  been hampered by  hoc,"  be  continuing  " p i e c e m e a l , " and  of youth r a t h e r problem, the  than adult  general t h a t new  Furthermore, recent  lack  of  on  a  learners.  consensus i s and  There  education  built  that  more e f f e c t i v e  government t a s k  "professional associations explore could  that  l a c k of p r o f e s s i o n a l i n t e r e s t .  p r e s e n t m e t h o d s h a v e many s h o r t c o m i n g s , a n d a p p r o a c h e s m u s t be  has  that programs of  l a r g e l y "ad  education  crux  sciences  expressed  force  t h e means w h e r e b y  made a c o n d i t i o n f o r p r a c t i c e , " w h i c h h a s  reports continu-  added  a  5  new sense o f urgency t o t h e t a s k (21)  (19).  PURPOSE T h i s s u r v e y o f t h e l i t e r a t u r e i s an attempt t o d e t e r m i n e t h e n a t u r e and  scope o f c o n t i n u i n g e d u c a t i o n  i n four of the health professions: 1960  m e d i c i n e , d e n t i s t r y , n u r s i n g , and pharmacy, c o v e r i n g t h e p e r i o d from t o 1970.  Such a r e v i e w  s h o u l d h e l p t o c l a r i f y some o f t h e p e r p l e x i n g  e d u c a t i o n a l i s s u e s , and i t might s e r v e as a medium f o r t h e exchange o f i d e a s and p r o c e d u r e s r e l a t e d t o t h e d e s i g n and conduct o f programs o f continuing education  i n the s e v e r a l h e a l t h p r o f e s s i o n s .  The major a s s u m p t i o n on w h i c h t h i s study published  i s based  i s that the  l i t e r a t u r e r e f l e c t s a c t u a l p r a c t i c e s and t r e n d s .  CLARIFICATION OF TERMS "Continuing sciences.  e d u c a t i o n " has been v a r i o u s l y d e f i n e d i n t h e h e a l t h  Some d e f i n i t i o n s a r e v e r y b r o a d , encompassing a l l f o r m a l  f o l l o w i n g completion  of the undergraduate c u r r i c u l u m  (16)  (1),  while  education others  a r e v e r y r e s t r i c t i v e and l i m i t t h e term t o s h o r t r e f r e s h e r - t y p e  non-credit  c o u r s e s d e s i g n e d f o r p r a c t i s i n g h e a l t h p r o f e s s i o n a l s (12)  Another  way  of d e f i n i n g continuing education  education  and a d u l t l e a r n i n g (2)  (9).  i s t o make i t synonymous w i t h a d u l t  (26).  Used i n t h i s way, c o n t i n u i n g  education  i n c l u d e s a l l l e a r n i n g a c t i v i t i e s , b o t h p r o f e s s i o n a l and p e r s o n a l , w h i c h c o n t r i b u t e t o an i n d i v i d u a l ' s f i e l d o f p r a c t i c e .  W h i l e no one would  dispute  the d e s i r a b i l i t y o f t h i s l a t t e r d e f i n i t i o n , as n o t e d by Cameron (2), " t h e p r o p o r t i o n s of the task a r e formidable The  indeed."  term c o n t i n u i n g e d u c a t i o n , a s used i n t h i s r e p o r t , i n c l u d e s any  6  non-degree course or other educational activity for practising health professionals "through which opoortunities for systematic learning are provided" (18).  Thus, in addition to formal courses, other planned  learning experiences such as the c l i n i c a l traineeship or study club are defined as continuing education in this review.  On the other hand, audio  tape recordings, telephone dial access and similar devices are referred to as information sources or supporting devices, depending on the context in which they are used. The terms "course" and "program" are used interchangeably in this project and refer to those learning activities which are designed for the achievement of specific instructional objectives within a specified period o f time.  Continuing education may be engaged in on a full-time or part-time  basis, but usually when full-time i t is of relatively short duration.  A  program may consist of a single session or a sequential series of sessions and may use any single or combination of methods and techniques of instruction  (25). DESIGN AND LIMITATIONS This report is organized by disciplines with a section devoted to each.  Since the major developments in continuing education are reported  in medicine, the greater portion of this study is devoted to continuing medical education.  Nevertheless, the sections devoted to the other three  health professions are sufficient to suggest the common elements which extend across the four health disciplines reviewed.  To permit comparisons,  the general framework used throughout this review i s that basic to program development.  7  Due presented  t o the p a u c i t y of l i t e r a t u r e of a research nature, the data were d e r i v e d from a v a r i e t y  summaries o f s u r v e y s . as  of descriptive  sources  as w e l l  as  S p e c i f i c reference to the nature of the l i t e r a t u r e  i t imposes l i m i t a t i o n s i s documented as t h e need  arises.  8  REFERENCES  American N u r s e s ' A s s o c i a t i o n , Avenues f o r Continued L e a r n i n g , New Y o r k , A m e r i c a n N u r s e s ' A s s o c i a t i o n ; 10 C o l u m b u s C i r c l e , 1967. C a m e r o n , D., " C o n t i n u i n g M e d i c a l E d u c a t i o n : Some T h o u g h t s on S p o n s o r s h i p , " Canadian M e d i c a l A s s o c i a t i o n J o u r n a l , 92:765-766, ( A p r i l 3, 1 9 6 5 ) . C o g g e s h a l l , L.T., P l a n n i n g f o r M e d i c a l P r o g r e s s T h r o u g h E d u c a t i o n ; A Report Submitted to the E x e c u t i v e C o u n c i l of the A s s o c i a t i o n of American Medical C o l l e g e s , Evanston, A p r i l , 1965. C o t t o n , W.E., The S u p p o r t i n g L i t e r a t u r e on B e h a l f o f A d u l t E d u c a t i o n : A H i s t o r i c a l Examination of the Supporting L i t e r a t u r e , Boston, C e n t e r f o r t h e S t u d y o f L i b e r a l E d u c a t i o n f o r A d u l t s , 1968. C u r t i s s , F., e t a l , C o n t i n u i n g E d u c a t i o n i n N u r s i n g , B o u l d e r : W e s t e r n I n t e r s t a t e C o m m i s s i o n f o r H i g h e r E d u c a t i o n , 1969. D e C r o w , R., "The S c o p e o f C o n t i n u i n g E d u c a t i o n , " E d u c a t i o n , ( J a n u a r y , 1 9 6 9 ) , pp.5 + 9. E l k i n s , W., "Education ( A p r i l , 1961).  i s Continuous,"  Nursing  Continuing  Outlook,  9:243-5,  H a l l e n b e c k , W.E., "The F u n c t i o n a n d P l a c e o f A d u l t E d u c a t i o n i n A m e r i c a n S o c i e t y , " I n K n o w l e s , M., (ed) , Handbook o f A d u l t E d u c a t i o n i n the U n i t e d S t a t e s , Washington, D.C, Adult Education Association, 1960. H o l l i n s h e a d , B., The S u r v e y o f D e n t i s t r y , W a s h i n g t o n , D . C , C o u n c i l on E d u c a t i o n , 1 9 6 1 .  American  H o r n b a c k , M., " C o n t i n u i n g E d u c a t i o n : Whose R e s p o n s i b i l i t y ? " J o u r n a l o f C o n t i n u i n g E d u c a t i o n i n N u r s i n g , 2:9-13, ( J u l y / August, 1971). Houle, CO., "To L e a r n t h e F u t u r e , " M e d i c a l C l i n i c s 54:5-17, (January, 1970).  of North  America,  Hozid, J . , "Role of Continuing Education i n Dental Obsolescence," J o u r n a l of the American D e n t a l A s s o c i a t i o n , 78:1299-1303, (June, 1969). M a g r a w , R.M.,  Ferment i n M e d i c i n e ,  P h i l a d e l p h i a , W.B.  Saunders,  1966.  9 14.  M i l l e r , G.E., "What i s t h e N e e d ? " , A m e r i c a n J o u r n a l o f 17:889-890, (June, 1966).  Cardiology,  15.  M i l l i s , J . , "The F u t u r e o f M e d i c i n e : The R o l e o f t h e C o n s u m e r , " J o u r n a l of the American M e d i c a l A s s o c i a t i o n , 20:498-501, (October, 1969).  16.  R a n d o l p h , K., " B a s e l i n e s and R e s p o n s i b i l i t i e s i n C o n t i n u i n g „Educational E f f o r t s , " J o u r n a l o f t h e A m e r i c a n C o l l e g e o f D e n t i s t s , 30:283-288, (December, 1 9 6 3 ) .  17.  P a t t e r s o n , W., "Continuing Education: A Challenge to the P r o f e s s i o n , " J o u r n a l of American C o l l e g e of D e n t i s t r y , 28:3-26, (March, 1960).  18.  P o p i e l , E., "The R o l e o f t h e U n i v e r s i t y i n C o n t i n u i n g E d u c a t i o n f o r N u r s e s , " P a p e r p r e s e n t e d a t t h e U n i v e r s i t y o f Texas-M.D. A n d e r s o n a n d Tumour I n s t i t u t e , H o u s t o n , T e x a s .  19.  R e p o r t o f t h e Committee on 1970.  20.  R e p o r t o f An I n t e r p r o f e s s i o n a l T a s k F o r c e : C o n t i n u i n g E d u c a t i o n f o r the H e a l t h P r o f e s s i o n s , Chicago: Center f o r the Study of M e d i c a l E d u c a t i o n , December, 1966.  21.  R e p o r t o f t h e N a t i o n a l H e a l t h Manpower C o m m i s s i o n , W a s h i n g t o n U.S. P r i n t i n g O f f i c e , 1 9 6 7 , V o l u m e .1.  22.  S o m e r s , A., H e a l t h C a r e i n T r a n s i t i o n : D i r e c t i o n s f o r t h e F u t u r e , C h i c a g o : H o s p i t a l R e s e a r c h of E d u c a t i o n a l T r u s t , 1971.  23.  S t a r k , N . J . , "The P u b l i c ' s C o n c e r n f o r P r o f e s s i o n a l C o m p e t e n c e , " J o u r n a l of the American M e d i c a l A s s o c i a t i o n , 189:27-30, ( J u l y , 1964).  24.  T a s k F o r c e R e p o r t s on Queen's P r i n t e r ,  25.  Verner, C, " D e f i n i t i o n of Terms." I n , J e n s e n , G., e t a l ( e d s . ) , A d u l t E d u c a t i o n : O u t l i n e s o f An E m e r g i n g F i e l d o f U n i v e r s i t y S t u d y , W a s h i n g t o n : A d u l t E d u c a t i o n A s s o c i a t i o n o f U.S.A., 1964. pp.  26.  W i l l i a m s , D., "A Taxonomy o f C o n t i n u i n g M e d i c a l E d u c a t i o n E n d e a v o u r , " C a n a d i a n M e d i c a l A s s o c i a t i o n J o u r n a l , 9 6 : 1 0 4 0 - 1 0 4 4 , ( A p r i l 8, 1967).  27.  W i l l i a m s , D., "The S h a p e o f T h i n g s t o Come," J o u r n a l , 10:12 (January, 1968).  t h e H e a l i n g A r t s , O t t a w a : Queen's  the Cost 1970.  of H e a l t h  Printer,  D.C.,  S e r v i c e s i n Canada, Ottawa:  British  Columbia  Medical  PART  TWO  CONTINUING EDUCATION I N M E D I C I N E  10  11  CHAPTER I I THE  In keeping m e d i c i n e has must be States few  with  reflected  CONTINUING EDUCATION  the r a p i d l y changing nature  u n d e r g o n e , and  continues  i n education  seeking  medical  d e s p i t e the an  this  at a l l l e v e l s .  i s o f f s e t by  c a r e has  immigration  of s c i e n c e  and  the  fact  I n b o t h C a n a d a and  been i n c r e a s i n g over the t h a t t h e number o f  i n c r e a s e d p r o p o r t i o n a t e l y (171) of f o r e i g n doctors  the  to maintain  (243).  what i s  o f p h y s i c i a n s has  created  which United  past  patients Moreover, considered  optimum p h y s i c i a n / p o p u l a t i o n r a t i o , u n e q u a l d i s t r i b u t i o n  utilization  society,  t o u n d e r g o many c h a n g e s , a l l o f  t h e number o f a c t i v e p h y s i c i a n s h a s  decades, but  t o be  PROFESSION AND  and  a d i s p a r i t y b e t w e e n demand and  supply  (171). P H Y S I C I A N COMPOSITION AND An  a n a l y s i s of medical  manpower r e v e a l s t h a t t h e number o f  employed i n t e a c h i n g , r e s e a r c h , t o d i r e c t p a t i e n t c a r e , has  DISTRIBUTION  a d m i n i s t r a t i o n , and  other  been i n c r e a s i n g i n r e c e n t  in private practice i s declining  activities  decades w h i l e  care  the  number  have a l s o o c c u r r e d  in private practice.  In the U n i t e d  S t a t e s , t h e number o f g e n e r a l  declined  50  the  percent  unrelated  (171).  Changes i n the p a t t e r n of p r o v i d i n g m e d i c a l  from roughly  physicians  of  with-  practitioners*  t o t a l number o f p h y s i c i a n s i n  1959,  A s u s e d i n t h i s s t u d y , " G e n e r a l P r a c t i t i o n e r " r e f e r s t o t h o s e M.D.'s w i t h no s p e c i a l t y t r a i n i n g a n d / o r t h o s e w i t h some s p e c i a l t y t r a i n i n g , b u t who a r e n o t b o a r d c e r t i f i e d , and who do n o t l i m i t t h e i r p r a c t i c e t o a s i n g l e field.  12 to approximately  31 p e r c e n t  i n 1967.  power i n Canada r e v e a l s a s i m i l a r physicians  i n general  to approximately Since are  being  (134)  54  i m p l i c a t i o n s of s t r e s s the  (160),  training  (257)  i n family Of  physicians  equal  percent,  i n 1968  the  provided  specialties,  this  and  by  other  changing p a t t e r n are  reiterate  the  t y p e o f g e n e r a l i s t be  p r e p a r e d who  to population.  Doctors  i t i s estimated  t h a t o v e r one  provincial  levels, varying  p o r t i o n of  the p o p u l a t i o n  population  ratio  i n C a n a d a i n 1967  favourable  ratio  of  Work  Patterns:  tend  clear.  (195)  Neverthethe  i n general  has  the  practice, Millis  graduate  directly with  the per  was  1:824, f o l l o w e d by ratio  A number o f r e c e n t  o f 1:1549  surveys  The  remaining  i n excess of state  c a p i t a i n c o m e and Thus, w h i l e  with  the  the  and  the  pro-  physician/  C o l u m b i a had  1 : 8 4 9 , and  100,000  the  most  Newfoundland  (76).  (127)(232)(242)(257) d i s c l o s e that  t o 63 h o u r w o r k w e e k , o f w h i c h r o u g h l y  d i r e c t patient care.  in  of  h a l f of a l l doctors  1:984, B r i t i s h Ontario  supply  to concentrate  i s a l s o found at the  i n urban communities.  least favourable  a v e r a g e a 56  not  the wide r e g i o n a l d i f f e r e n c e s i n the  disproportionate distribution  the  h e a l t h workers  recommendation of  are p r e s e n t l y p r a c t i s i n g i n communities w i t h populations  with  dropped  general p r a c t i t i o n e r s  g r o w i n g c o n c e r n o f b o t h t h e p u b l i c and  (195)  concern are  in relation  This  f i g u r e had  of  medicine.  l a r g e r u r b a n a r e a s and  (257).  p h y s i c i a n man-  the percentage  d e c l i n i n g numbers of p h y s i c i a n s  (96)  t h a t a new  67  on  W h e r e a s i n 1965  services formerly  p r o f e s s i o n over the  many a u t h o r s  report  the  trend.  information  (243) .  r e d i s t r i b u t e d among t h e  l e s s , most, r e p o r t s  and  percent  some o f  (92), the  medical  p r a c t i c e was  Current  20 p e r c e n t  80  percent  or l e s s of  physicians  i s spent  the p h y s i c i a n ' s  in time  13  is and  spent i n o f f i c e a d m i n i s t r a t i o n , continuing h o s p i t a l meetings, research  belief  and/or teaching.  that o f f i c e practice i sdecreasing,  a v e r a g e more t h a n t w i c e visits  education,  medical  Contrary  studies  reveal  to the popular that  a s many p a t i e n t - p h y s i c i a n c o n t a c t s  t h a n t h e y do t h r o u g h h o s p i t a l v i s i t s  (242)  (127)  (232)  that  "One l i m i t  we h a v e a l m o s t s u r e l y r e a c h e d . . . t h e to  (16).  i n thedoctor's  office  While most  authors  productivity  number o f h o u r s t h a t h e c a n b e e x p e c t e d  work."  Changing Patterns Ideally, and  physicians  through  g e n e r a l i z a t i o n s c a n n o t b e made f r o m t h e l i m i t e d d a t a p r o v i d e d , a g r e e w i t h Anne Somers  society  of Practice: group p r a c t i c e which b r i n g s  s p e c i a l i s t s who c a n s h a r e t h e i r  of  supporting  „ r WJ_  ~ ~-.-. \,aX.\^  should  personnel,  « ~ i . C O U J . L X U g  {z^.„„ JL J - W i l l  also f a c i l i t a t e  measure t h e lengthy  and t h e s e r v i c e s  development t o o f f s e t t h e  .—..-. „ o p C L I O  the sharing  general p r a c t i t i o n e r s  expertise, f a c i l i t i e s ,  i sa l o g i c a l  „ _ , 3 x i l U J L C a O C U  together  1 i— X X ^ d U X U L L  o f on c a l l  w o r k week o f p h y s i c i a n s .  f -\ c r\\ J  time,  •  c—iJ U L U  - - — - - - ~ ~ d l LClUgCUlCllLi)  thus r e l i e v i n g  Despite  these o f t  a d v a n t a g e s , t h e a d o p t i o n o f group p r a c t i c e has been r e l a t i v e l y Canada and t h e U n i t e d  States  (232)  (195).  fragmentation  Moreover, there  i n some  quoted slow i n both  i s no  conclusive  e v i d e n c e t o p r o v e t h a t group p r a c t i c e does i n f a c t improve t h e e f f i c i e n c y or e f f e c t i v e n e s s o f medical care On  theother  (171).  hand, t h emajor development i n t h eo r g a n i z a t i o n o f  m e d i c a l p r a c t i c e has been t h e trend Without elaborating there  toward h o s p i t a l based s e r v i c e s  on t h e n a t u r e o f t h i s  trend,  h a s b e e n a n i n c r e a s i n g number o f a r t i c l e s  i t i s worth noting and r e p o r t s  that  reflecting the  growing i n t e r n a l as w e l l as e x t e r n a l c o n t r a d i c t i o n s o f the m e d i c a l system.  (232).  care  T h e r e a r e many comments a b o u t t h e i n e q u i t i e s i n h o s p i t a l p r i v i l e g e s ,  14  i n t e r p r o f e s s i o n a l s t r e s s e s and  s t r a i n s , and  the s o a r i n g c o s t s of  care  Furthermore,  i t has  (243)  (196)  h o s p i t a l system  (183)  (232).  i s more p r o d u c e r  so busy "keeping  i n step w i t h medical advances,  charge  t h e k n o w l e d g e and  i s heard  b u l k of m e d i c a l p r a c t i c e i n d i c a t e d by  increasingly  technology  that  t h a n c o n s u m e r o r i e n t e d , and  t h e m e d i c a l n e e d s o f t h e community" (252) The  been s a i d  t h a t i t has  hospital the  t h a t i t has lost  step with  (232) . t h a t w h i l e m e d i c a l s c i e n c e now  to promote e f f e c t i v e  "health medicine",  i s d i s e a s e o r c u r e o r i e n t e d (243)  t h e T a s k F o r c e on H e a l t h C o s t s i n C a n a d a ( 2 4 3 )  (195).  less  has  the  As  "more t h a n 95 p e r c e n t  o f h e a l t h c o s t s a r e s p e n t on h o s p i t a l and m e d i c a l c a r e s e r v i c e s , t h e m e n t c o m p o n e n t , w h i l e p u b l i c h e a l t h and  been  the p r e v e n t i v e aspects  treat-  constitute  than 5 percent." The  Report  o f t h e Committee on  t h e H e a l i n g A r t s (195)  d e f i n e s the  pircf sm iii co'T.cTTsts tdrms, i t sts.tss * T h i s i s not the f a u l t o f the i n d i v i d u a l p r a c t i t i o n e r s : most a r e a l r e a d y overworked i n p r o v i d i n g c u r a t i v e s e r v i c e s . I t i s the f a u l t r a t h e r , of a h e a l t h system i n which m e d i c a l s c h o o l s have f a i l e d t o emphasize preven-tive h e a l t h . . . a n d i n which the rewards i n i n c o m e and p r o f e s s i o n a l s t a t u s a r e r e l a t i v e l y l o w e r i n t h i s t y p e o f w o r k t h a n f o r o t h e r a s p e c t s of. m e d i c a l p r a c t i c e . Furthermore, and more i m p o r t a n t l y , t h e s y s t e m i s i l l o r g a n i z e d f o r t h e p r o v i s i o n o f c o m p r e h e n s i v e h e a l t h c a r e . . . T h e m e d i c a l t e c h n o l o g y i s now d i v i d e d among p o o r l y c o - o r d i n a t e d g r o u p i n g s o f p r a c t i t i o n e r s and a g e n c i e s , s p e c i a l i s t s , g e n e r a l p r a c t i t i o n e r s , h o s p i t a l s , c o m m u n i t y s e r v i c e s , and p u b l i c h e a l t h a g e n c i e s . T h i s summary e m p h a s i z e s t h a t t h e i s s u e s and care system  are enormously  c o m p l e x and w i l l  same t i m e , a s n o t e d b y P a t r i c k  Storey  to improve m e d i c a l p r a c t i c e through the e x i s t i n g  system,  and  (237)  problems of the  n o t s o o n be  resolved.  i n the Utah  report:  medical At  "any  the attempt  c o n t i n u i n g e d u c a t i o n must t a k e i n t o  r e l a t e e f f e c t i v e education to that  system."  account  15  NEED FOR CONTINUING  EDUCATION  Three d i s c r e t e phases of e d u c a t i o n a r e d i s t i n g u i s h a b l e i n the f i e l d of medicine: education leading  undergraduate education  covering the i n t e r n e s h i p , residency, or other  t o advanced academic degrees o r m e d i c a l  education, comprising "both  l e a d i n g t o t h e M.D.  those  activities  to refresh the individual  degree;  full  specialties;  time  study  and c o n t i n u i n g  engaged i n by p r a c t i s i n g  i n various aspects  graduate  of h i s basic  physicians medical  e d u c a t i o n , a n d t o i n f o r m h i m o f new d e v e l o p m e n t s i n h i s own a n d r e l a t e d . fields  of medical  p r a c t i c e , b u t w h i c h do n o t l e a d t o a n y f o r m a l  standing i n the p r o f e s s i o n " (51). This t h i r d to  as t h e " l a s t undeveloped f r o n t i e r  concern  phase, f r e q u e n t l y r e f e r r e d  of medical  education," constitutes the  of t h i s review. The  •  problem of keeping  up w i t h t h e r e s e a r c h r e v o l u t i o n i s p a r t i c u l a r l y  a c u t e . i u medicine  w h e r e new d e v e l o p m e n t s a r e , p e r h a p s ,  t h a n i n any o t h e r  field.  o c c u r r i n g more r a p i i i l y  The p h y s i c i a n i s c o n f r o n t e d by t h e e v e r i n c r e a s i n g  demands o f a b u s y p r a c t i c e a n d b y t h e o m n i p r e s e n t t h r e a t o f Although  organized medicine  attempting  obsolescence.  h a s i n v e s t e d money, m a n p o w e r , a n d t i m e , i n  t o h e l p p h y s i c i a n s keep c u r r e n t , t h e r e t u r n s from t h i s  a r e now b e i n g q u e s t i o n e d . estimate  advanced  Manning  (145) and o t h e r s  t h a t o n l y 10 t o 25 p e r c e n t  investment  (86) (194) (275) (222)  o f t h e p r a c t i s i n g p h y s i c i a n s engage i n  c o n t i n u i n g e d u c a t i o n d e s p i t e t h e m u l t i t u d e o f o p p o r t u n i t i e s t o do s o a v a i l a b l e to  them.  To w h a t e x t e n t  the q u a l i t y  education are responsible f o r this it  k n o w n how many o f t h o s e  from t h e programs o f f e r e d .  and t e c h n i q u e s  seeming d i s i n t e r e s t  problem.  medical  i s unclear, nor i s  p h y s i c i a n s who do p a r t i c i p a t e a c t u a l l y b e n e f i t Although  much h a s b e e n w r i t t e n a b o u t t h e n a t u r e  of the problem there i s a l a c k of s u f f i c i e n t the  of postgraduate  reliable  data  to  understand  16 Continuing education  i n medicine  i s not without  i t s landmarks.  Indeed, most o f t h e problems b e i n g d e b a t e d and t h e c o n c e p t s c o n s i d e r e d new o r r e v o l u t i o n a r y h a v e b e e n r e c o g n i z e d  currently  and documented i n a  number o f s t u d i e s a n d i m a g i n a t i v e r e p o r t s p u b l i s h e d i n t h e l a s t Early  century.  Developments: In  1930,  half  hishistorical  continuing medical  deficiencies  (227) r e p o r t s t h a t p r i o r t o  education.  I t was n o t u n t i l  viewed as the n e c e s s a r y  rapidly,  "third  i n the l i f e - l o n g  I n 1930 and 1 9 3 1 , t h r e e m e d i c a l  Albany  education programs.  description of the early Michigan r e g i o n a l i z a t i o n advocated  today  education of the  initiated  planning f o r  Dr. Benjamin  program d e f i n e s p r e c i s e l y  (108)  came t o b e  schools, the University of  C o l l e g e , and T u f t s U n i v e r s i t y ,  regional continuing medical  specialty  that continuing education  stage  correcting  the t h i r t i e s ,  o f t h e p r o p r i e t o r y s c h o o l s c l o s e d and g r a d u a t e  programs began t o develop  Michigan,  Sheperd  e d u c a t i o n was l a r g e l y d i r e c t e d t o w a r d  i n basic medical  when t h e l a s t  physician."  chronology,  Horning's  the concept  of  (68):  The U n i v e r s i t y o f M i c h i g a n m e d i c a l s c h o o l h a s a c c e p t e d t h e p r i n c i p l e s t h a t g r a d u a t e and c o n t i n u i n g m e d i c a l e d u c a t i o n s h o u l d be d e c e n t r a l i z e d and d e v e l o p e d a b o u t t h e r e g i o n a l and community h o s p i t a l s , and t h a t m e d i c a l e d u c a t i o n c h a n n e l s s h o u l d extend from t h e medical s c h o o l s out through such h o s p i t a l s t o the r u r a l p h y s i c i a n s . A r e p o r t by t h e Commission on M e d i c a l E d u c a t i o n  of the American  M e d i c a l A s s o c i a t i o n p u b l i s h e d i n 1932 n o t e d : 1.  That t h e e d u c a t i o n sequence from p r e m e d i c a l e d u c a t i o n t o • r e t i r e m e n t f r o m p r a c t i c e be l o o k e d upon b r o a d l y as a s i n g l e p r o b l e m , n o t a s u c c e s s i o n o f i s o l a t e d and u n r e l a t e d e x p e r i e n c e s .  2.  That t h e c o n t i n u e d e d u c a t i o n o f p h y s i c i a n s i s synonymous w i t h g o o d m e d i c a l p r a c t i c e , a n d p r o v i s i o n s s h o u l d b e made u l t i m a t e l y whereby every p h y s i c i a n w i l l be a b l e t o c o n t i n u e h i s e d u c a t i o n . The t i m e may come when e v e r y p h y s i c i a n may b e r e q u i r e d i n t h e p u b l i c i n t e r e s t to take c o n t i n u a t i o n courses to i n s u r e that h i s p r a c t i c e w i l l be k e p t a b r e a s t o f c u r r e n t methods o f d i a g n o s i s , t r e a t m e n t , and p r e v e n t i o n .  3.  That the problems of postgraduate medical e d u c a t i o n are c l o s e l y i n t e r w o v e n w i t h t h o s e o f p r a c t i c e and e d u c a t i o n . The g r e a t n e e d a t t h e moment i s t o s e c u r e j o i n t l e a d e r s h i p i n a p r o g r a m w h i c h w i l l embody t h e e d u c a t i o n a l i d e a l s a n d m e t h o d s o f t h e u n i v e r s i t y and t h e h i g h e s t t y p e o f m e d i c a l p r a c t i c e ( 2 2 7 ) .  Others Upham ( 2 5 0 ) for  repeating these admonitions  i n 1937,  a critical  were meeting  and  Rappelye  who  a l s o s t r e s s e d the  programs to determine  landmark i n the h i s t o r i c a l  c o u r s e s e v e r a l months e a r l i e r the q u a l i t y  and  t o 30 p h y s i c i a n s who  had  by u s i n g a s e l f - d e v i s e d  o f m e d i c a l p r a c t i c e , he  each p a r t i c i p a n t ' s p r e - c o u r s e performance  the study i s important because i t appears  the f i r s t  t h e s m a l l s a m p l e and  attempt  in  very apparent  "The  dealt with patients  limited  approach. were:  teaching... I t i n the wards  or w i t h v a r i o u s t e c h n i c a l procedures  and  of  t r e a t m e n t , w e r e t h e most v a l u a b l e p a r t o f t h e t e a c h i n g , " and  t e a c h e r o f t h e p h y s i c i a n s t u d e n t must p o s s e s s  a l s o a s y m p a t h e t i c a p p r e c i a t i o n o f t h e p r o b l e m s and the p r a c t i t i o n e r s by B e t w e e n 1937 of  scale for  to the t e a c h i n g - l e a r n i n g process  t h a t the work which  the o u t p a t i e n t departments  d i a g n o s i s and  rating  crude methodology  "...the decided s u p e r i o r i t y of the p r a c t i c a l over d i d a c t i c was  attended h i s  at program e v a l u a t i o n u s i n g a r e s e a r c h  o b s e r v a t i o n s b y Youmans r e l a t i v e  (256)  against h i s post-course  his  Two  they  c o m p a r e d w h a t he b e l i e v e d t o  Although  be  whether  e v o l u t i o n of c o n t i n u i n g  performance.  to  need  a p r o g r a m e v a l u a t i o n r e p o r t e d b y Youmans i n 1935  Youmans made u n n a n n o u n c e d v i s i t s  findings,  J.H.  the needs of p r a c t i s i n g p h y s i c i a n s .  m e d i c a l e d u c a t i o n was  be  recommendations were  i n 1940  re-examination of e x i s t i n g  A significant  measuring  (227)  and  the American  a busy and  not o n l y knowledge limitations  but  imposed  on  practice."  1940,  t h e C o u n c i l on M e d i c a l E d u c a t i o n a n d  M e d i c a l A s s o c i a t i o n conducted  the f i r s t  Hospital  n a t i o n a l survey  to  18  determine the nature study  revealed  visited  of e x i s t i n g postgraduate  that c i r c u i t  (191).  I t noted  type  courses  and  t h e n move on  were e v i d e n t bedside  were b e i n g  t o a new  throughout the  t o two  a r e a " and  i n s t r u c t i o n of l i m i t e d  most d i r e c t outcome of  American Medical  s e l e c t i n g courses  While published  annually  the  sources in  f i r s t on  of i n f o r m a t i o n c o n c e r n i n g  the United  States  (227).  field  Thus, the  the  exception  with  (227),  the  a setback  i n the  o n s e t o f W o r l d War  I I , this  and  shifted  the major r e s p o n s i b i l i t y  their medical  thirties  saw  s e v e r a l program  the n a t i o n as  schools"  planning  published the  major  education the  innovations;  a whole.  to t h e i r  schools  some  and  hospitals  q u a l i t y and  quantity,  education  t r a d i t i o n a l l y belonged, to (168).  education  i s t h o u g h t t o have had  for continuing medical  t h e p r o f e s s i o n a l s o c i e t i e s where i t had u n i v e r s i t i e s and  of  continuing medical  the medical  re-examine t h e i r programs w i t h r e s p e c t  physicians  sponsors i n  e v o l u t i o n of c o n t i n u i n g medical  long range b e n e f i t s i n that i t "forced to  a s e r v i c e to  of  e d u c a t i o n a l l y sound programs were  r a t h e r than the r u l e i n terms of  Although occurred  to Sheperd  and  the  listing  c o n s t i t u t e s one  decade of the  e m e r g e n c e o f a number o f v e r y m o d e r n i d e a s nevertheless, according  of  and  graduate-  a q u a r t e r l y b a s i s , i t i s now  the  of  schools  the d e c i s i o n of  a i d to course  This  programs  term r e s i d e n c i e s " .  publishing a nation-wide  "Annual Course L i s t i n g " .  a  the  week o r l o n g e r p e r i o d s  r e p o r t was  as a n  states  p h y s i c i a n or  intimate instructor  short  this  the  months i n a r e g i o n o f  a v a i l a b l e , " b o t h as  t o a t t e n d , and  programs." as  this  A s s o c i a t i o n to begin  programs of c o n t i n u i n g e d u c a t i o n in  used i n ten of  groups w i t h p r o v i s i o n i n medical  r e l a t i o n s h i p s c h a r a c t e r i z e these The  r e p o r t of  that " i n - r e s i d e n c e type  c o u n t r y . . . O n e , two  i n h o s p i t a l s f o r b o a r d a n d / o r l o d g i n g , and student  The  t h a t : " U n d e r t h i s a r r a n g e m e n t , one  t e a m o f p h y s i c i a n s w o u l d s p e n d f r o m one circuit  programs.  the  from  19  One growing  major study of the e a r l y post-war  concern  e d u c a t i o n was  t h e 1949  D e i t r i c k - B e r s o n study  recommendations of t h i s  were t h a t :  1) c o u r s e s  p a r t i c i p a t e and increasingly be and  reflected  a  f o r the r o l e of the m e d i c a l s c h o o l i n c o n t i n u i n g m e d i c a l  survey of m e d i c a l s c h o o l programs i n c l u d i n g The  p e r i o d which  report related  s h o u l d be  t h e i r performance  located  designed be  ( 4 5 ) w h i c h was  national  continuing medical  education.  to c o n t i n u i n g medical so t h a t s t u d e n t s c a n  evaluated;  i n medical schools;  a  2) c o u r s e s  education  actively  should  be  3) m e d i c a l s c h o o l f a c u l t i e s  should  i n c r e a s e d t o m e e t t h e i n c r e a s i n g demands o f p o s t g r a d u a t e m e d i c a l e d u c a t i o n ; 4)  t h a t a c c u r a t e c o s t s s h o u l d be  determined.  P r o b a b l y t h e most comprehensive c o n t i n u i n g m e d i c a l e d u c a t i o n was  and  attendance  s i g n i f i c a n t n a t i o n a l study  that undertaken  A s s o c i a t i o n b e t w e e n 1 9 5 2 - 1 9 5 5 b y D. producers  and  Vollan.  f o r the American  Medical  This study included both  consumers w i t h i n f o r m a t i o n c o l l e c t e d  b y o v e r 200  persons  i n programs  institutions  t h r o u g h a q u e s t i o n n a i r e s u r v e y o f 5,000 r e s p o n s e s  from  physicians.  The  study  summarized as 1.  recommendations of t h i s  of  and o r g a n i -  z a t i o n s , and  m a j o r c o n c l u s i o n s and  the  through o b s e r v a t i o n ,  a t c o u r s e s , i n t e r v i e w s w i t h m o r e t h a n 400  c o n t i n u i n g medical education sponsored  on  practising are  follows:  Postgraduate Medical Education Lacks  Direction:  . . . I f postgraduate medical education i s to develop soundly i t i s e s s e n t i a l t o have the major purpose c l e a r l y .understood, the s p e c i f i c o b j e c t i v e s d e l i n e a t e d , l o n g range p l a n s to o b t a i n the . g o a l s , and e f f e c t i v e l e a d e r s h i p . 2.  General P r a c t i t i o n e r s are Neglected: ...The g r e a t e s t s i n g l e n e e d i n t h i s f i e l d t o d a y i s f o r m o r e a n d better refresher courses f o r general p r a c t i t i o n e r s . These s h o u l d be p l a n n e d s p e c i f i c a l l y f o r them i n c o - o p e r a t i o n w i t h l o c a l general p r a c t i t i o n e r groups.  3.  Q u a l i t y of Courses i s not C o n s i s t e n t : . . . T h i s i s l a r g e l y due t o u n d u e e m p h a s i s o n e n r o l l m e n t f i g u r e s , h a p h a z a r d p r e p a r a t i o n o f c o u r s e s and t h e p r a c t i c a l l i m i t a t i o n s that often obstruct educational ideals. T h i s m a l a d y c a n o n l y be  20  c o r r e c t e d by an e m p h a s i s on: a) c a r e f u l s e l e c t i o n o f f a c u l t y and d e f i n i t e r e s p o n s i b i l i t y o f f a c u l t y f o r p o s t g r a d u a t e education; b) s y s t e m a t i c e v a l u a t i o n o f p o s t - g r a d u a t e t e a c h i n g methods; and c ) e v e n t u a l l y , some f o r m o f a c c r e d i t a t i o n p r o c e d u r e s may b e n e c e s s a r y i n t h i s f i e l d . 4.  Many P h y s i c i a n s , D o N o t C o n t i n u e T h e i r E d u c a t i o n : ...The b e s t p o t e n t i a l c u r e f o r t h i s c o n d i t i o n i s a n i m p r o v e m e n t i n t h e d i r e c t i o n and q u a l i t y o f p o s t g r a d u a t e c o u r s e s s o a s t o a t t r a c t t h e s e p h y s i c i a n s . The o t h e r f a c t o r s t o be c o n s i d e r e d include: a) a r r a n g i n g p a t i e n t c o v e r a g e w h i l e t h e p h y s i c i a n i s a w a y ; b) f i n d i n g w a y s t o a t t r a c t t h e p h y s i c i a n ; f o r e x a m p l e , c e r t i f i c a t e , c o m p u l s o r y a t t e n d a n c e ; and c ) d e v e l o p i n g t h e a t t i t u d e and h a b i t o f l i f e l o n g l e a r n i n g i n t h e u n d e r g r a d u a t e .  5.  P h y s i c i a n ^ Time i s L i m i t e d : ...The p r a c t i c e o f m e d i c i n e g e n e r a l l y c o n s u m e s 6 0 , h o u r s o r m o r e a w e e k . E v e r y e f f o r t s h o u l d be made t o u t i l i z e t h e t i m e t h e p h y s i c i a n can g i v e to c o n t i n u i n g m e d i c a l e d u c a t i o n .  6.  P o s t g r a d u a t e O p p o r t u n i t i e s a r e Too Few and M a l d i s t r i b u t e d : . . . 9 0 % o f t h e h o u r s a r e c o n c e n t r a t e d i n s i x s t a t e s and m o s t o f t h e s e a r e i n a few l a r g e c i t i e s . . . P o s t g r a d u a t e o p p o r t u n i t i e s s h o u l d be m o r e e q u i t a b l y d i s t r i b u t e d ( 2 5 6 ) .  E m e r g i n g f r o m V o l l a n ' s s t u d y w e r e a number o f i m p o r t a n t i t e m s , n o t a b l y a Guide Regarding  O b j e c t i v e s and  Education Programs. the statement Other Darley  Basic Principles  of Continuing M e d i c a l  T h i s p u b l i c a t i o n , w i t h m i n o r r e v i s i o n s , now  of standards  f o r the f i e l d  (70) , D r y e r  ( 7 9 ) , and  Storey  as  of c o n t i n u i n g medical education  i m p o r t a n t r e p o r t s t h a t f o l l o w e d V o l l a n ' s s t u d y , were those (237) , a l l o f w h i c h  plan for continuing medical education.  Although  the establishment of a " u n i v e r s i t y without  f o c u s s e d on a  o f f e r a sound  walls."  (65).  by national  the recommendations of  r e p o r t s have not been implemented, they c o l l e c t i v e l y for  serves  these  framework  21  CHAPTER I I I P A R T I C I P A T I O N I N CONTINUING  Organized  EDUCATION  s y s t e m a t i c programs f o r t h e c o n t i n u i n g e d u c a t i o n o f  p h y s i c i a n s a r e n o t n e c e s s a r i l y a new d e v e l o p m e n t b u t t h e t r e m e n d o u s g r o w t h i n o p p o r t u n i t i e s and i n t e r e s t has o c c u r r e d r e c e n t l y . definitive  study of the educational a c t i v i t i e s  b e e n a number o f a t t e m p t s  o f p h y s i c i a n s y e t t h e r e have  t o a s s e s s t h e amount o f p a r t i c i p a t i o n a n d t h e  degree of p h y s i c i a n i n t e r e s t . physicians i n defining  A s y e t t h e r e h a s b e e n no  Some s u r v e y s h a v e a t t e m p t e d  t h e i r own f e l t  to involve  l e a r n i n g n e e d s , and as w e l l ,  t h e i r o p i n i o n s w i t h r e g a r d s t o how t h e s e n e e d s m i g h t b e s t b e m e t . studies disclose  that postgraduate  g a i n i n g new m e d i c a l k n o w l e d g e  attendance a steady While  rate  a more o p t i m i s t i c  The o f t q u o t e d  are at variance with  thirty  to f i f t y  percent  i n c r e a s e may n o t a c c u r a t e l y d i s t i n g u i s h  t h e number o f i n d i v i d u a l  that physician participation  p r o b a b l y somewhat g r e a t e r t h a n h a s b e e n g e n e r a l l y a s s u m e d N e v e r t h e l e s s , many m e d i c a l e d u c a t o r s  a h a r d c o r e o f p h y s i c i a n s who n e v e r p o s t g r a d u a t e work and w i l l On t h e o t h e r h a n d , p o l l s  avail  express  themselves  n o t , unless attendance  reveal  indicate  the past several years (54).  physicians attending formal courses, i t i s f e l t is  time,  (263) (117) ( 3 7 ) . Recent r e p o r t s from m e d i c a l s c h o o l s  increase i n enrollment f i g u r e s over  this  Most  ( 8 3 ) ( 2 0 0 ) ( 2 5 6 ) ( 1 1 7 ) b u t , a t t h e same  estimates of t e n t o twenty-five percent attendance suggest  solicit  c o u r s e s a r e r a t e d h i g h l y a s a means o f  t h e a c t u a l e x t e n t o f p h y s i c i a n p a r t i c i p a t i o n i s n o t known.  recent surveys which  to  concern  (6) (37) that there  (50). remains  of opportunities f o r  i s made m a n d a t o r y  that the majority of p r a c t i t i o n e r s  (6) (263). are of  22  the o p i n i o n that attendance concerned  of Practice; that specialists  d e v o t e more t i m e t o c o n t i n u i n g  m e d i c a l e d u c a t i o n t h a n do g e n e r a l p r a c t i t i o n e r s i s reported that s p e c i a l i s t s  (42) (185) (256) ( 1 7 7 ) ,  spend a p p r o x i m a t e l y 5 p e r c e n t o f t h e i r  w e e k i n some f o r m o f t e a c h i n g a n d / o r r e s e a r c h , w h e r e a s g e n e r a l are said Vollan  condition  (254) (260).  Most s t u d i e s i n d i c a t e  it  and " t h e y a r e  b y t h e m o u n t i n g p r e s s u r e t o make c o n t i n u i n g e d u c a t i o n a  for practice" Field  s h o u l d be a v o l u n t a r y m a t t e r  t o engage i n a l m o s t no f o r m a l t e a c h i n g a c t i v i t i e s  (256) a t t r i b u t e d  these d i f f e r e n c e s , i n p a r t ,  (185) found  interneship  no s i g n i f i c a n t  and subsequent  A recent C a l i f o r n i a  typical  practitioners  (258) (127)  Carolina  r e l a t i o n s h i p between t h e l e n g t h o r type o f  postgraduate survey  study  (37) found  habits. t h a t when a d e t a i l e d  analysis  o f s p e c i a l t y p r a c t i c e was u n d e r t a k e n ,  a high percentage  n o n - p a r t i c i p a n t s were found  specialties, notably psychiatry,  i n select  anesthesiology, neurosurgery, t i o n e r s expressed greater interest revealed  of the d i s s a t i s f i e d  and o t h e r s u b - s p e c i a l t i e s , w h i l e g e n e r a l  practi-  g r e a t e r s a t i s f a c t i o n w i t h c o u r s e s a t t e n d e d , and d i s p l a y e d i n planned  programs o f c o n t i n u i n g e d u c a t i o n .  that some"specialists,p a r t i c u l a r l y  internists  This  and s u r g e o n s  than those i n general surgery) attended courses o f t e n .  The I n d i a n a  (117)  between  and  (42).  to the longer period of  f o r m a l e d u c a t i o n r e q u i r e d f o r s p e c i a l t y p r a c t i c e , however, the N o r t h study  Further,  d i s c l o s e d no s i g n i f i c a n t  difference  i n attendance  study (other survey  generalists  specialists.  Practice  Arrangements: Although  i t i s g e n e r a l l y assumed t h a t group p r a c t i c e  encourages  p a r t i c i p a t i o n i n c o n t i n u i n g e d u c a t i o n , r e s e a r c h f i n d i n g s do n o t s u p p o r t  this  work  23  assumption.  At least two studies (37)(185) disclosed that while physicians  i n group p r a c t i c e were s l i g h t l y better able to attend programs than were those i n i n d i v i d u a l p r a c t i c e , the difference i n p a r t i c i p a t i o n was not s t a t i s t i cally significant.  In f a c t , one study found that while costs deterred  r e l a t i v e l y more physicians i n solo practice from attending as many programs as they would l i k e , more respondents i n group arrangements said they limited t h e i r attendance because of d i f f i c u l t i e s getting away from t h e i r p r a c t i c e s . Storey (237) notes that while 37 percent of the physicians mentioned too many patients as an obstacle to course attendance, only 21 percent l i s t e d the absence of a substitute physician as an obstacle.  He a t t r i b u t e s this seeming  inconsistency to the t r a d i t i o n a l North American concept of "medical care as a personalized service provided by the private p r a c t i t i o n e r himself, and which therefore, cannot be e a s i l y delegated to others." On the other hand., a recent survey by the Canadian Medical Association (196) provides some i n t e r e s t i n g figures r e l a t i v e to group practice and continuing education.  As shown i n Table I, these data suggest that group  practice promotes not only post graduate study, but even more important, i t provides a great v a r i e t y of less formal but ongoing opportunities f o r learning continuously. TABLE I.  QUALITY OF CARE PROCEDURE IN GROUPS (Canada, 1967)  FEATURES OF GROUPS  NO.  PERCENT  Total number of groups Member s e l e c t i o n Supervision of new members C l i n i c a l Conferences Frequent consultations Postgraduate study Reference l i b r a r y  246 240 204 151 239 226 160  100 98 83 61 97 92 65  SOURCE: Report of the Committee on the Healing Arts; Volume 3, Table 29.5; p. 171. (196)  24  M e n z e l , K a t z , and drugs occurred offices, (185) as  on  C o l e m a n (154)  t h e a v e r a g e .of two  t h a n where d o c t o r s  found that p h y s i c i a n s  a convenient  and  at formal  courses,  months s o o n e r where p h y s i c i a n s  practised along.  Both Clute  (46)  and  of  new  shared Peterson  themselves f r e q u e n t l y mentioned group p r a c t i c e  inexpensive  p r a c t i c e a r r a n g e m e n t s may  d i s c l o s e d that the adoption  not  means o f c o n s u l t a t i o n .  n e c e s s a r i l y be  i t appears to p r o v i d e  organized  Thus, w h i l e to m a x i m i z e  c o n d i t i o n s conducive to  group attendance  continuous  learning. • L o c a t i o n of P r a c t i c e : A l t h o u g h p h y s i c i a n s p r a c t i s i n g i n r u r a l a r e a s no more d i f f i c u l t y the  i n arranging  community does not  continuing education. that physicians o f t e n t h a n do they  a t t e n d p r o g r a m s , an  i n Smaller c i t i e s  several studies and  areas,  than t h e i r m e t r o p o l i t a n  consultations available, while c o u r s e a t t e n d a n c e f o r new  Vollan  (256)  and  Peterson  i n continuing  size  of  and,  peers  (37)  (185)  attend  when t h e y (37).  i n f o r m a t i o n and  (185)  in  reveal  courses more do  attend,  R i s i n g et a l to  greater  t o t h e number o f p r o f e s s i o n a l  t h o s e i n s m a l l e r c o m m u n i t i e s must depend more professional contacts.  made s i m i l a r o b s e r v a t i o n s .  t h a t p h y s i c i a n s p r a c t i s i n g i n the year  (256)  somewhat l o w e r a t t e n d a n c e i n l a r g e r c i t i e s  d e p e n d e n c e on h o s p i t a l s t a f f m e e t i n g s a s w e l l a s  on  i n c r e a s e i n the  outlying distrieLs  those i n l a r g e r metropolitan  a t t r i b u t e d the  experience  necessarily correlate with increased participation Conversely,  a r e more s a t i s f i e d  (204)  to  doubt  largest cities  Both  They a l s o  found  averaged the most h o u r s  per  education.  Y e a r s of P r a c t i c e : Age  a p p e a r s t o be  continuing medical an a g e  an  education.  important  v a r i a b l e r e l a t e d to p a r t i c i p a t i o n  Both V o l l a n  r e l a t e d p a t t e r n of p a r t i c i p a t i o n ,  (256)  and  Peterson  c h a r a c t e r i z e d by  (185)  a gradual  in  disclosed increase  25  in  the percentage  of  years  of physicians attending postgraduate  i n practice  declining  i n c r e a s e d , r e a c h i n g a peak i n t h e f i f t h  thereafter.  (15). Appel concluded  that this  years ago" ( 6 ) . in  few years  Others  today  to the r e a l i z a t i o n by  t h a t they cannot  "coast  i n p r a c t i c e as c o u l d t h e i r p r e d e c e s s o r s  suggest  basic medical education  a t f o r m a l courses (177)  trend i s related  younger p h y s i c i a n s s t a r t i n g out i n p r a c t i c e along f o r the f i r s t  decade and  More r e c e n t r e p o r t s r e v e a l a s i m i l a r p a t t e r n b u t w i t h  y o u n g e r p h y s i c i a n s a v e r a g i n g more r e g u l a r a t t e n d a n c e (37)  c o u r s e s a s t h e number  that this  (37)  twenty  t r e n d may b e d u e m o r e t o d e f i c i e n c i e s  (15).  OPINIONS-AND PREFERENCES Numerous s t u d i e s h a v e s o u g h t  some m e a s u r e o f t h e p h y s i c i a n ' s  a t t i t u d e s about c o n t i n u i n g e d u c a t i o n and attempted the p r o v i s i o n s  o f p r o g r a m s w h i c h may e n c o u r a g e o r i n h i b i t  These i n c l u d e such m a t t e r s and  content.  participation.  as f e e s , s c h e d u l i n g , i n s t r u c t i o n a l  Most o f these f a c t o r s  programs, consequently in  to identify factors i n  the findings  l i ewithin from  processes  t h e domain o f those p r o v i d i n g  surveys can provide clues u s e f u l  planning.  Deterrents to Attendance: The  major o b s t a c l e t o a t t e n d i n g programs o f c o n t i n u i n g e d u c a t i o n i s  the i n a b i l i t y with courses (34)  t o l e a v e a busy p r a c t i c e , r a t h e r than g r o s s  dissatisfaction  a t t e n d e d , o r lack o f a v a i l a b l e e d u c a t i o n a l o p p o r t u n i t i e s (37)  (39) (117).  As m i g h t be e x p e c t e d ,  greatest d i f f i c u l t y  i n getting  general practitioners  away f o r a d d i t i o n a l s t u d y  experience the  (37) (200) (117).  A t t h e same t i m e , t h e y e x p r e s s a g r e a t e r n e e d f o r i t t h a n do  specialists  26 who  a r e more l i k e l y  alternate routes.  to f e e l One  t h a t they can get needed i n f o r m a t i o n t h r o u g h  study  ( 3 7 ) o f n o n - p a r t i c i p a n t s r e v e a l e d t h a t 81  of those p h y s i c i a n s i n s u r g i c a l gave "get  specialties  i n f o r m a t i o n from o t h e r s o u r c e s " as  a t t e n d i n g , w h i l e o n l y 30 p e r c e n t reason. "time  The  primary reason  committed Other  factory  and  to  60 p e r c e n t i n m e d i c a l  of the general p r a c t i t i o n e r s  f o r n o n - p a r t i c i p a t i o n g i v e n by  listed  the  t h i s group  same  was  patients."  deterrents to attendance  mentioned  by p h y s i c i a n s i n c l u d e d u n s a t i s -  (37)  (117); l a c k of awareness of courses a v a i l a b l e  felt  h i m s e l f t o be  adequately  informed  and  not  ( 3 9 ) ; and,  (229)  (197)  t h a t the p h y s i c i a n  i n need of f u r t h e r  study.  Stipends: Most p h y s i c i a n s p r e f e r J  _ j.. x-j c u u t d L i u u  is,  specialties  t h e i r primary reason f o r not  scheduling of programs; c o s t s ; u n s u i t a b l e s u b j e c t matter  F e e s and  percent  - j  ctnu a.i.c uus,  auveise  t o assume r e s p o n s i b i l i t y LU  L U I L I U U  c J-CCO  /ncr\\  J  \~> i )  however, l e s s agreement w i t h r e s p e c t to r e c e i v i n g  f o r course  attendance.  In the C a l i f o r n i a  f o r t h e i r own  survey  /irv/.A )  /tens \x.\jy  financial  Surgeons were l e a s t  I n New  d i s a p p r o v e d o f s t i p e n d s , 11 p e r c e n t a p p r o v e d ,  •  ( 3 7 ) , 39 p e r c e n t o f  i n favour of f i n a n c i a l  g e n e r a l p r a c t i t i o n e r s were most i n f a v o u r .  mi j  and  mcic  remuneration  w e r e somewhat i n f a v o u r o f s t i p e n d s , 32 p e r c e n t d i s a p p r o v e d , and indifferent.  continuing  respondents  the r e s t  were  assistance, while  J e r s e y ( 9 9 ) , w h i l e 40 49 p e r c e n t d i d n o t  percent  respond  to the q u e s t i o n . S c h e d u l i n g of  Programs:  Physicians are overwhelmingly l a s t i n g one indicate  week o r l e s s  (233)  (99)  i n favour of concentrated short (260)  (266)  (37)  (256)  t h a t e i t h e r w e e k - e n d o r e v e n i n g p r o g r a m s w o u l d be  to a t t e n d , but  e x p r e s s a p r e f e r e n c e f o r week-ends  (37)  (6)  (107).  courses  Most  '  relatively  easy  (169).  two  In  27  s u r v e y s p r a c t i t i o n e r s gave as t h e i r Thursday  combination  held i n their  local  major a problem (185). to  Vollan  (233)  (114).  communities  first With  (117)  c h o i c e , Wednesday o r  few e x c e p t i o n s , t h e y p r e f e r  (266)  (99)  (20) b u t  found  Opinions  d i f f e r w i t h regards  t h e c o u r s e was  a university medical center  (233)  (192)  Others would l i k e programs brought  Long term programs a r e not endorsed T h e r e i s some i n d i c a t i o n the p o t e n t i a l worth (107). to  I n one  study  local hospital  one.  preference  (192) (192)  (117)  ( 6 ) , or (37) .  (200).  as u n i f o r m l y as a r e s h o r t c o u r s e s .  t h a t p h y s i c i a n s a r e i n c r e a s i n g l y becoming aware of  of l e n g t h i e r i n — h o s p i t a l  type t r a i n i n g programs  ( 3 7 ) , t h r e e t o s i x month c l i n i c a l  Similarly,  38 p e r c e n t o f t h e r e s p o n d e n t s o v e r a p e r i o d o f f r o m one  i n a very recent survey  f a v o u r e d an extended  (6)  (192)  t r a i n e e s h i p s , and  t h r e e week i n s e r v i c e p r o g r a m s w e r e c o n s i d e r e d i m p o r t a n t by  f a m i l i a r w i t h them.  short  Many d o c t o r s  (20), a l o c a l hotel  to t h e i r  willing  hence g i v e f i r s t  r e s o r t a r e a s where they can combine e d u c a t i o n w i t h r e c r e a t i o n  as  patients"  a relatively  to the p l a c e of meeting.  p r e f e r t o l e a v e -the i n t e r r u p t i o n s o f p r a c t i c e and to  to h i s  t h a t t w o - t h i r d s of the p h y s i c i a n s were  t r a v e l 100 m i l e s o r m o r e , a s l o n g a s  courses  d i s t a n c e i s not  as t h e p h y s i c i a n s ' f e e l i n g o f r e s p o n s i b i l i t y (17)  a.Wednesday-  (169)  t h o s e who of  intermittent  one were  psychiatrists, course  offered  to n i n e months.  Sponsors: Specialty education courses with  (42)  s o c i e t i e s r e p r e s e n t an i m p o r t a n t s o u r c e o f c o n t i n u i n g  (117)  sponsored  by  (197)  (99) .  specialty  According to the C a l i f o r n i a  below these w i t h l o c a l medical s o c i e t i e s indicated  (37),  s o c i e t i e s were r a t e d most h i g h l y by p h y s i c i a n s ,  t h o s e by m e d i c a l s c h o o l s r a t e d s e c o n d .  the respondents  survey  Other  agencies  rated last.  ranked c o n s i d e r a b l y  Approximately  a lack of f a m i l i a r i t y w i t h courses  41  percent  co-sponsored  by  28  medical  schools  a n d h o s p i t a l s , a n d 38 p e r c e n t  sponsored by h o s p i t a l s  were n o t . f a m i l i a r w i t h  alone.  In contrast, a recent  survey  Commission f o r Higher Education  (200) co-sponsored by t h e Western I n t e r s t a t e  and t h e M o u n t a i n S t a t e R e g i o n a l  ( h e r e i n a f t e r r e f e r r e d t o a s t h e WICHE s t u d y ) d i s c l o s e d t h a t states, with  the exception  s o c i e t i e s ranked third;  first;  and medical  no  fourth.  Wenrich  a medical  s o c i e t i e s and n a t i o n a l o r g a n i z a t i o n s schools.  Lectures,  touch with  seminars, c l i n i c  technique  physicians  instructional  teaching  processes.  films, (200)  l e c t u r e has been c r i t i c i z e d rate i t f i r s t  symposia, (99)  as a d i d a c t i c ,  i n their  list  Some p h y s i c i a n s i n  t h i s was b e c a u s e " g r o u p d i s c u s s i o n s a n d  were o f t e n d o m i n a t e d b y more v o c a l d o c t o r s  reflect  the i n t e r e s t s of the group."  i n d i c a t e t h a t t h e exchange o f i d e a s  conversations  w i t h p e e r s c a n be an i m p o r t a n t  (212)  Two s t u d i e s s u g g e s t t h a t  (263).  conflict.  reality."  (169) (37) (177) (233) (239).  (61) i n d i c a t e d t h a t  periods  necessarily  the physician  and a p p r o v e d b y most  i n a number o f s t u d i e s , d o c t o r s  techniques  Ruhe's s u r v e y question  of programs,  demonstrations, educational  Although the t r a d i t i o n a l  of p r e f e r r e d  clinical  that  seem t o p r e f e r t h e m o r e f a m i l i a r  grand rounds, a r e g e n e r a l l y f a m i l i a r  passive  are rated  Processes  panels,  (114).  that  While these d i f f e r e n c e s a r e  many r e s p o n d e n t s w e r e o f t h e o p i n i o n  Physicians  (233)  societies  ( 2 6 3 ) (42)  to regional v a r i a t i o n i n the a v a i l a b i l i t y  s c h o o l had " l o s t  Instructional  and  medical  ( 2 6 3 ) s u g g e s t s t h a t i t may a l s o b e r e l a t e d t o t h e "town-gown"  In h i s study, in  Other s t u d i e s a l s o r e v e a l  t h a n those sponsored by m e d i c a l  Program  i n the mountain  h o s p i t a l programs second; s t a t e m e d i c a l  schools  doubt due i n p a r t  Medical  o f Nevada, programs sponsored by l o c a l  programs sponsored by m e d i c a l higher  courses  who d i d n o t  On t h e o t h e r  and i n f o r m a t i o n  h a n d , many i n informal  reason f o rattending  supervised  clinical  courses  p r a c t i c e , which i s  29  r a r e l y used a t p r e s e n t , i s g a i n i n g i n p o p u l a r i t y (37) Physicians a l s o express  interest  i n t h e newer u s e s o f t h e mass m e d i a  such  as t e l e v i s i o n , r a d i o , and r e c o r d i n g s , b u t t h e y  than  t h e p e r s o n a l c o n t a c t methods  b e due i n p a r t t o t h e f a c t regions  (200).  tend  (37) (117) ( 2 6 3 ) .  t o r a t e them  While  lower  this rating  t h a t these media are not always a v a i l a b l e  may  in a l l  (200) (99) (39) ( 2 1 2 ) , i n C a l i f o r n i a , where a l l t h r e e m e d i a a r e used  extensively  i n continuing medical  education, responses  indicate  that  they  a r e p e r c e i v e d b y p h y s i c i a n s a s s u p p l e m e n t a r y when m e a s u r e d a g a i n s t t h e t o t a l s p e c t r u m o f a v a i l a b l e methods and t e c h n i q u e s ( 3 7 ) . According  t o a number  i n s t r u c t i o n i s correspondence programmed In  o f s u r v e y s , t h e l e a s t p o p u l a r method o f study  ( 1 9 2 ) ( 3 7 ) ( 2 0 ) . One s t u d y  i n s t r u c t i o n was w e l l r e c e i v e d general, specialists  ward rounds,  compatible courses term  specialties.  General  clinical  teaching  (42) (117).  listed  However,  among t h o s e  of the  p r a c t i t i o n e r s p r e f e r t h o s e methods more  w i t h a busy p r a c t i c e .  i n medical  f o r reading,  applied techniques  there are considerable d i f f e r e n c e s i n the preferences different  that  (263).  indicate a preference  and o t h e r more c l i n i c a l l y  found  They r a t e t h e mass m e d i a and b e d s i d e  schools r e l a t i v e l y  clinical  h i g h , as opposed t o r e a d i n g and l o n g  traineeships (37).  Younger p h y s i c i a n s f a v o u r more p a r t i c i p a t i o n are also better acquainted more d i s c r i m i n a t i v e  w i t h the d i f f e r e n t  i n evaluating their  (200) (117) ( 3 7 ) .  teaching techniques  They  and a r e  e f f e c t i v e n e s s . - Thus i n t h e C a l i f o r n i a  survey, w h i l e younger p h y s i c i a n s tended  to r a t e short courses  o l d e r p h y s i c i a n s , they were l e s s  t o c o n s i d e r them a p p l i c a b l e t o a l l  subject matter  t h a n were t h e i r  w h i c h was r a n k e d  fairly  likely  elders.  h i g h , they  than d i d t h e i r o l d e r c o l l e a g u e s .  With  considered  higher  than  the exception of audio-digest t h e mass m e d i a l e s s  effective  30  Felt Learning  Needs:  Surveys d i s c l o s e immediately (212) is  (84)  p r a c t i c a l and (37).  The  that psychiatrist  (258)  (34)  courses  t h a t p h y s i c i a n s want s u b j e c t m a t t e r  (229).  t e a c h e r s do n o t u n d e r s t a n d  Studies suggest  (229)  was  that physicians attending  (233).  to increase t h e i r  In short, p r a c t i t i o n e r s  skills  54  percent  given to recent  of  the respondents  innovations i n medical  m o r e p r e v a l e n t among g e n e r a l i s t s a n d amongst s u r g e o n s  those  felt  unusual  i n medical  are of  coverage of s e v e r a l s u b j e c t s  in  the b a s i c s c i e n c e s  In  one  procedures  (37) (126).  This opinion specialties  o r two  (126)  was  than  topics i n  (192)  (107)  some 90 p e r c e n t  (37), but  In another  of the respondents  study  were i n f a v o u r o f more s u c h  t h e r e i s no  (107).  continue  t o be  approximately  refresher  courses this.  that basic sciences  o f f e r e d , but  69 p e r c e n t  courses, with s p e c i a l i s t s  a b l e , w h i l e g e n e r a l p r a c t i t i o n e r s were l e a s t  even  g e n e r a l a g r e e m e n t on  felt  depth,  (37).  that p r a c t i t i o n e r s would l i k e  r e s e a r c h programs should  (107).  (245)  i n common  t h i s o p i n i o n more o f t e n t h a n a r e g e n e r a l i s t s , b u t  T h e r e i s some e v i d e n c e  degree  (217)  developments  techniques.  g e n e r a l i s t s p r e f e r more i n t e n s i v e c o v e r a g e o f c o n t e n t  clinical  treat  (37).  r a t h e r than a broad  study  and  that i n s u f f i c i e n t a t t e n t i o n  P h y s i c i a n s a l s o w a n t p r o g r a m s t o d e a l w i t h one  Specialists  problems  postgraduate  a r e more i n t e r e s t e d  t h i s d o e s n o t mean t h a t t h e y w o u l d i g n o r e new  study,  situation  i n communication  p r o b l e m s r a t h e r t h a n e s o t e r i c d i s e a s e s and  (190), but one  their practical  i n p s y c h i a t r y want t o l e a r n c o n c r e t e ways t o d i a g n o s e  medical  In  a p p l i c a b l e to t h e i r p a r t i c u l a r p r a c t i c e  m o s t common c r i t i c i s m o f n o n - p s y c h i a t r i s t p h y s i c i a n s  p a r t i c u l a r p a t i e n t s , and (36)  which i s  interested  to a  of the  i n medicine (37).  and  lesser  respondents more  favour-  31  At least two studies suggest that physicians would also l i k e more courses dealing with medico-social problems, notably i n the areas of "physicianpatient r e l a t i o n s h i p s , " and medico-legal  problems (67) (37).  According to the C a l i f o r n i a report (37) , the subject matter most frequently requested by physicians r e l a t e s to the diagnosis and treatment of disease. is  Moreover, physicians' i n t e r e s t pertaining to medical  conditions  to a considerable extent s p e c i f i c to t h e i r area of s p e c i a l i z a t i o n and  place of p r a c t i c e (42) (229) (20). that while endocrinopathies arrythmias  Thus, i n the Utah study  (42) i t was found  rated highest among a l l groups, and cardiac  second, these were ranked very low by surgeons.  Similarly, i n  one area where the socio-economic l e v e l of the population was higher, a l l physicians displayed a greater i n t e r e s t i n p s y c h i a t r i c subjects than did those from l e s s prosperous areas.  When i n d i v i d u a l practices were examined,  great v a r i a t i o n s occurred .in the physicians' perceptions of t h e i r learning needs. The Utah (42) and the WICHE (200) studies indicated there was l i t t l e c o r r e l a t i o n between a physician's expressed  learning needs and those conditions  most frequently encountered i n medical p r a c t i c e .  Of a l l groups, generalists  were found to be the most r e a l i s t i c i n r e l a t i n g educational needs to p r a c t i c e problems.  At the same time, i t was observed that a great deal of the  p r a c t i t i o n e r ' s time was spent i n treating minor ailments which could have been delegated  to medical a s s i s t a n t s .  Other Information  Sources:  Harris reviewed the published research on the u t i l i z a t i o n of medical communication sources  (111) and concluded  that the majority of doctors were  acquiring their medical information through v i s i t s from the pharmaceutical  32  r e p r e s e n t a t i v e , d i r e c t m a i l , drug sample l i t e r a t u r e , m e d i c a l c o n s u l t a t i o n w i t h c o l l e a g u e s , and formal  courses.  change. (117) with  (263)  c o l l e a g u e s , and  these  (15)  t h e d e t a i l man  (265), medical  most p h y s i c i a n s use  cal  and  survey  rating in  by  general content  At  the  less valuable  literature,  consultation  extensively  necessarily find  them t o o  C a r o l i n a study  (185),  t h e m o s t common  criticism  p r a c t i t i o n e r s was  that medical  too r e l e v a n t to medical  Hamburg  (109)  o f g e r i p T ^ l i s t s have not -  p r a c t i c e and  literature  of urology.  his interest  journals.  characteristics  useful  practice.  c h a n g e d , w i t h o v e r 50 as  of l i t t l e  Nonetheless,  i n seeking  use  Peterson  new  A more  and  as  the  a source  of  information  his colleagues  q u a l i t y of a  study  (263)  i s both l i m i t e d  a s h a v e many o t h e r s only p a r t i a l l y  on and  the use limiting  subsequently,  p h y s i c i a n s who  respondsn  (185)  identifying  of  (275), Peterson  "that basic medical  were  physician's  i n one  of  the  small  written  sought t h e i r  of i n f o r m a l sources (150)  time,th  of  discussion with related health  s i o n a l s i n the h o s p i t a l than d i d those research  recent  percent  or e d u c a t i o n a l i n f l u e n t i a l s  i n f o r m a l c o n s u l t a t i o n s , and  Although  theoreti-  knowledge through the purchase  S i m i l a r l y , Wenrich's p i l o t  of "gatekeepers"  j o u r n a l s were too  c o m m u n i t y h o s p i t a l f o u n d t h a t s u c h p h y s i c i a n s r e l i e d much m o r e o n  learning  may  suggests that d e s p i t e the passage of  t o show a p o s i t i v e c o r r e l a t i o n b e t w e e n t h e  sources,  by  same t i m e , w h i l e p h y s i c i a n s  do n o t  current medical  medical  little  they  not  by D o h n e r and  the f i e l d  able  (117).  through  (109).  the  opinions  (263)  been  as  p r o f e s s i o n a l meetings, are u t i l i z e d  (200)  I n the North expressed  i s generally perceived  journals, unsolicited  information sources,  (185)  p r o f e s s i o n a l meetings, r a t h e r than  Subsequent s t u d i e s s u g g e s t t h a t t h e r e has  Although  journals,  profesadvice.  continuing e_t a i l c o n c l u d e ,  education  has  been  successful i n i n c u l c a t i n g i n future p r a c t i t i o n e r s both  the  33  a b i l i t y and t h e d e s i r e t o seek out t h r o u g h a v a r i e t y of i n f o r m a l s o u r c e s , g r e a t e r knowledge and u n d e r s t a n d i n g o f m e d i c i n e throughout t h e i r lives"  (185).  professional  34  CHAPTER .  The education  ORGANIZATION  AND  IV ADMINISTRATION  r e c o g n i t i o n o f t h e n e c e s s i t y f o r and i m p o r t a n c e o f c o n t i n u i n g  has grown s t e a d i l y  participation  i s reflected  i n recent  years.  This  growth i n i n t e r e s t and  i n t h e i n c r e a s e d number o f c o u r s e s  reported  as  w e l l a s t h e i n v o l v e m e n t o f more and more i n s t i t u t i o n s  and o r g a n i z a t i o n s i n  the  practitioners.  sponsorship  with  of educational a c t i v i t i e s  f o r medical  t h e g r o w t h i n o p p o r t u n i t i e s a n d p a r t i c i p a t i o n h a s come  trends  Along  identifiable  i n t h e o r g a n i z a t i o n and a d m i n i s t r a t i o n o f c o n t i n u i n g e d u c a t i o n  programs.  ORGANIZATION A v a r i e t y of patterns  fnT  ed^^^tdein  sponsorship  Tnprixcine.  of o r g a n i z a t i o n are encountered  These p a t t e r n s  are determined  i n continuing  t c some e x t e n t  by t h e  of t h e program.  Numbers o f C o u r s e s a n d S p o n s o r s : The the past  number o f c o u r s e s  decade, w i t h an a v e r a g e i n c r e m e n t o f a p p r o x i m a t e l y  from 1961 t o 1970. over the preceding in  a v a i l a b l e t o p h y s i c i a n s has been i n c r e a s i n g over  I n ' 1 9 7 0 - 1 9 7 1 t h e r e was a n e v e n g r e a t e r year  t h e t o t a l number o f i n s t i t u t i o n s  presenting  this  increased  77 m e d i c a l and  societies,  percent  increase  courses.  sponsored or co-sponsored  courses  i n 1970-1971 (54) .  represented  These  s c h o o l s , 2 9 1 n o n - s c h o o l o r c o m m u n i t y h o s p i t a l s , 50 c i t y ,  state medical  general  t o 611 i n s t i t u t i o n s  per year  i n c r e m e n t o f 15  a n d t h i s was. a c c o m p a n i e d b y a n e q u a l l y s h a r p  I n 1 9 6 8 - 1 9 6 9 , 372 i n s t i t u t i o n s and  5 percent  66 s p e c i a l t y m e d i c a l  p r a c t i c e , 33 v o l u n t a r y h e a l t h a g e n c i e s ,  societies  county,  and academies o f  a n d 94 " o t h e r s , " i n c l u d i n g  TABLE  II  CONTINUING MEDICAL EDUCATION COURSES LISTED  Year  1961-62 1962-63 1963-64 1964-65 1965-66 1966-67 .1967-68 1968-69 1969-70 1970-71  Total Number of Courses Reported  1,105 1,146 1,2.64* 1,569 1,641 1,608 1,830 1,922 • 2,016 2,319  1961-1962 TO 1970-1971  Number of Primary Sponsors  206 208 267* 251 252 262 263 300 323 303  Courses Sponsored by Medical Schools Number Percent —  626 760* 857 863 910 1,000 1,024 886 813  55% 60% 55% 53% 57% 54% 53% 44% 35%  *Includes courses offered by f i v e Canadian schools not reported i n other years. SOURCE: J.A.M.A.,  214:1526 (November 1970).  Courses Sponsored by Hospitals Number Percent  104 163 265 351 338 224 370 441 374  9% 13% 16% 21% 21% 12% 19% 22% 16%  36  schools of p u b l i c h e a l t h , postgraduate medical s c h o o l s , p r i v a t e f o u n d a t i o n s , o r l o c a l and The  major producers  community h o s p i t a l s . o v e r one to  44  As  of courses have been the m e d i c a l s c h o o l s  noted  i n Table  I I , medical schools alone  f r o m 1961  percent  i n 1 9 6 9 - 7 0 and  t o 35 p e r c e n t i n 1 9 7 0 - 7 1 , m e d i c a l s c h o o l p r o g r a m s  t h e m o s t e x t e n s i v e i n t h a t t h e number o f c o u r s e s  agencies.  o f f e r e d by  other  C o u r s e C o n t e n t and  (59)  (61).  (61).  general medicine,  gynaecology  o r i e n t a t i o n , o v e r one  and  i n that  Other major f i e l d s w i t h a s u b s t a n t i a l pediatrics,  courses l i s t e d  Despite this  specialty  obstetrics,  B e c a u s e o f t h e v a r y i n g b a c k g r o u n d s and  differing  groups,  Ruhe (220)  t h a t the experience of m e d i c a l s c h o o l s d i s c o u n t s  concern  a s m e d i c a l s c h o o l c o u r s e s a r e more o f t e n d e s i g n e d  audience.  An  exception to t h i s  provide different (88)  (231).  offered course  might q u e s t i o n the wisdom o f t h i s ,  At  three course (88).  formats:  of  suited  the  learning  however, this  for a general  i s p s y c h i a t r y where t h e r e i s a tendency  l e v e l s of i n s t r u c t i o n  the U n i v e r s i t y  and  generalist  n e e d s o f t h e two notes  one  number  half  d u r i n g t h e p a s t f i v e y e a r s have been open t o b o t h  specialist.  to  hospitals  include surgery, pathology, opthalmology, (59).  twelve  t h e g r e a t e s t number o f c o u r s e s h a v e b e e n  i n i n t e r n a l m e d i c i n e , p s y c h i a t r y , and (54)  school  Eligibility:  For the past seven years  (52)  decreased  sponsoring  c o u r s e s p e r s c h o o l p e r y e a r , compared w i t h community courses per h o s p i t a l per year  this  o f f e r e d per  M e d i c a l schools are reported to average approximately  w h i c h a v e r a g e r o u g h l y two  offered  Although  produced  offered  thirteen  t o 1969.  and  of a l l courses  f a r g r e a t e r t h a n t h e number o f c o u r s e s  order  (61).  half  are s t i l l is  n a t i o n a l government a g e n c i e s  clinics,  t o the needs of  non-psychiatrists  of Southern  California, practitioners  a b a s i c , an  i n t e r m e d i a t e , and  an  to  are  advanced  37  While designed  i t i s impossible t o determine  for interprofessional education,  number i s s m a l l  (198).  the extent  t o which programs a r e  the general impression  One p r o g r a m w h i c h a p p e a r s s u i t a b l e  i s that the  t o an i n t e r d i s c i p l i n -  a r y approach i s t h e "Care o f t h e Premature I n f a n t " which o r i g i n a t e d a t C o r n e l l Medical and  Center  nurses  i n 1949 ( 1 9 ) .  T h i s p r o g r a m was d e s i g n e d  f o r teams o f p h y s i c i a n s  a n d t h e p r o g r a m m o d e l h a s b e e n u s e d i n a number o f c e n t e r s i n b o t h  Canada and t h e U n i t e d  States  (115)  (19).  More r e c e n t l y , s e v e r a l R e g i o n a l  M e d i c a l Programs have r e p o r t e d s u c c e s s f u l m u l t i p r o f e s s i o n a l programs on t h e "Management a n d R e h a b i l i t a t i o n p h y s i c i a n s , nurses involvement  of the Stroke P a t i e n t . "  and p h y s i c a l t h e r a p i s t s p r o v i d e  I n most o f t h e s e ,  t h e team n u c l e u s  of occupational therapists, rehabilitation  c o u n s e l l o r s , and o t h e r  e s s e n t i a l h e a l t h w o r k e r s where these a r e a v a i l a b l e and r e q u i r e d fields (20).  o f study  reporting occasional interprofessional efforts  and p u b l i c h e a l t h  with  (252).  Other  are psychiatry  (182).  P a t t e r n s o f Course O r g a n i z a t i o n In  t h e annual  listing  of courses  r e p o r t e d i n t h e A.M.A. J o u r n a l , t h e r e  are s i x major patterns of course o r g a n i z a t i o n : 1.  Continuous of hours,  2.  courses days,  a r e those  conducted  over  a consecutive  o r weeks, and u s u a l l y o f s h o r t d u r a t i o n .  I n t e r m i t t e n t courses  extend  over  a p e r i o d o f time w i t h a c e r t a i n  number o f h o u r s p e r week o r month d u r i n g t h a t courses  3.  Circuit  4.  Traineeships are c l i n i c a l l y programs r a n g i n g  5.  are presented  i n r u r a l areas  time. by t r a v e l l i n g  oriented in-hospital residency  i n l e n g t h from f i v e  Home S t u d y i n v o l v e s c o r r e s p o n d e n c e tape  number  faculty. type  days t o one y e a r .  s t u d y , programmed  r e c o r d i n g s and s i m i l a r a c t i v i t i e s  that enable  instruction,  t h ep h y s i c i a n  38  t o s t u d y i n h i s own  time.  6. T V - R a d i o c o u r s e s a r e s i m i l a r through  radio or t e l e v i s i o n  Of t h e s e s i x t y p e s , c o n t i n u o u s p a t t e r n as w e l l as t h e most p o p u l a r . these accounted  to continuous  t o p h y s i c i a n s a t home.  c o u r s e s a p p e a r t o be t h e m o s t common  In the four years reported i n Table I I I  f o r some 62.14 p e r c e n t i n 1966-67.  of a l l courses  o f 66.79 p e r c e n t  reached  courses  accounted  f o r 65.54 p e r c e n t o f a l l c o u r s e s  lasting  one week o r l e s s . Intermittent  courses but offered  D u r i n g 1969-70  i n 1964-65 w i t h a h i g h (59) t h e 1261  continuous  o f f e r e d w i t h 83.74  percent  c o u r s e s were t h e n e x t most f r e q u e n t p a t t e r n w i t h a h i g h  o f 31.42 p e r c e n t o f a l l c o u r s e s  i n 1964-65 b u t s h o w i n g a d e c l i n e  1 9 6 6 - 6 7 a n d a r e c o v e r y t o 30.95 p e r c e n t  i n 1969-70.  t o 26.86 p e r c e n t i n  I n t h a t .year t h e s e  courses  a v e r a g e d 31 1/2 h o u r s o f i n s t r u c t i o n a n d a p p e a r t o h a v e t h e p o t e n t i a l f o r p r o v i d i n g more c o n t i n u i n g i n s t r u c t i o n . P s y c h i a t r y makes t h e g r e a t e s t u s e o f i n t e r m i t t e n t it  i s felt  in  changing  s c h e d u l i n g where  that i n s t r u c t i o n extended over a longer p e r i o d of time i s e s s e n t i a l a t t i t u d e s and t e a c h i n g p s y c h i a t r i c  p e r c e n t of. a l l  psychiatric  throughout  courses are offered  few  extend  for  the poor o v e r - a l l attendance  busy p r a c t i t i o n e r s  the whole academic year  find  concepts.  C u r r e n t l y , over  70  i n t e r m i t t e n t l y , and o f t h e s e , a (59) .  T h i s i n p a r t may  account  (217) (245) ( 2 2 9 ) , s i n c e as p r e v i o u s l y  i t inconvenient to t r a v e l  noted,  l o n g d i s t a n c e s f o r a few  hours of i n s t r u c t i o n . Postgraduate publicity,  T r a i n e e s h i p s a r e o f f e r e d b y many h o s p i t a l s w i t h o u t  h e n c e t h e number r e c o r d e d  formal  i n t h e A n n u a l C o u r s e L i s t i n g s may n o t be  an a c c u r a t e r e f l e c t i o n o f what i s c u r r e n t l y  being offered  listed  on a f u l l  f o r 1969-1970 ( 5 9 ) , a l l were o f f e r e d  ( 5 9 ) . Of t h e 77  time b a s i s ranging i n  TABLE I I I PERCENTAGE D I S T R I B U T I O N OF CONTINUING EDUCATION COURSES BY T Y P E OF COURSE 1 9 6 4 - 6 5 TO  Type o f c o u r s e  Continuous Intermittent Circuit Traineeships Home S t u d y TV-Radio Not  Stipulated  1964 -65 Number Percent 975 493 17 55 9 13 1 1569  SOURCE':  J o u r n a l o f the American  62.14 31.42 1.08 3.50 .57 .82  100.00  !  1969-70  Year 1966--67 Number Percent  1968 -69 Number ! P e r c e n t  1074 432 4 65 16 14  66.79 26.86 .24 4.04 .99 .87  1264 555 15 54 19 12  65.76 28.87 .78 2.80 .98 .62  1261 624 14 77 14 12  3  .18  3  .15  8  .39  1608  100.00  1922  100.00  2016  100.00  1 9 6 9 -70 Number ! P e r c e n t 1 1 '  M e d i c a l A s s o c i a t i o n , 190:645, 198:232, 206:2051, 210:1523  62.54 30.95 .69 3.81 .69 .59  40  l e n g t h f r o m f i v e d a y s t o one dates,  the remaining  implying year.  61 s p o n s o r s  t h a t e n r o l l m e n t was  In a l l but  clinical to  Of  specialist  Fees v a r i e d g r e a t l y  f r o m no  o f K a n s a s and  of programs.  •  of program i s s a i d to expand  t o be  The  has  been suggested  a number o f m e d i c a l (8)  (35)  (10).  the  possible solution  (189).  the Veteran's  schools  to these problems  In t h i s  (47)  Pittsburgh  (61) for  plan, practising  physicians  f o r one  o f p r o v e n t e a c h e r s w o u l d be  to  twelve  assigned  to  invited  as  (74).  the o p e r a t i o n a l l e v e l ,  success  (44)  o r more o f  i n a d d i t i o n , o u t s t a n d i n g p r a c t i t i o n e r s w o u l d be  relative  of  u s i n g one  the Center  At  report  proposal c a l l i n g  A permanent s t a f f  clinicians  type  Major deterrents to  month p e r i o d s .  visiting  i n this  s u c c e s s f u l T u f t s r e g i o n a l program  w o u l d be. o f f e r e d f u n d e d t r a i n i n g p o s i t i o n s a t t h e C e n t e r  and,  variety  A program of p h y s i c i a n  of a N a t i o n a l Graduate Medical Center  Administration Hospitals.  in the  f a c i l i t i e s ; the c h r o n i c shortage  A n o t h e r s u g g e s t i o n i s Diamond's h i g h l y a m b i t i o u s  the establishment  schools, with  States, physician interest  offerings  groups.  e i g h t month e x p e r i e n c e  t h e g r e a t e s t n u m b e r and  i n c r e a s i n g , and  enrollment  r e m a i n d e r were open to b o t h  offering  h o u s e s t a f f exchange f a s h i o n e d a f t e r  (23).  limited  Maryland  and  one  academic  used i n a d d i t i o n to  s p e c i f y i n g , o n l y 10  l o s s of p h y s i c i a n income  as  the  were m e d i c a l  the United  course  arranged"  sponsors  t h e i r present  the  specific  of the  d a t e have been: the l a c k of u n i v e r s i t y p h y s i c i a n s ; and  provided  i n s t r u c t i o n was  f e e , t o $ 2 , 3 5 0 f o r one  Universities  C a n a d a and  sponsors  t h e s c h e d u l i n g t o "be  sponsors  or g e n e r a l i s t .  O v e r 80 p e r c e n t  both  left  16  n e g o t i a b l e anytime throughout  t h e 68  pediatrics.  In  While  three cases, planned  experience.  either  plans  year.  at Dalhousie  ( 1 8 6 ) , and  a p l a n w h i c h has  University  more r e c e n t l y , b y  in Halifax  been implemented  with  (67) , S t a u n t o n  Clinic  the Washington/Alaska  Regional  in  Medical  41 Program  (71), i s a t r a i n e e s h i p o f f e r e d on a p a r t - t i m e  over a f a i r l y long period Program has organized  o f time.  basis but extending  The W a s h i n g t o n / A l a s k a R e g i o n a l  a postgraduate preceptorship  Medical  network i n v o l v i n g s i x t e e n  u n i v e r s i t y a f f i l i a t e d and community h o s p i t a l s . Circuit reported.  c o u r s e s h a v e shown a s t e a d y d e c l i n e d u r i n g  Probably  t h e most s u c c e s s f u l c i r c u i t  the U n i v e r s i t y o f Kansas' M e d i c a l  Center.  has  o f f e r e d s i x symposia i n each o f e i g h t  the  s t a t e o f Kansas b r i n g i n g c o n t i n u i n g  rural physicians Michigan.  annually  Towsley  (267) .  (6) r e p o r t s  p r o g r a m s a n d 637 a t t e n d i n g  been Dalhousie 34  centers,  faculty  that  F o r the past circuit  centers  education  this  program  d i s t r i b u t e d throughout  to approximately  5 0 0 t o 600  1,033 p h y s i c i a n s  attending  a t l e a s t one o f t h e  I n Canada, t h e s u c c e s s f u l p i o n e e r  has  U n i v e r s i t y which p r e s e n t l y o p e r a t e s r e g i o n a l programs i n v o l v i n g  each o f which r e c e i v e d  extension  centers, with  of this  five  circuit  o r s i x v i s i t s p e r year from t h e Dalhousie  concept t o i n c l u d e t h e development o f  h o s p i t a l s , b o t h r u r a l and urban) as l e a r n i n g  ongoing i n f o r m a l and f o r m a l  what i s r e c e i v i n g t h e g r e a t e s t education  today  programs o f c o n t i n u i n g  emphasis i n t h e l i t e r a t u r e  (215) (246) (85) (104).  89-239, a u t h o r i z i n g funds f o r c o n t i n u i n g  by m e d i c a l Medical  seven y e a r s ,  i n t h e y e a r 1967-1968 programs were o f f e r e d  both.  community h o s p i t a l s ( n o n - t e a c h i n g  Law  program i s t h a t operated by  (15). An  medical  years  Another s u c c e s s f u l model i s that operated i n  twice y e a r l y i n twenty areas w i t h two  the four  schools  Programs  on p o s t g r a d u a t e  The i m p l e m e n t a t i o n o f P u b l i c  education  developed  and h e a l t h a g e n c i e s w i t h i n t h e framework o f  ( h e r e i n a f t e r r e f e r r e d t o a s RMPS) o n h e a r t ,  and  related diseases,  this  trend  i s reported  i n the United  States  Presently, there  co-operatively Regional  stroke,  t o have been a major f a c t o r  (252).  education, i s  cancer,  facilitating  a r e 55 RMPS  42  distributed evidence  throughout  t h e n a t i o n , a n d some o f them p r o v i d e  o f t h e wisdom o f d e v e l o p i n g  part of health Radio,  continuing education  substantial  as an  integral  services. television,  only s l i g h t v a r i a t i o n over  a n d home s t u d y the years  Another type of extramural the postgraduate  cruise.  As n o t e d  a r e f e w i n number a n d h a v e s h o w n  reported i n Table I I I .  program which deserves  b r i e f mention i s  earlier, physicians indicate a  preference  f o r a program which combines a v a c a t i o n w i t h a l i m i t e d  amount o f s t u d y .  a number o f y e a r s A l b a n y  College  (277), the U n i v e r s i t y  of F l o r i d a  the Academies o f General  Practice  (125) have sponsored  but  t h e h i g h c o s t and t h e time  factor are said  SPONSORSHIP: ROLES AND While the d i v e r s i t y  such  to limit  active  t h e i r use  i n the f i e l d ,  education  a t t h e same t i m e  c o - o r d i n a t i o n a n d c o - o p e r a t i v e p l a n n i n g h a s become a c c e n t u a t e d proliferation  of programs.  ( 2 6 7 ) , and programs, (256).  RESPONSIBILITIES  one o f t h e s t r e n g t h s o f c o n t i n u i n g m e d i c a l of agencies  cruise  For  lies in  t h e need f o r by t h e g r e a t  I n 1955 V o l l a n (256) c o n c l u d e d :  T h e r e a r e o v e r 300 d i f f e r e n t i n s t i t u t i o n s a n d o r g a n i z a t i o n s i n t h e U n i t e d S t a t e s known t o b e e n g a g e d i n p o s t g r a d u a t e m e d i c a l e d u c a t i o n i n o n e way o r a n o t h e r . This d i v e r s i t y of sponsorship r e s u l t s i n d u p l i c a t i o n o f e f f o r t s as t o t h e c o n t e n t , f a c u l t y , f a c i l i t i e s , and s c h e d u l i n g o f c o u r s e s w i t h i n g i v e n a r e a s . The n e t e f f e c t i s i n e f f i c i e n t u t i l i z a t i o n o f t e a c h i n g r e s o u r c e s and f r u s t r a t i o n o n t h e p a r t o f t h e p h y s i c i a n who h a s t o c h o o s e f r o m among a l a r g e s e l e c t i o n o f c o m p e t i n g o f f e r i n g s . Although c o m p e t i t i o n i n i t s e l f i s not h a r m f u l , i n t h i s case i t r e s u l t s i n w a s t e d t i m e , e f f o r t , a n d money. I n t h e i n t e r v e n i n g y e a r s , t h e number o f s p o n s o r s and  studies both  on a n a t i o n a l and r e g i o n a l b a s i s m e r e l y  clusion of the V o l l a n report  (230) (219) (64). (114).  has i n c r e a s e d reiterate  I n 1952, the  two-fold,  the conMassachusetts  43  Medical  S o c i e t y met t h i s p r o b l e m o f d u p l i c a t i o n a n d m a l d i s t r i b u t i o n o f  courses  by e s t a b l i s h i n g  as a c e n t r a l all  c l e a r i n g h o u s e and s i n g l e  continuing medical  states  (264).  statewide  the Postgraduate  education  Medical I n s t i t u t e , which  source  f i v e years  of information pertinent to  i n Massachusetts  a n d t h e o t h e r New  The C a l i f o r n i a M e d i c a l A s s o c i a t i o n e s t a b l i s h e d a  i n f o r m a t i o n s e r v i c e i n 1964.  educational activities  similar  are available  I n a d d i t i o n , as a f u r t h e r a i d t o p l a n n i n g  a s s o c i a t i o n now p u b l i s h e s i n i t s j o u r n a l a n a n n u a l education  England  Presently, data projected three to  on a l l C a l i f o r n i a and H a w a i i  to program sponsors.  serves  courses, the  summary o f c o n t i n u i n g  f o r the State of C a l i f o r n i a (64).  With  t h e e x c e p t i o n o f t h e s e , and t h e few s u c c e s s f u l  p l a n s whereby m e d i c a l  schools, medical  societies,  co-sponsorship  and p u b l i c h e a l t h  depart-  ments have j o i n e d f o r c e s t o p l a n and c o - o r d i n a t e c o n t i n u i n g e d u c a t i o n f o r an  entire  s t a t e (207) (252)  or region  c o - o r d i n a t i o n remains unsolved. to i t ,  ( 1 7 8 ) ( 2 5 2 ) (6) , the, p r o b l e m o f  Related  to t h i s  p r o b l e m and c o n t r i b u t i n g  i s t h a t o f d e f i n i n g r e s p e c t i v e r o l e s and r e s p o n s i b i l i t i e s .  of c o n t i n u i n g medical major r e s p o n s i b i l i t y between m e d i c a l  education  i s replete with i l l u s t r a t i o n s  and m e d i c a l  schools  history  i n which the  f o r c o n t i n u i n g e d u c a t i o n lias s h i f t e d b a c k and  societies  The  forth  (45) ( 2 5 6 ) , and more r e c e n t l y ,  c o m m u n i t y h o s p i t a l s a n d RMPS h a v e become i n v o l v e d i n t h e d i l e m m a ( 6 ) . Medical  Schools: As n o t e d  half While  e a r l i e r , medical  of the courses  s c h o o l s have been r e s p o n s i b l e f o r over  o f f e r e d to p r a c t i c i n g p h y s i c i a n s over  t h e number o f s c h o o l s o f f e r i n g  t r e n d has been toward suggest  that this  such  decade.  programs has v a r i e d , t h e o v e r a l l  increased participation  involvement  the past  one  (61) (59) (54) .  Research  data  i n c o n t i n u i n g e d u c a t i o n does n o t n e c e s s a r i l y  44  indicate  that the medical  of c o n t i n u i n g medical  s c h o o l s h a v e made a m a j o r c o m m i t m e n t  education.  Norwood's s u r v e y  i n 1952.(174) of  medical  s c h o o l s r e v e a l e d t h a t w h i l e m o s t o f them r e g a r d e d  medical  societies  activities  continuing medical  the m e d i c a l  e d u c a t i o n was  s c h o o l s , t h e i r own  o n l y warm.  The  a d m i n i s t r a t o r s i n t e r v i e w e d tended to favour  Ruhe's s t u d y disclosed criteria  to regard (220)  o u t l i n e d by  program o f f e r i n g s and  frequently lacking i n specific  K r y s t a l ' s more r e c e n t for psychiatrists  schools f e l t  Canadian medical  survey  (135)  u n r e l a t e d t o one Of  schools, the  another  the American s c h o o l s ,  education  as a m a j o r  responsibility,  so. of i n s t i t u t i o n s p r o v i d i n g c o n t i n u i n g  the r e s p o n s i b i l i t y  o n l y n i n e t e e n departments of p s y c h i a t r y were a c t u a l l y t h a t t h i s was  1963,  m a j o r i t y of  found that w h i l e f o r t y - t w o responding  t h a t c o n t i n u i n g e d u c a t i o n was  were emphatic i n s t a t i n g  The  and  In  programs r a t e d "good" by  objectives.  w h i l e o n l y f o u r of the Canadian s c h o o l s d i d  education  twelve  courses  only thirty-seven rated continuing medical  in  graduate  "extra chore."  t h e C o u n c i l on M e d i c a l E d u c a t i o n .  c o n s i s t e d of i s o l a t e d  interest  m a j o r i t y of educators  c o n t i n u i n g e d u c a t i o n as an  t h a t o n l y t w e n t y - f i v e s c h o o l s had  local  for educational  t h e u n d e r g r a d u a t e and  o f e i g h t - s i x A m e r i c a n and  field  eighteen  s t a t e and  as a p p r o p r i a t e l y c a s t i n t h e s u p p o r t i n g r o l e  a d m i n i s t e r e d by  p r o g r a m s , and  to the  of  offering  the r e s p o n s i b i l i t y  medical universities,  courses.  Five  of the p r o f e s s i o n a l  societies. Many w r i t e r s s u g g e s t t h a t m e d i c a l fulfilling  their leadership role  the u n i v e r s i t i e s sibilities one  gets  and  the  (208)  continue  i n continuing education.  their medical  i n the f i e l d  schools  (137)  schools f o r not (240)  impression that the medical  (6)  (230)  to f a l l Each  short i n  admonishes  recognizing their (246) .  respon-  From s u c h  s c h o o l s have e x e r t e d v e r y  writing  little  45 effort  indeed.  But  this  i s m i s l e a d i n g a s many m e d i c a l s c h o o l s h a v e b e e n  steadily  improving  strative  arrangements f o r programs of c o n t i n u i n g e d u c a t i o n .  States this  t r e n d has  Federal aid this In  t h e i r p r o g r a m s and  b e e n f o s t e r e d by  increasing  c o - o p e r a t i v e l y sponsored  Still  t o be  o r d i n a t i o n , and s i b i l i t y medical of  jointly  of medical  r e p o r t an  even  schools would  increasing  trend  (14)  (8).  by m e d i c a l  continue.  toward schools  A l s o reported are plans  schools  (11)  to  P r o b a b l y Hudson  f u t u r e r o l e of the m e d i c a l  and  implement  (10).  p e r h a p s e v e n m o r e i m p o r t a n t , t h e q u e s t i o n o f how s c h o o l s s h o u l d and/or can  United  without  r e s o l v e d , however, i s the q u e s t i o n of n a t i o n a l  practising physicians.  p o s i t i o n and  89-239 b u t  admini-  In the  p r o g r a m s , more o f t e n i n v o l v i n g m e d i c a l  or m e d i c a l s o c i e t i e s  programs sponsored  P u b l i c Law  involvement  C a n a d a , a number o f u n i v e r s i t i e s  hospitals  e s t a b l i s h i n g more e f f e c t i v e  co-  much  respon-  assume i n t h e c o n t i n u i n g e d u c a t i o n (120)  summarized b e s t the  present  schools:  Many f a c u l t i e s h a v e a s e n s e o f o b l i g a t i o n t o c o n t r i b u t e t o c o n t i n u i n g e d u c a t i o n . . . B u t i n t h e f a c t o f s h o r t a g e o f f u n d s and p e r s o n n e l a n d o v e r w h e l m i n g t e a c h i n g and r e s e a r c h c o m m i t t m e n t s , t h e r e i s a n e q u a l l y s t r o n g f e e l i n g o f f r u s t r a t i o n t h a t t o t a k e on m o r e w o u l d be i m p o s s i b l e . The f a u l t i s n o t t h a t a g r e a t d e a l c a n ' t be d o n e . . . i t i s b e i n g done. The m o d e l s e x i s t b u t a n e x a m p l e h e r e and t h e r e i s n o t a d e q u a t e t o d e m o n s t r a t e t h e f a c t t h a t p h y s i c i a n s m u s t h a v e e a s y a c c e s s t o c u r r e n t i n f o r m a t i o n t h a t c a n be u s e d f o r the b e n e f i t of t h e i r p a t i e n t s . In future, I believe i t i s i n e v i t a b l e t h a t u n i v e r s i t i e s and t h e i r m e d i c a l s c h o o l s w i l l a s s u m e a m a j o r share of r e s p o n s i b i l i t y i n the f i e l d of c o n t i n u i n g m e d i c a l education. A major share i s not the whole of r e s p o n s i b i l i t y . I hope t h a t t h e p e r i p h e r y may c o - o p e r a t e w i t h t h e c e n t e r b y t r a d i n g i d e a s and p e r s o n n e l i n s u c h a way t h a t t h e t e a c h e r l e a r n s a n d t h e s t u d e n t t e a c h e s , and t h a t t h e r e w i l l b e a n e x c h a n g e o f f a c t and k n o w l e d g e f o r w i s d o m and e x p e r i e n c e . C o m m u n i t y H o s p i t a l s and  RMPS:  S i n c e community h o s p i t a l s a r e g e o g r a p h i c a l l y w i d e s p r e a d by most p h y s i c i a n s as p a r t o f t h e i r d a i l y  and  p r a c t i c e , a great d e a l of  utilized attention  46  i s now  being  medical  d i r e c t e d toward  education  (236)  regular hospital staff other  r o u t i n e day  serve  as  in  their  (269)  d e v e l o p m e n t as  (216) .  conferences,  t o day  I t has  committee reviews,  a c t i v i t i e s were e f f e c t i v e l y  p r a c t i c e (188).  c o u l d be  a u d i t were enforced On  the other  Werch's s t u d y utilized  (264)  constructively.  (225)  hand, p h y s i c i a n s of f i v e  s e r v i c e , and  and  This  o f t e n used simply  as  consultations,  organized,  and  these  c o u l d become a  i s t h e one  could builtis a  p l a c e where the  ongoing program of c u r r e n t  quality  case  (139)• i n p r a c t i c e may  now  share these  community h o s p i t a l s r e v e a l e d t h e p r i m e o b j e c t i v e was  even gross  study  that while  a l l five  t o meet t h e  I n many i n s t a n c e s , t h e r e was  e r r o r s were overlooked  and  minimum a  not  views.  general  criticized  a l s o d i s c l o s e d t h a t c o n s u l t a t i o n s were more  a means t o t r a n s f e r p a t i e n t s t o a n o t h e r p h y s i c i a n  r a r e l y was  there  Robertson's review  only 30percertof existing  i f an  of h o s p i t a l a c c r e d i t a t i o n .  "hands o f f " p o l i c y ,  and  (85)  regular chart reviews,  standards  Fox  assessed  continuing  E v e n more i m p o r t a n t l y , t h e r e  growing consensus that the h o s p i t a l s e t t i n g of medical, care  of  been emphasized t h a t i f the  the media through which c o n t i n u i n g education  component o f m e d i c a l  medical  the major f o c i  an e x c h a n g e o f m e d i c a l  (103)  viewpoints.  of e i g h t y - s i x C o n s u l t a n t ' s  t h e r e p o r t s i n c l u d e d r e l e v a n t new  Wenrich's study  Moreover, i n not (263)  i n one  one  c a s e was  to  a reference  t o p a r t i c i p a t e on  c o m m i t t e e s , and  made a t t e n d a n c e a t h o s p i t a l s t a f f  "whatever t h e i r  educational value,  that  information or r e i n f o r c e d the  cited.  community h o s p i t a l d i s c l o s e d t h a t  h o s p i t a l by-laws required a c t i v e p h y s i c i a n s  conferences  t h e y w e r e v i e w e d by  a d m i n i s t r a t i v e o b s t r u c t i o n s , designed  Similarly,  L e t t e r s found  i n f o r m a t i o n which might have been of e d u c a t i o n a l v a l u e  referring physicians.  or  since  review compulsory,  physicians  to p o l i c e the p r a c t i c e of  as medicine."  47  Winrich level  q u o t e s Dr.  can  be  N.  Stearn  successful only  o n l y as p h y s i c i a n s b u t responsibility The education  "educational a c t i v i t i e s  i f i n d i v i d u a l p h y s i c i a n s see  a l s o as  teachers,  phenomenal growth of s e p a r a t e  in  recent  years  facilitate  t h e r o l e and  d e f i n e d and only  saying,  a few  and  are w i l l i n g  for preparation, participation,  ment w h i c h w i l l activity,  as  and  trend  f u n c t i o n of  As  variable, with  some e v e n r e s i s t i n g  hospitals  i n developing  education  (14)  Medical  a significant  a relatively  s t u d i e s d i s c l o s e t h a t i n many i n s t a n c e s , m e d i c a l education  t h e r e s p o n s e o f i n d i v i d u a l h o s p i t a l s t o t h i s new  The  as  1967  their  own  medical  new  and  develop-  educational  a d m i n i s t r a t i v e u n i t s are not  h o u r s a week t o c o n t i n u i n g m e d i c a l  not  t o a s s u m e some  h o s p i t a l departments of  (104).  these  themselves  local  presentation."  i s v i e w e d b y many a u t h o r s this  a t the  clearly  d i r e c t o r s devote  (188)  (25).  Moreover,  more demanding r o l e  a t t e m p t s by m e d i c a l  schools  to a s s i s t  ongoing programs of c o n t i n u i n g  medical  Planning  and  G o a l s C o n f e r e n c e s p o n s o r e d by  the  California  recommended:  1.  T h a t c o m m u n i t y h o s p i t a l m e d i c a l s t a f f s be e n c o u r a g e d t o o r g a n i z e a committee to study the problems of c o n t i n u i n g education. T h i s s h o u l d n o t be c o n f u s e d w i t h t h e r e g u l a r program committee.  2.  T h a t t h e CMA s h o u l d c o m m u n i c a t e w i t h h o s p i t a l s t o i n f o r m them of e d u c a t i o n a l a s s i s t a n c e that i s a v a i l a b l e . For example, some h o s p i t a l s t a f f do n o t know t h a t some m e d i c a l s c h o o l s w i l l h e l p them w i t h p l a n n i n g . h o s p i t a l s t a f f m e e t i n g s .  3.  T h a t t h e CMA e n c o u r a g e c o m m u n i t y h o s p i t a l m e d i c a l s t a f f s a n d medical schools to enter i n t o experimental p r o j e c t s designed t o d i s c o v e r f e a s i b l e r e l a t i o n s h i p s t h a t m i g h t be d e v e l o p e d .  R e c e n t r e p o r t s by (59)  directions.  As  a stimulus  the  (188).  A s s o c i a t i o n (188)  Association  is  (61)  t h e C o u n c i l on  Education  s u g g e s t t h a t some p r o g r e s s  of  has  the American  Medical  b e e n made i n  these  p r e v i o u s l y m e n t i o n e d , RMPS h a v e i n many i n s t a n c e s  served  i n e n c o u r a g i n g community h o s p i t a l s to assume a more  as  significant  48  role, are  and i n t u r n t o seek a s s i s t a n c e from t h e m e d i c a l  t h e m s e l v e s now b e i n g  necessarily Medical  charged w i t h developing  comp.lementary t o t h o s e  schools.  "parallel  of u n i v e r s i t i e s  Some RMPS  offerings not  and component s o c i e t i e s "  and S p e c i a l t y S o c i e t i e s : Historically,  postgraduate  courses  local  and s t a t e m e d i c a l  f o rphysicians  (191).  s o c i e t i e s were t h e p i o n e e r s  Although  still  According  to the Council's  Annual Reports  societies  are presently  At  percent  (54) (59) (61) g e n e r a l m e d i c a l  or l e s s of the t o t a l  t h a t most m e d i c a l i s reported  on t h e i n c r e a s e  hours of i n s t r u c t i o n .  that the business  Although  many m e d i c a l  t o improve t h e i r  consensus i s  and s o c i a l  functions f r e q u e n t l y take  pre-  (263) (256).  societies are presently re-assessing  current programs, others  producers of continuing education advanced t h i s  (163) , b u t t h e g e n e r a l  s o c i e t y programs l a c k c o - o r d i n a t i o n and c o n t i n u i t y , and  cedence ovex e d u c a t i o n a l a c t i v i t i e s  ing  postgraduate  averaging  t h e same t i m e , n a t i o n a l , s t a t e , a n d l o c a l m e e t i n g s w i t h a n e d u c a t i o n a l  component a r e r e p o r t e d  it  reported  of  active i n the f i e l d ,  t h e i r programs have been d e c l i n i n g s t e a d i l y .  one  (6) .  (6).  are questioning  At a recent  and a t t e m p t -  their  r o l e as  d i s c u s s i o n , Evans (268)  view:  Leadership as a l e a r n e d s o c i e t y i s p a s s i n g from m e d i c a l s o c i e t y t o h o s p i t a l s t a f f . . . I do n o t h o l d t h a t t h i s i s g o o d o r b a d , s i m p l y that i ti s happening. L o c a l groups that a r e h i g h l y organized a r e perhaps b e t t e r a b l e t o c a r r y out programs o f c o n t i n u i n g e d u c a t i o n t h a n m e d i c a l s o c i e t i e s w h i c h may h a v e many c o m p o n e n t b o d i e s concerning themselves w i t h education, thus having confusing r e - d u p l i c a t i o n s . The r o l e o f t h e m e d i c a l s o c i e t y i s r e a l l y t h e c o - o r d i n a t i o n o f t h i s k i n d of a c t i v i t y , t h e development o f a m u l t i - p h a s i c approach, including medical colleges. An of  application of this kind of role  the California Medical  Association.  i s illustrated  by t h e a c t i v i t i e s  In addition to co-ordinating  o f f e r i n g s and a c c r e d i t i n g programs f o r t h e S t a t e o f C a l i f o r n i a  course  (187) , t h e  49  Association i s conducting Regional Medical Institutes s e v e r a l of the s t a t e ' s medical staffs of  community h o s p i t a l s  x  schools  (6).  To  i n cooperation with  further assist  the  i n developing effective continuing education  programs, the A s s o c i a t i o n r e c e n t l y p u b l i s h e d a supplement to the Medical A s s o c i a t i o n ' s Guide the p o t e n t i a l  ( 3 8 ) , and  i s operating a pilot  r o l e o f t h e community h o s p i t a l  as p u r v e y o r s  y e a r s they have averaged hours  of i n s t r u c t i o n  comparison courses  specialty  of c o n t i n u i n g education.  from e l e v e n to twenty  (52)  (61).  While  project  For  societies the past  percent of the t o t a l  t h e i r o f f e r i n g s a r e few  equals the attendance  (54), specialty medical societies  of General P r a c t i c e o f f e r e d  collectively  29,590 p h y s i c i a n s a t an a v e r a g e schools offered  1,128  467  reported  i n number i n  and  Academies  c o u r s e s which were a t t e n d e d  o f 63.36 p e r c o u r s e .  c o u r s e s w i t h an a t t e n d a n c e  seemingly  In contrast,  by  medical  o f 34,106, a t an a v e r a g e  s u c c e s s f u l performance,  are p r e s e n t l y r e c e i v i n g  m e d i c a l s c h o o l and  t h e same c r i t i c i s m  to others, e i t h e r w i t h i n  to other meetings, another  often i s strikingly  dimension  to the problem  specialty  of  lacking" when he  at  In short, i t i s said  t h a t t h e r e l e v a n c e o f "one the meetings  medical  that i s directed  g e n e r a l m e d i c a l s o c i e t y programs.  t h e i r p r o g r a m s a r e e p i s o d i c , and  presentations  still  several  course.  Despite this  that  are  r e p o r t e d at m e d i c a l s c h o o l programs.  Thus f o r t h e y e a r 1968-1969  societies  to examine  w i t h m e d i c a l s c h o o l s , t h e number o f p h y s i c i a n s a t t e n d i n g s p e c i a l t y  almost  30.26 p e r  American  (38).  In contrast to general medical s o c i e t i e s , well established  medical  themselves  (230).  Miller  or  set of relative  (159)  adds  writes:  The i n c r e d i b l e s u c c e s s o f m o d e r n p r e v e n t i v e and t h e r a p e u t i c measures i n medicine i s changing the b a s i c n a t u r e of m e d i c a l p r a c t i c e . The g r o w i n g h o s t o f a g i n g p a t i e n t s , o f t h o s e w i t h c h r o n i c d e b i l i t y o r d i s e a s e , c a l l s f o r a k i n d of c a r e t h a t i s l e s s r e a d i l y measured by p r e c i s e i n s t r u m e n t s o r i n p r e c i s e u n i t s . The " R e c e n t A d v a n c e s . . . "  50  i n d e a l i n g w i t h these problems a r e as o f t e n p r o v i d e d by b e h a v i o u r a l s c i e n t i s t s as by t h o s e from t h e p u r e l y b i o l o g i c disciplines; t h e s u b t l e t i e s and c o m p l e x i t i e s o f p a t i e n t c a r e i n t h i s c o n t e x t a r e o n l y b e g i n n i n g t o be e l a b o r a t e d b y s e r i o u s s t u d e n t s and have y e t had l i t t l e i m p a c t upon p r a c t i t i o n e r s o r t h e e d u c a t i o n a l p r o g r a m s o f f e r e d t o them. I t w i l l require the most s k i l f u l l e a d e r s h i p t o i n t r o d u c e s u c h i m p o r t a n t components o f the contemporary s o c i a l f a b r i c i n t o the i n s t r u c t i o n o f p h y s i c i a n s whose f o c u s h a s f o r so l o n g been t h e d i s p o s i t i o n o f a c u t e problems...  PROGRAM PLANNING AND ADMINISTRATION The limited  l i t e r a t u r e p e r t a i n i n g t o program p l a n n i n g  to the medical  schools, consequently,  arrangements w i t h i n schools Administrative In  Arrangements:  a l l articles  division with a f u l l (38). This In schools  on t h e o r g a n i z a t i o n o f c o n t i n u i n g e d u c a t i o n t h e  time  be a c l e a r l y  i d e a l has been achieved  i n b u t a few m e d i c a l  schools  program today.  1 9 6 3 , Ruhe ( 2 2 0 ) f o u n d t h a t w h i l e 54 A m e r i c a n , a n d 6 C a n a d i a n  reported having  a department, s e c t i o n , d i v i s i o n ,  the planning  and  1 Canadian s c h o o l had a f o r m a l l y r e c o g n i z e d  and implementation  57 A m e r i c a n a n d 7 C a n a d i a n s c h o o l s continuing education,  there a f u l l - t i m e  director  t h a t o f t h e 65 m e d i c a l a listed  or standing  of continuing education,  D i r e c t o r y of the A s s o c i a t i o n of American Medical  had  d e f i n e d department o r  d i r e c t o r o r head r e s p o n s i b l e f o r t h e o v e r a l l  for  for  section i s confined to  of medicine.  r e c o m m e n d a t i o n i s made t h a t t h e r e s h o u l d  (207)  this  and a d m i n i s t r a t i o n i s  committee  only 5 American,  department i d e n t i f i e d Colleges.  Moreover,  reported a part-time person  i n the while  responsible  i n . o n l y 3 A m e r i c a n a n d i n no C a n a d i a n s c h o o l was o r head.  schools  As l a t e as 1967, S u l l i v a n  offering  department o r d i v i s i o n  courses  (241) noted  i n the Annual L i s t i n g ,  of continuing medical  education.  20  percent  51  Reporting  on t h e c u r r e n t a c c r e d i t a t i o n program i n t h e U n i t e d  Ruhe (218) i d e n t i f i e s  t h e l a c k o f c e n t r a l a u t h o r i t y as one o f t h e m a j o r  problems f a c i n g the a c c r e d i t a t i o n committee. institutions  programs a r e d e v e l o p i n g  co-operation  among d e p a r t m e n t s .  some i n s t i t u t i o n s programs i s l e f t basis. to  t h a t i n many  or hospitals with  little  f o r the development o f e d u c a t i o n a l  educational offerings are said  planned  on a  departmental  t o range from e x c e l l e n t  poor.  w h i l e twelve division,  (241) o f m e d i c a l  of the fourteen responding  a f u l l - t i m e person i n charge. responsibility  to three quarter indicated  disclosed that  s c h o o l s had an e s t a b l i s h e d department,  time.  The r e m a i n i n g  schools  reported  on a p a r t - t i m e b a s i s , r a n g i n g  o n l y one persons  f r o m one q u a r t e r  On t h e o t h e r h a n d , a l l f o u r t e e n r e s p o n d i n g  that the postgraduate  t h e s e l e c t i o n and a r r a n g i n g  appointed  schools  s e c t i o n , o r s t a n d i n g committee on c o n t i n u i n g e d u c a t i o n ,  assuming t h i s  for  w i t h i n schools  t o i n d i v i d u a l s o r groups r a t h e r than  I n C a n a d a , a 1968 s u r v e y  had  I t has been found  Even where t h e r e i s c e n t r a l a u t h o r i t y , i n  the r e s p o n s i b i l i t y  As a r e s u l t ,  States,  division of course  o r s e c t i o n assumed m a j o r content  universities responsibility  under t h e d i r e c t i o n o f an  chairman.  Instructors: Courses sponsored by m e d i c a l  schools  of t h e r e g u l a r f a c u l t y o r by guest l e c t u r e r s  a r e taught  from other m e d i c a l  Non-academic p h y s i c i a n s o r non-medical p e r s o n n e l frequently  (45)) ( 2 2 0 ) (241) .  physicians should them i n t h e i r  l a r g e l y b y members  are u t i l i z e d  A view gaining strength i s that  be encouraged  to participate  own c o n t i n u i n g e d u c a t i o n  centers.  f a r less practising  i n teaching, thereby  a n d a t t h e same t i m e  some o f t h e e x c e s s i v e demands made o n t h e m e d i c a l  involving  alleviating  school faculty.  The  52  evolving  r o l e of the teacher  probably i l l u s t r a t e s best The  pilot  utilizes  project  reported  by t h e T u f t s  New E n g l a n d M e d i c a l  consultants  the trend  the exception  toward g r e a t e r  of psychiatry  In p s y c h i a t r y ,  short  others.  of c l i n i c i a n s  as  teachers, sparse.  t r a i n i n g courses f o r program d i r e c t o r s and  In a recent  editorial  Stratos  I n s t i t u t e of Mental  (238) r e p o r t s  P r a c t i c e Committee and t h e P h y s i c i a n  American  Psychiatric Association plan  intensive  teacher  t r a i n i n g sessions  to n o n - s p y c h i a t r i s t s . U n i v e r s i t y plans  a visiting  Health's  the Psychiatry  Education Project of the  t o expand c o n s u l t a t i o n s e r v i c e s and  field, teacher  a recent  i n teaching proposal  clinical  psychiatry  by McMaster  program i n which both  from the r e g i o n w i l l work i n the McMaster  u n i t s to update t h e i r Although there  that  f o r those involved  From t h e g e n e r a l  to provide  t i o n e r s and c o n s u l t a n t  has  program model.  E d u c a t i o n B r a n c h ; The A m e r i c a n Academy o f G e n e r a l P r a c t i c e ; a n d  Medical  quality  community  h a v e b e e n u n d e r t a k e n b y a v a r i e t y o f g r o u p s i n c l u d i n g : WICHE; t h e  Continuing  teaching  Center (210)  t r a i n i n g programs a r e s t i l l  A m e r i c a n P s y c h i a t r i c A s s o c i a t i o n ; The N a t i o n a l  and  and p r o m i s i n g  utilization  teacher  approach.  i n several of the small  i n Maine which i s another i n n o v a t i v e  Despite  teachers  i n r e g i o n a l programs (208)  the successful implementation of t h i s  r e s i d e n t s as teaching  hospitals  with  as c o n s u l t a n t  clinical  s k i l l s (11).  i s a growing i n t e r e s t i n t h e need t o improve t h e  of i n s t r u c t i o n i n the undergraduate m e d i c a l t r a i n i n g program,  not extended g e n e r a l l y  into continuing  education.  The g e n e r a l  that p r o f i c i e n c y i n medicine i s the p r i n c i p a l p r e r e q u i s i t e s t i l l without regard  to teaching  by  participants.  by  providing  practi-  ability  o r t o t h e amount o f l e a r n i n g  this  feeling  persists achieved  Some moves a r e u n d e r w a y t o i m p r o v e t h e q u a l i t y o f i n s t r u c t i o n  clinicians with  t r a i n i n g f o rthe i n s t r u c t i o n a l role.  53  Finances:  •  F i n a n c i a l support to school  (220).  f o r c o n t i n u i n g education v a r i e s w i d e l y from  In g e n e r a l , the major sources  some g o v e r n m e n t h e a l t h g r a n t s , and percentage almost  of the medical  negligible.  as w e l l as f a c u l t y  s c h o o l budget devoted  time, t h e i r  from the l e g i s l a t u r e  and  institutions operate  (9); s t i l l  grants  solely  (45)  including  to continuing education  provided  tuition  (55).  federal training  More r e c e n t l y , p a r t i c u l a r l y ment h a s  (9)  on  (45).  receive  Others  additional  support educational financed other  the c o n t r i b u t e d  Most i n s t i t u t i o n s  seek  grants, pharmaceutical  the K e l l o g g Foundation, i n medicine  (8)  (45)  firms,  a l lcontribute  (12)  (55)  S t a t e s , the f e d e r a l  a s s i s t a n c e to continuing medical  (207) . governeducation.  C h i l d s noted  that p r o j e c t s supported  accelerating  t h e development o f more i n n o v a t i v e programs o f c o n t i n u i n g  medical  education  Publicity  and  by  to  Professional associations,  i n the U n i t e d  greater financial  and  is  facilities  insignificant  to s t a t e u n i v e r s i t i e s  for special projects.  philanthropic societies  significantly  provide  o t h e r programs a r e managing t o b r e a k even' o r  voluntary health agencies, and  to continuing education  s t a t e h e a l t h departments.  almost  fees,  The  some c o n t i n u i n g e d u c a t i o n p r o g r a m s a r e  s e r v i c e s of the r e g u l a r f a c u l t y and  (14).  f o r i n d i v i d u a l programs or c o n s u l t a t i o n s e r v i c e s to  a t a modest p r o f i t  donations  (135)  tuition  c o n t r a c t s w i t h community h o s p i t a l s t o r u n  programs f o r r e s i d e n t s t a f f ; fees charged  (274)  c o n t r i b u t i o n i s not  schools attached  t h e i r programs through  by  (8)  N e v e r t h e l e s s , s i n c e m o s t s c h o o l s do  Some m e d i c a l funds  donations  of revenue are  school  government have proven e f f e c t i v e  (44).  Promotion:  In the U n i t e d  States, sponsoring  i n s t i t u t i o n s may  publicize  their  in  54  course in  offerings  through  the "Annual Course L i s t i n g " p u b l i s h e d each  year  the e a r l y August i s s u e of the J o u r n a l of the American M e d i c a l A s s o c i a t i o n .  In a d d i t i o n , medical selected  course  j o u r n a l s i n both  offerings.  p e r s o n a l announcements  A number o f s t a t e m e d i c a l continuing medical  p h y s i c i a n s and  societies  t i m e , p l a c e , and  England  tuition  of courses  Health Sciences. practitioners well  (64)  publicize  One  programs  (241).  r e p o r t the use  of  a  such, which i s mailed  to  S t a t e s , announces a l l f o r m a l  e s s e n t i a l i n f o r m a t i o n as  of B r i t i s h Columbia  to  their  (8) p u b l i s h e s a n  the D i v i s i o n of C o n t i n u i n g Education  This i s mailed their  in  to a l l p h y s i c i a n s i n the p r o v i n c e to p e r s o n a l programs of c o n t i n u i n g  annual the assist  education  i n advance. Because these p u b l i c a t i o n s are o f t e n overlooked  course (222)  States  (248).  o f f e r e d by  i n planning  England  including  In Canada, the U n i v e r s i t y listing  (6)  education b u l l e t i n .  h o s p i t a l s i n t h e New  p r o g r a m s o f f e r e d i n New  the U n i t e d  O t h e r t r a d i t i o n a l methods of a d v e r t i s i n g  i n c l u d e p o s t e r s , d i r e c t m a i l and  special  C a n a d a and  sponsors (269)  are using reinforcement  and  newspaper, t e l e v i s i o n ,  through  by  p h y s i c i a n s , some  personal v i s i t s  or r a d i o announcements  to p h y s i c i a n s  (11)  (269).  Programming: In s p i t e of a l l these the problem of relevance programs o f f e r e d (84)  from medical test 1952,  schools  i s thought  (173).  i g n o r e t h e i n t e r e s t s and  efforts  to l i m i t  the market f o r c o n t i n u i n g e d u c a t i o n Norwood  (174)  found  t h i s view suggest  needs of p r a c t i s i n g  t h a t many u s e  t h a t i t was  education,  the e f f e c t i v e n e s s of most  Those e x p r e s s i n g  expressed  suggest  to promote c o n t i n u i n g m e d i c a l  t h a t programs  physicians.  Reports  questionnaires e x t e n s i v e l y to  (220)  (241).  a common p r a c t i c e  I n d e e d , as e a r l y f o r medical  as  schools  55  to for  send out r e q u e s t  f o r m s on w h i c h  p h y s i c i a n s could note  as M i l l e r i n d i c a t e s , become c o n f u s e d  i n the process  determine exhibit  need."  concealed  Sodeman ( 2 3 0 ) b u i l t to s u i t  The  t h e programs most l i k e l y the planning process.  as a c o l l e c t i o n  and  to succeed  That present  on  on b o t h  sides"  of t h i s  are those which  principle  perhaps  i s that  i n v o l v e the l e a r n e r i n  o r g a n i z a t i o n a l s t r u c t u r e s and  t o meet t h i s  admini-  r e q u i r e d i s i m p l i e d i n t h e many  continuing medical education  (104)  (225)  (246)  (219). to i n v o l v e the  consumer i n p l a n n i n g programs of c o n t i n u i n g e d u c a t i o n i n m e d i c i n e . r e p o r t s a s u c c e s s f u l s e l f - s p o n s o r e d and  program has  review f o r i n t e r n i s t s evolved over  the whole f i e l d .  While  the years  preparing f o r board into  an  ongoing  Although  i n terms of i n c r e a s e d e n r o l l m e n t  years),  i n the words of MacLeod:  ( f r o m 26  on  initiated  examinations,  this  comprehensive review  t h e m a i n c r i t e r i o n o f " s u c c e s s " has  largely  MacLeod  s e l f - a d m i n i s t e r e d course  i n t e r n a l ' m e d i c i n e a t the Yale-New Haven M e d i c a l C e n t e r . as an a n n u a l  (159).  individual  o f e a c h p h y s i c i a n , and  implication  a  syllables  p r o g r a m i s "an  S e v e r a l r e c e n t e x p e r i m e n t a l programs have attempted  (144)  to  to the n e x t ,  of nonsense  disappointment  requirements  obvious  patterns are unable on  end  s t r e s s e d that the i d e a l  the s p e c i f i c  or  l e a r n i n g . . . a n d r e q u i r e s them t o  of each step before proceeding  irritation  has  a few more l i k e h i m . "  critiques  p h y s i c i a n s ' "wants"  Moreover, "unless the teacher i s c a r e f u l  p r o g r a m o f g r e a t e s t r e l e v a n c e may with carefully  d e f i n e d o b j e c t i v e s and,  of implementation  where h i s s t u d e n t s a r e i n t h e i r  some u n d e r s t a n d i n g  strative  with clearly  w i t h o r s u b o r d i n a t e t o w h a t t h e p r o g r a m m e r s "want  t h i n k the p r a c t i t i o n e r s  one  suggestions  courses. Many p r o g r a m s a r e n o t d e s i g n e d  may  their  of  been measured  t o 60 p h y s i c i a n s o v e r  four  56  The g r o w t h o f t h i s h i g h l y s t r u c t u r e d y e t i n f o r m a l r e v i e w c o u r s e appears to have been a f u n c t i o n of the r e l e v a n c y of t h e ' c o u r s e m a t e r i a l and a s e n s i t i v i t y t o t h e c h a n g i n g n e e d s o f t h e g r o u p . The p r i n c i p l e s o f s t u d e n t p a r t i c i p a t i o n i n p l a n n i n g and adminis t r a t i o n , and c o n t i n u o u s f e e d b a c k t h r o u g h q u e s t i o n n a i r e s , served as the b a s i c framework f o r t h e o r g a n i z a t i o n o f the c o u r s e . These p r i n c i p l e s are important c o n s i d e r a t i o n s f o r others d e s i r i n g to s e t up s u c h a c o u r s e and m e r i t e m p h a s i s by t h e A m e r i c a n M e d i c a l A s s o c i a t i o n ' s C o u n c i l on M e d i c a l E d u c a t i o n i n s e t t i n g s t a n d a r d s f o r a c c r e d i t a t i o n of i n s t i t u t i o n s p r o v i d i n g postgraduate courses. Another experimental  p r o j e c t w h i c h p o i n t s out  the need t o  consider  a l t e r n a t i v e a d m i n i s t r a t i v e arrangements f o r programming, i s that r e p o r t e d Torrens  (246)  specially  of  S t . L u k e ' s H o s p i t a l i n New  created  h o s p i t a l department c a l l e d  R e l a t i o n s O f f i c e was practitioners with continuing  established i n order  patient referral  education  the  oriented  teaching  and  research  utilization  of  c o n f e r e n c e s and  t i o n e r s had  ignored  recommends t h a t  can  as  "other  department to serve knows he  p r o b l e m s and  in their  i n c r e a s i n g i s o l a t i o n of general  teaching  increased  physicians  as  f r o m w h i c h he  the  teaching  local practice.  teaching  to  to  specialist  resulted i n  s e r v i c e s as w e l l as general  community  the  practi-  t o them i n t h e i r p r a c t i c e s . "  to w h i c h the  day  Initiated  hospitals establish a similar  a single place  day  p r a c t i t i o n e r s from the  grand rounds which p r e v i o u s l y the use  general  to o f f e r  t o meet t h e  h o s p i t a l s , t h i s program has  little  Physician  concurrently  designed  the h o s p i t a l ' s r e f e r r a l  "of  can  obtain information  hospital^ for  Webster  Torrens  office  or  physician  (262)  describes  a v a i l a b l e a t any  a b o u t p a t i e n t s he  has  referred  to  care." a program i n North C a r o l i n a i n which a  r i d i n g p s y c h i a t r i s t made r e g u l a r v i s i t s was  Community  a  t u r n f o r a s s i s t a n c e w i t h problems of p a t i e n t s i n h i s p r a c t i c e ,  and  and  The  In t h i s p r o j e c t ,  to a s s i s t n o n - a f f i l i a t e d  programs s p e c i f i c a l l y  p r o b l e m s e n c o u n t e r e d by offset  York C i t y .  by  to a l l p h y s i c i a n s  time p h y s i c i a n s wished  in five  to c o n s u l t him  circuit  counties  about  cases.  57  During the number o f  first  two  y e a r s i n w h i c h t h i s p r o j e c t was  a d m i s s i o n s to the  s t a t e mental h o s p i t a l from t h i s  a r e a decreased whereas a d m i s s i o n s from other program i s being mental health The is  still  expanded throughout the  preceptorship  preceptorship  project  the  i s a s k e d t o o u t l i n e w h a t he  the  physician.  The  physicians  the  program, the  who  adjunct  to  physician  on  of  offered  i s able  the  auspices  two  The community  t h e y must r e c o g n i z e  indicate conferences.  d a t e , 92  reported  objectives.  "In this  to  percent  have  Although  care  educational  for  objectives To  t o show i m p r o v e d p a t i e n t  a  studies  the  program are  t o s a t i s f y h i s own  to  a program of  noted that  the  requesting  f r e e s t u d y and  educational  RMP  t o meet  h i s a p p l i c a t i o n form.  as  type  a of  needs w h i c h  to h i s p r a c t i c e . " t h e O r e g o n RMP,  p r o g r a m s on  the  M e i g h a n and  experimental  Oregon communities are  "process"  physician  with  to design  their  e f f e c t i v e n e s s o f an  educational  b a s e d on M i l l e r ' s  of  designed  w i s h e s t o l e a r n and  p r o g r a m , D a v i d s o n e_t a l _ ( 7 1 )  professionals,in  by  The  have p a r t i c i p a t e d i n the  e v i d e n c e was  Under the investigating  increased.  t h e p r o g r a m i s b a s e d on  the p h y s i c i a n  makes h i s e x p e r i e n c e r e l e v a n t  t h e i r own  of  at l e a s t three-fourths  statistical  r e s u l t of  information  evaluation  s t a t e d o r i g i n a l l y by  no  an  county  the Washington/Alaska  w i s h e s a s t r u c t u r e d p r o g r a m o r one  planner then uses t h i s  satisfied  s p o n s o r e d by  individual physician.  The  the  s t a t e as  five  the  services.  l e a r n i n g needs of  of  counties  a n o t h e r example of a program s p e c i f i c a l l y  w h e t h e r he  i n operation,  care  given of  the  Burg  that  i n v o l v i n g t h e m i n i d e n t i f y i n g p r o b l e m s and  are  p r o j e c t ' i n which an  opportunity  stroke  this  seeking  adults  i s best  health  to  patient.  model w h i c h assumes t h a t b e f o r e  t h e i r n e e d t o k n o w , and  (152)  develop This  is  learn  accomplished  solutions.To  58  implement t h i s ,  " s t r o k e study  groups"were formed, membership of w h i c h  was  interdisciplinary  representing a l l health care p r o f e s s i o n a l s a v a i l a b l e  the communities.  T h e i r t a s k was  delivery  to " i d e n t i f y  o f o p t i m a l s t r o k e c a r e and  then  t o s u r m o u n t them...The p r o j e c t s t a f f the groups to work t o g e t h e r p l a n n i n g programs..."  To  two  participated  submitted  a proposal f o r a grant  the experimental group can  p r o j e c t ends.  function without  local  as  facilitators  the  approaches.  to continue M e i g h a n and  enabling  e d u c a t i o n a l needs or  groups have planned  w h i c h d i f f e r w i d e l y i n o b j e c t i v e s and  to  to d e s i g n e d u c a t i o n a l programs  in identifying  date,  existing barriers  in  One  in  community programs of these  groups  has  the program independently  when  Burg q u e s t i o n "whether such  a  a d m i n i s t r a t i v e a s s i s t a n c e from o u t s i d e  the  community..."  CURRENT AND Despite  RECURRING I S S U E S AND  t h e many u n r e s o l v e d  continuing medical  education  i s thriving.  m e n t s a r e o c c u r r i n g w h i c h c a n be there are s t i l l  i s s u e s and  expected  TRENDS  o p e r a t i o n a l problems,  C o n c u r r e n t l y , a number o f to i n f l u e n c e f u t u r e trends  developbut  many i s s u e s t h a t r e q u i r e t h e a t t e n t i o n o f t h e p r o f e s s i o n .  Accreditation: Since  the p u b l i c a t i o n of the o r i g i n a l  M e d i c a l A s s o c i a t i o n has  been working  institutions  programs of c o n t i n u i n g e d u c a t i o n .  sponsoring  C o u n c i l on M e d i c a l E d u c a t i o n d i r e c t i o n a number o f s i t e of such  a plan  (219).  a c c r e d i t a t i o n was  As  on  " G u i d e " i n 1957,  appointed  American  a v o l u n t a r y system to a c c r e d i t I i i 1961, i t s  an a d v i s o r y c o m m i t t e e , and  surveys were conducted  to determine  a r e s u l t o f t h e s t u d y , an  p r o p o s e d and  the  a p p r o v e d by  the  under i t s feasibility  a c c e p t a b l e program  t h e A s s o c i a t i o n ' s House  of  of  59  Delegates. 1970,  I n 1967, formal  86 i n s t i t u t i o n s  a c c r e d i t a t i o n was i n i t i a t e d  included  inferior  i n t h i s Annual L i s t .  quality w i l l  discontinued The  Ultimately, only  "Guide" provides  the c r i t e r i a  (65).  u s e d „by t h e s u r v e y  The C a l i f o r n i a M e d i c a l  Briefly  or  them ( 6 1 ) .  "Guide" as t h e statement o f b a s i c p r i n c i p l e s (187).  will  I n t h i s way i t i s h o p e d t h a t p r o g r a m s o f  b e c a u s e p h y s i c i a n s do n o t a t t e n d  t a t i o n o f programs  accredited courses  e i t h e r b e i m p r o v e d t o meet a c c r e d i t a t i o n s t a n d a r d s  f o r a c c r e d i t i n g programs this  By September  and/or o r g a n i z a t i o n s had been a c c r e d i t e d and l i s t e d as  such i n t h eAnnual Course L i s t i n g . be  (81).  s t a t e d , these  teams  responsible  A s s o c i a t i o n has adopted  f o r i t s proposed a c c r e d i criteria  (65) a r e :  1.  T h e r e s h o u l d b e ADMINISTRATION o f t h e c o n t i n u i n g e d u c a t i o n program by a r e s p o n s i b l e p e r s o n h a v i n g t h e r e s p e c t and support o f the p r o f e s s i o n a l s t a f f o f the o r g a n i z a t i o n o r i n s t i t u t i o n .  2.  The BUDGET s h o u l d b e a d e q u a t e t o t h e e d u c a t i o n a l p r o g r a m u n d e r t a k e n to i t s c o n t i n u i n g improvement. S o l e dependence on t u i t i o n f e e s tends t o r e s t r i c t unduly the q u a l i t y of continuing education programs.  3.  The TEACHING STAFF s h o u l d c o n s i s t o f p h y s i c i a n s a n d t h e i r o f p r o v e n a b i l i t y , t r a i n i n g , and e x p e r i e n c e .  4.  5.  associates  •  The CURRICULUM o f a n y c o n t i n u i n g m e d i c a l e d u c a t i o n p r o g r a m s h o u l d be d e s i g n e d t o e x p l o r e w i t h c o n s i d e r a b l e d e p t h o n e s u b j e c t o r a c l o s e l y r e l a t e d group o f s u b j e c t s . The e d u c a t i o n a l m e r i t o f d e v o t i n g s u f f i c i e n t c o n s e c u t i v e s e s s i o n s t o e x p l o r e more t h a n s u p e r f i c i a l l y t h e background and advances i n one s u b j e c t i s emphasized. There s h o u l d be a v a i l a b l e FACILITIES t h a t encourage methods o f e d u c a t i o n .  participative  6. The EDUCATIONAL METHODS s h o u l d i n c l u d e more t h a n a s e r i e s o f l e c t u r e s or panel d i s c u s s i o n s i nwhich the p h y s i c i a n s a r e p r i m a r i l y passive recipients. Emphasis on p r o b l e m - s o l v i n g i s l i k e l y t o i n c r e a s e student involvement.  7.  METHODS OF EVALUATION o f t h e e f f e c t i v e n e s s o f c o n t i n u i n g m e d i c a l e d u c a t i o n programs s h o u l d be d e v e l o p e d and used a s p a r t o f e a c h program.  60  8.  E a c h P H Y S I C I A N ' S REWARD f o r p a r t i c i p a t i o n i n c o n t i n u i n g m e d i c a l e d u c a t i o n a l w a y s s h o u l d be h i s i m p r o v e d a b i l i t y t o c a r e f o r h i s p a t i e n t s a n d t h e s t i m u l a t i o n o f h i s own s p i r i t o f i n t e l l e c t u a l adventure.  While i t i s too e a r l y  to p r e d i c t  the long  term e f f e c t s  of  this  a c c r e d i t a t i o n p r o g r a m , i t i s g e n e r a l l y v i e w e d as a n o n - r e s t r i c t i v e m e c h a n i s m w h i c h w i l l u l t i m a t e l y p r o v i d e some d i r e c t i o n of  the f i e l d  National  f o r the  regulatory  development  (61).  Plans:  D a r l e y and C a i n  (70) p r o p o s e d i n 1961  Academy w h i c h w o u l d c e n t r a l i z e  to t h i s ,  Study Committee  National  the nation's educational resources f o r continuing  medical education thereby helping Subsequent  the establishment-of a  t o c o - o r d i n a t e and f u r t h e r  i t s development.  the major n a t i o n a l m e d i c a l a s s o c i a t i o n s formed a  to consider  the development  o f s u c h an Academy.  The  Joint committee's  r e p o r t , w r i t t e n b y D r y e r ( 7 9 ) p r o p o s e d t h e c r e a t i o n o f a n Academy w h i c h w o u l d be a " u n i v e r s i t y w i t h o u t w a l l s . "  Under t h i s p l a n , a n a t i o n a l agency  develop a c o r e c u r r i c u l u m " r e s p o n s i v e t o the needs of the n a t i o n ' s  would  physicians."  U s i n g mass c o m m u n i c a t i o n m e d i a , t h e s e o n g o i n g c o m p r e h e n s i v e p r o g r a m s w o u l d f o c u s e d n a t i o n a l l y , r e g i o n a l l y , and l o c a l l y ,  a n d p h y s i c i a n s w o u l d be a b l e t o  c h o o s e t h o s e programs w h i c h w o u l d b e s t meet t h e i r i t s many f a r s i g h t e d r e c o m m e n d a t i o n s ,  the report  s h i p of our major medical resources w i l l p o s s e s s s e p a r a t e l y , and articulate  i n d i v i d u a l needs. emphasized t h a t . . . " a  t h a t s u c h an e f f i c i e n t  the p u b l i c a t i o n of t h i s  Among partner-  g i v e s t r e n g t h t o a l l w h i c h none b a l a n c e c a n be o r g a n i z e d  and r e i n f o r c e n a t i o n a l , r e g i o n a l , s t a t e ,  Following  report,  and l o c a l  to  plans."  the American Medical  Associ-  a t i o n u n d e r t o o k t o p u r s u e s u c h a p l a n and u n d e r t h e l e a d e r s h i p o f S t o r e y a n i n t e n s i v e s t u d y o f p h y s i c i a n s ' n e e d s was In  1966,  t h i s p r o j e c t was  be  begun i n a p i l o t  d i s c o n t i n u e d b e c a u s e i t was  felt  project  that  local  (237),  i n Utah. and  61  r e g i o n a l c o n d i t i o n s were n o t ready f o r such a l a r g e s c a l e u n d e r t a k i n g ( 7 4 ) . The  many h i g h l y i m a g i n a t i v e  r e p o r t s a r e germane. Darley  and c r e a t i v e i d e a s  i n these  The I n t e r u n i v e r s i t y C o m m u n i c a t i o n s C o u n c i l f o u n d e d by  a n d a s m a l l g r o u p o f i n t e r d i s c i p l i n a r y u n i v e r s i t y p e o p l e i n 1 9 6 5 was  a product  of h i s o r i g i n a l plan f o r the establishment  (163).  S i m i l a r l y , Dimond's p r o p o s a l  Medical  Center would have t h i s  without  w a l l s " (73).  and  inherent  called  t h e AMA P l a n .  f o rthe creation of a National  Center serve  The most r e c e n t  o f a N a t i o n a l Academy Graduate  as the base f o r Dryer's " u n i v e r s i t y  proposal  was t h a t o u t l i n e d b y B l o o m ( 6 )  I n summary i t n o t e s :  1.  Among a l l f o r c e s i n v o l v e d , t h e A m e r i c a n M e d i c a l A s s o c i a t i o n w o u l d be t h e a p p r o p r i a t e l e a d e r i n c o n t i n u i n g e d u c a t i o n , i m p l e m e n t i n g an i n t i m a t e p a r t n e r s h i p w i t h u n i v e r s i t i e s o r m e d i c a l s c h o o l s and R e g i o n a l M e d i c a l Programs.  2.  I n t h i s w a y , t h e AMA w o u l d e x p a n d i t s p r e s e n t p r o g r a m s t o a p p r o v e e x i s t i n g o f f e r i n g s a n d s t i m u l a t e new e f f o r t s i n i t s c o n s t i t u e n t state societies.  3.  What i s n e e d e d i s c l e a r s t a t e m e n t o f t h e AMA r o l e a s a . n a t u r a l p a r t n e r w i t h RMP i n a s s e s s i n g n e e d s a n d e v a l u a t i n g p e r f o r m a n c e , and a s a n a t u r a l p a r t n e r w i t h u n i v e r s i t i e s o r m e d i c a l s c h o o l s i n continuing education.  4.  F u r t h e r , t h e AMA s h o u l d f o r m a l l y i n v i t e o t h e r s t o h e l p d e s i g n a n d j o i n a new s e c t o r f o r g e n u i n e c o l l a b o r a t i o n i n a l l a s p e c t s o f continuing education. T h i s c o u l d be c a l l e d t h e " h e a l t h p r o f e s s i o n s e d u c a t i o n c o u n c i l ; " w i t h r e g i o n a l , s t a t e , and n a t i o n a l components; e a c h composed o f AMA, u n i v e r s i t y a n d RMP e l e m e n t s ( p l u s a n y o t h e r p e r t i n e n t representation). This s e c t o r would guide o p e r a t i o n s of a t o t a l system from i d e n t i f i c a t i o n o f needs t o c u r r i c u l u m t o programs, t o e v a l u a t i o n and feedback. The e x i s t e n c e o f t h i s d e v i c e w o u l d i n t e r r u p t c u r r e n t s e p a r a t i o n w h e r e AMA, RMP, u n i v e r s i t i e s , v a r i o u s p r o f e s s i o n a l s o c i e t i e s a n d m u l t i p l e other forces proceed u n i l a t e r a l l y i n continuing medical education.  Incentives f o r Learning: Under i n c r e a s i n g p u b l i c p r e s s u r e ,  many l e a d e r s  i n medicine  forecast  62 that  the problem of m a i n t a i n i n g  p r o f e s s i o n a l competence i n p h y s i c i a n s  r e s u l t u l t i m a t e l y i n p e r i o d i c mandatory criteria  In the  absence of  f o r measuring " p r o f e s s i o n a l competence," the m e d i c a l  profession  r e m a i n s d i v i d e d on Education  (195)  to physicians  should  has  continuing  education  According  activities  i n Continuing  cover a wider range of Certificate, physicians n i t i o n Award  (128).  i s to o f f e r a  three  and  the  years,  at  the  reported  Award' those  c r e d i t hours  have responded w e l l to  completion of  Education"  but  its first f o r the  has  year,  award  extended  activities.  of  more (61).  as  Physician's  followed  to  this  Recoghas  T h e r e i s some c o n c e r n b e i n g  this  l o s s of  s t a t e m e d i c a l s o c i e t y m e m b e r s h i p w o u l d h a v e on  t o how  such p h y s i c i a n s  medicine than outside  l e a d by  making  a c o n d i t i o n f o r member-  (182).  of organized  e x p r e s s e d as  this  ship  that  scheme  a c o n d i t i o n f o r membership,  medical education  Many f e e l  the  a  Academy o f G e n e r a l P r a c t i c e  education Society  of  this  Upon r e c e i v i n g  q u a l i f y f o r t h e AMA  i t s i n c e p t i o n , the  Oregon S t a t e M e d i c a l  umbrella  For  concrete  hours, i n e l e c t i v e s "  to have q u a l i f i e d  automatically  p a r t i c i p a t i o n i n continuing  "under the  only  A s s o c i a t i o n i s i s s u i n g a s i m i l a r award of  Medical  non-participating physician.  the  h o u r s o r more made up  r e m a i n i n g 90  informal educational  Since  60  150  on  continuing  'Recognition  medical education.  requirements are  of  valid  c o m m i t t e e o f t h e AMA's C o m m i t t e e  c o n d i t i o n f o r r e l i c e n s u r e , but  p a r t i c i p a t i o n i n continuing  r e c e n t l y the  regular  are  California Medical  "Certificate  hoc  t o most a c c o u n t s , p h y s i c i a n s  a c c r e d i t i n g scheme and  The  and  the  i n a period  t h a n 14,000 p h y s i c i a n s  required  be  to q u a l i f y , "the  educational  voluntary  ad  participating i n continuing  wishing  (184).  An  taken i n t h i s respect  physicians  required  issue.  proposed r e c e n t l y that r e g u l a r p a r t i c i p a t i o n i n  medical education a c t i o n t h e AMA  this  relicensure.  will  much e f f e c t the c h r o n i c a l l y are  i t " (6).  better  63  Stein reports and  re-certification  (236)  t h a t " w h i l e the g e n e r a l s u b j e c t of  of l i c e n s e d  p h y s i c i a n s has  t h e F e d e r a t i o n o f S t a t e M e d i c a l B o a r d s and E x a m i n e r s , no  d e f i n i t e d e c i s i o n has  its  ( 5 5 ) , and  intention The  for  the N a t i o n a l Board of  stipulated  t o implement a r e c e r t i f i c a t i o n  devised  h e l p an i n d i v i d u a l  additional  Medical  every  six  announced  (118). a voluntary  test.  examination  I t i s hoped t h a t  i n t e r n i s t become m o r e a w a r e o f h i s d e f i c i e n c i e s  s e e k ways t o c o r r e c t t h e gaps i n h i s m e d i c a l  5,000 o f t h e 1 5 0 , 0 0 0 ACP  members t o o k  the  t e s t , and  knowledge.  since that time,  5,600 members a n d non-members h a v e p a r t i c i p a t e d .  Rosenow ( 2 1 3 ) , t h e r e a c t i o n s t o t h e e x a m i n a t i o n  this so  Initially, an  According  to  have been e n t h u s i a s t i c .  More  r e c e n t l y , the American P s y c h i a t r i c A s s o c i a t i o n ( 4 0 ) , the American C o l l e g e Pediatrics  (69) , and  developing  similar  o t h e r n a t i o n a l s p e c i a l t y a s s o c i a t i o n s (142)  are  of  reported  programs.  Commenting on to  by  newly e s t a b l i s h e d  recertification  procedure  A m e r i c a n C o l l e g e o f P h y s i c i a n s has  t h a t he w i l l  The  r e c e n t l y , the American Board of I n t e r n a l Medicine  i n t e r n i s t s w h i c h s e r v e s as a s e l f - a s s e s s m e n t  will  been r e p e a t e d l y d i s c u s s e d  been reached."  American Board of F a m i l y P r a c t i c e has years  by  re-examinations  the v a r i e d approaches c u r r e n t l y being  ensure p r o f e s s i o n a l competence, M i l l e r  (159)  tried  i n an  effort  writes:  The p u r p o s e o f l i c e n s i n g i s t o c e r t i f y t h a t c o m p e t e n c e h a s b e e n a c h i e v e d , n o t t o s p e l l out the method o f a c h i e v i n g i t , or e q u a t i n g p a r t i c i p a t i o n i n a s p e c i f i e d number o f w h o l e s o m e a c t i v i t i e s w i t h achievement of the g o a l . The A m e r i c a n Academy o f G e n e r a l P r a c t i c e h a s a l r e a d y d o n e s o a n d i s o f t e n commended f o r t h e c o u r a g e o u s d e c i s i o n t h a t made p a r t i c i p a t i o n i n a c c r e d i t e d p r o g r a m s o f p o s t graduate e d u c a t i o n a requirement f o r c o n t i n u e d membership. One can o n l y applaud the motives t h a t l e d to t h i s d e c i s i o n , but the t h o u g h t f u l may q u e s t i o n t h e p h i l o s o p h y u n d e r l y i n g i t a n d t h e p r a c t i c e s accompanying i t . For the s p i r i t of t h i s r e s o l u t i o n seems t o s a y , t h a t h a v i n g l e d a h o r s e t o w a t e r , y o u c a n make h i m d r i n k . In Education  t h e same v e i n , a r e c e n t o f t h e New  statement  i s s u e d by  Y o r k Academy o f M e d i c i n e  (55)  t h e C o m m i t t e e on  concludes:  Medical  64 . . . t h e c e r t i f i c a t e c o n c e p t , i f j u d g e d o n l y on t h e b a s i s o f t o t a l n u m b e r o f h o u r s i n some k i n d o f p o s t g r a d u a t e c o u r s e i s f a l l a c i o u s i n t h a t i t i m p l i e s unwarranted m e r i t to c o u r s e work. The c o m m i t t e e a l s o s t r o n g l y o p p o s e s any m a n d a t o r y e x a m i n a t i o n s f o r m a i n t e n a n c e o f t h e c u r r e n c y o f o n e ' s m e d i c a l l i c e n s e . The a v a i l a b l e i n f o r m a t i o n does not s u p p o r t a p o s i t i v e r e l a t i o n between the r e s u l t s of most s u c h t e s t s and t h e q u a l i t y o f c a r e p r o v i d e d by p r a c t i s i n g p h y s i c i a n s for their patients... Accordingly,  this  c o m m i t t e e recommends: "the  b a s e d on management t y p e o r a u d i t  establishment  of  programs  type p r o c e d u r e s whereby b o t h h o s p i t a l  c o m m u n i t y p h y s i c i a n s may  p a r t i c i p a t e i n mass a u d i t e x e r c i s e s , r e v i e w i n g  other's  room c h a r t s  charts  particular their  or record  diseases  w h i c h m u s t be  g e n e r a l l y , to i n d i c a t e features  considered  and  appropriate  and each  of  approaches  in  management." Whatever the m e r i t s  clearly medical  the  trend  education"  and/or l i m i t a t i o n s of  these v a r i e d  approaches,  i s "to give recognition for p a r t i c i p a t i o n i n (61).  continuing  65  CHAPTER  V  INSTRUCTIONAL PROCESSES  In medicine,  the l i t e r a t u r e  the terms a p p l i e d to i n s t r u c t i o n a l processes  n a t e l y and of  d e s c r i b i n g programs of c o n t i n u i n g e d u c a t i o n  without  the processes  terminology  e i t h e r p r e c i s i o n or consistency.  are inadequate  of a d u l t education  as p r e s e n t e d  r a t h e r than  Since  to allow t r a n s l a t i o n i t w i l l be  attempting  necessary  are used  into  p o s s i b l e to i d e n t i f y course  techniques  the- s t a n d a r d literature  to synthesize i t .  employed  the major methods.  i n t e r m i t t e n t , and  methods e n c o u n t e r e d clinical practice,  (255).  The  clearly  differentiate  Nevertheless, i t i s  most used method i s t h a t of  circuit  i n c l u d e ward rounds, and  courses case  the d i s c u s s i o n group.  The  of attempts  to assess  clinical  literature  Other,  conferences,  i n which  there i s scant  the e f f e c t i v e n e s s of the methods nor  the  being  described earlier.  seminars,  m e t h o d s a r e d i s c u s s e d i s p r i m a r i l y d e s c r i p t i v e and  these  evidence  t o compare  one  another. The  described those  the d e s c r i p t i o n s  o r c l a s s w i t h t h r e e major v a r i a n t s o r p a t t e r n s of t h i s method  the continuous,  with  indiscrimi-  t o summarize the  Among o t h e r t h i n g s , t h e r e p o r t s o f p r o g r a m s do n o t b e t w e e n t h e m e t h o d s and  in  techniques  of i n s t r u c t i o n r e p o r t e d are e q u a l l y p o o r l y d e f i n e d  so t h a t terms d e s c r i b i n g methods a r e u s e d i n t e r c h a n g e a b l y  identifying  techniques.  a r e o f t e n t r e a t e d as  Furthermore,  instructional  l a n g u a g e makes i t v i r t u a l l y  i n s t r u c t i o n a l aids or  techniques.  The  i m p o s s i b l e to assess  o f v a r i o u s p r o g r a m d e s i g n s w i t h any  validity.  and  with  devices  resultant confusion i n  the comparative  It i s clear  that  effectiveness those  66  c o n d u c t i n g programs f o r c o n t i n u i n g e d u c a t i o n i n medicine a b o u t how  learning occurs i n adults,  l e a r n i n g , nor  skilled  W h i l e no importance, considered  one  of i n f o r m a t i o n .  facilitate  I n 1940, has  thought  that followed.  Any  (256), Dryer  ( 7 9 ) , and  of a wide v a r i e t y  of p a r t i c i p a t i v e  C o u n c i l ' s r e v i e w o f t h e 1964-1965 A n n u a l courses  defined  listed,only  i n t h i s s u r v e y as  22percent  Course  specified  "the l e c t u r e ,  should  expressed,  was  i n t h e many r e p o r t s  definition,  Listing  Listing  the use  on  courses  consistently Thus  r e v e a l e d t h a t of  the the  of s o l e l y d i d a c t i c ' f o r m a t s brief  audio-visual aids"  o f t h e 2,016  have  techniques.  t h e l e c t u r e and  p e r i o d , o r t h e s e p l u s p a n e l d i s c u s s i o n and t h e same r e s t r i c t i v e  conferences  (65).  In the meantime, courses r e p o r t e d i n the Annual  1,529  and  are  along with a lengthy explanatory section  s p e c i f i c ways t o i n c r e a s e p a r t i c i p a t i o n i n l e a r n i n g  the use  instruction  t h e C o u n c i l on M e d i c a l E d u c a t i o n i n c o r p o r a t e d t h e  recommendation i n i t s Guide,  publicized  techniques.  w e l l conceived program  This recommendation,variously  (174), V o l l a n  I n 1957  of the g r e a t e s t problems  e x p e r i e n c e under guidance,  a r e the most s u c c e s s f u l forms of t e a c h i n g .  r e p e a t e d by Norwood  recipient  lectures...while didactic lectures  firsthand  (227).  generally  the l e a r n e r i s a p a s s i v e  s t a t e d , "too o f t e n postgraduate medical  valuable, demonstrations,  these methods"  a l lothers i n  of n o n - p a r t i c i p a t i v e , or d i d a c t i c  b e e n g i v e n s o l e l y by d i d a c t i c  stress  instruction.  to outweigh  I n c o n t i n u i n g m e d i c a l e d u c a t i o n one  Rappelye  achieve  the a p p l i c a t i o n of knowledge are  s u p e r i o r to those i n which  has been the e x c e s s i v e use  to  knowledgeable  INSTRUCTION  t e c h n i q u e c a n be  those which t o be  the c o n d i t i o n s e s s e n t i a l  i n t h e d e s i g n and management o f  PATTERNS OF  are not  listed  discussion (57).  Using  i n 1969-1970,  67  r o u g h l y 20 p e r c e n t All  indicated  others specifying  work, or c l i n i c a l  the use  of o n l y n o n - p a r t i c i p a t i v e  t h e l e c t u r e and  conferences  such  t h i n g s as  techniques.  the seminar, l a b o r a t o r y  (59).  These f i g u r e s a l o n e are m i s l e a d i n g , s i n c e the m a j o r i t y of c o u r s e s continuing medical education are both enrollment reaches difficult  t h e h u n d r e d s , and  to incorporate a v a r i e t y  active learner participation  s h o r t t e r m and time i s l i m i t e d ,  (57).  still  other d i d a c t i c techniques The  (88)  Council's survey  techniques  remains r e l a t i v e l y said  (57) .  would  I t i s not s u r p r i s i n g  make u s e (129)  format  i s no  of the l e c t u r e ,  When  extremely  facilitate  therefore, that i n longer reported symposia,  and  (267) .  b y m e d i c a l and  specialty  More r e c e n t a c c o u n t s  unchanged, but  (220),  panel,  i n 1956-1957 r e v e a l e d t h a t a s i g n i f i c a n t l y  p r o p o r t i o n of courses sponsored didactic  i t becomes  of t e c h n i q u e s which  a c t u a l p r a c t i c e , w h i l e the p u r e l y d i d a c t i c the m a j o r i t y of sponsors  f o r l a r g e groups.  in  suggest  t h e s t r u c t u r e and  s o c i e t i e s used that the  quality  to vary c o n s i d e r a b l y according to the p a r t i c u l a r  larger solely  situation  of programs i s  society  i n v o l v e d (263) .  Thus, the C a l i f o r n i a M e d i c a l S o c i e t y i s r e p o r t e d r e - s h a p i n g i t s programs facilitate graduate ratio  g r e a t e r p h y s i c i a n p a r t i c i p a t i o n and  i n s t i t u t e s w e r e h e l d w i t h 885  o f 1:10.  Similarly  i n 1968,  seven r e g i o n a l  (230)  some o f t h e n a t i o n a l m e d i c a l c o n f e r e n c e s  period;  and as  seminars  (263).  Rhue r e p o r t e d t h a t i n 1 9 6 3 , indicated  post-  p a r t i c i p a n t s but w i t h a f a c u l t y - s t u d e n t  c o n v e n t i o n s a r e a l s o r e p o r t e d u s i n g more s m a l l group methods s u c h or c l i n i c s  to  43 p e r c e n t o f t h e r e s p o n d i n g m e d i c a l  schools  t h a t t h e y v/ere u s i n g t h e l e c t u r e a l o n e o r l e c t u r e p l u s q u e s t i o n  21 p e r c e n t l i v e  clinics;  9 p e r c e n t l a b o r a t o r y w o r k ; and  20 p e r c e n t g r o u p c o n f e r e n c e s  7 percent bedside  rounds  and  (220) .  u n p u b l i s h e d survey of Canadian m e d i c a l s c h o o l s r e v e a l s s i m i l a r  seminars;  A more r e c e n t findings  (241).  68  I n b o t h Canada and t h e U n i t e d programs suggests t h a t g r e a t e r supervized future  clinical  (235) Of  the expansion of r e g i o n a l  u s e w i l l b e made o f s m a l l g r o u p  p r a c t i c e and o t h e r  more p a r t i c i p a t i o n  seminars,  techniques  i n the  (97).  t h e s p e c i a l t i e s , p s y c h i a t r y has c o n s i s t e n t l y o f f e r e d the g r e a t e s t  number o f c o u r s e s w i t h defined  States,  enrollment  limited  as any l e a r n i n g group w i t h  n o t e d , i t makes t h e g r e a t e s t  t o s m a l l groups  (arbitrarily  25 p a r t i c i p a n t s o r l e s s ) a n d , a s p r e v i o u s l y  use of i n t e r m i t t e n t scheduling ( 5 9 ) .  SMALL GROUPS The clinical  s m a l l d i s c u s s i o n group r e f e r r e d t o v a r i o u s l y as t h e s e m i n a r , o r  conference,  i s widely  used i n c o n t i n u i n g medical  education  p r e v i o u s l y n o t e d , s u r v e y s d i s c l o s e t h a t many p h y s i c i a n s p r e f e r lecture. the  Sheeley  (226) r e p o r t s  same p s y c h i a t r i c c o u r s e s i m u l t a n e o u s l y  and  registrants while  The l e c t u r e s e r i e s h a d o v e r  t h e d i s c u s s i o n s e r i e s a t t r a c t e d none.  Since  acceptance  a c t i v e p a r t i c i p a n t i n v o l v e m e n t a r e two p r i m a r y f a c t o r s i n t h e e f f e c t i v e n e s s  Psychiatric  Case  psychiatrists held  the varying  (239) concluded  i n t h e f r e e g i v e and t a k e  be i n i t i a l l y a t r a u m a t i c  didactic  r e s u l t s of a p s y c h i a t r i c course f o r non  i n three Washington counties  Stuen and h i s a s s o c i a t e s taking part  i t suse.  Seminars:  In reviewing  can  offered  by two d i f f e r e n t methods: a s e r i e s  o f t h e d i s c u s s i o n g r o u p m e t h o d , i t may b e u s e f u l t o i l l u s t r a t e  of  as  the formal  an experiment i n which an i n s t i t u t i o n  of l e c t u r e s and a s e r i e s o f d i s c u s s i o n s e s s i o n s . 25  but,  experience.  approach then g r a d u a l l y  shifting  over a three year  t h a t many p h y s i c i a n s  period,  are not capable  of the p s y c h i a t r i c seminar T h e y recommended b e g i n n i n g to the study  which with  a  o f c a s e m a t e r i a l s and  69  the use by  of d i s c u s s i o n .  keeping  the  participated  B r o d y and  his colleagues  group under t e n , even the most " d i f f i d e n t  p r o j e c t , Mead  on  the  (151)  concluded  concluded  with  their  in insufficient  p r o j e c t was To  t h a t the  modified  cases were l e a s t l i k e l y solely  preparation  on  i n b a s i c m e t h o d o l o g y , so  t o i n c l u d e l e c t u r e s as w e l l as  m a t t e r how  the  Clinical  c u r r e n t w i d e s p r e a d use the  greatly modified,  course"  Utah was  to  also  practice Utah  discussions.  discuss  the program i n Elmhurst,  of  to each seminar,  their  B a l i n t s have emphasized t h a t  who  appointment  New as  (22).  original psychiatric "such v e n t u r e s ,  r e q u i r e much m o r e t i m e t h a n t h e p o p u l a r  no  week-end  (17).  Conferences:  One  of  t h e more i n t e n s i v e t y p e s o f c l i n i c a l  consecutive  case conference  a panel  discharged.  the  reluctance  He  that the  case o r i e n t e d  o f f e r i n g i n d i v i d u a l p s y c h i a t r i s t c o n s u l t a t i o n s by  case seminar technique,  of  to r e c e i v e i t .  an h o u r ' s c o n s u l t a t i o n s e r v i c e p r i o r  C o m m e n t i n g on  c a s e as  actively  four state  cases from the p h y s i c i a n s '  circumvent the problem of a p h y s i c i a n ' s  York incorporated  In t h i s ,  that  degree of p h y s i c i a n p a r t i c i p a t i o n  case problems i n the p s y c h i a t r i c group s e t t i n g ,  the  physician  p s y c h i a t r i c case seminar used i n the  that concentrating  resulted  G.P.  found  r e l a t e d to h i s f a m i l i a r i t y w i t h p s y c h i a t r y , thus those p h y s i c i a n s  most needed h e l p  w e l l as  (31)  i n discussion."  Reporting  directly  In Brooklyn,  The  of experts  analyzes  physicians  are  i t comes u n d e r r e v i e w . CCC  (CCC)  devised the  required  charts  management o f  the  their  own  case with  of  ten patients  Although i t i s stressed  p e r f o r m a n c e and the h e l p  is  the American Heart A s s o c i a t i o n .  to account f o r t h e i r  i s e d u c a t i o n a l , namely, to p r o v i d e  t o r e f l e c t b a c k on  by  conferences reported  "an  conduct of  t h a t the  opportunity  to gain  consecutively  for  insight into  of acknowledged e x p e r t s "  each  purpose physicians the  (270),  most  70  w r i t e r s agree on  the  (270)  part  (263)  of  (254)  the  w h i c h compared the  t e s t e d by  that  i t requires  practising physicians.  i n improving c l i n i c a l as  (282)  relative  A s t u d y by  e f f e c t i v e n e s s of  judgement, found  simulated  considerable  "no  ego  Williamson  the  CCC  and  strength and  the  overall significant  McGuire  lecture  difference  p a t i e n t problems s i x months a f t e r c o m p l e t i o n of  the  instruction." More s u c c e s s f u l programs u s i n g of i n d i v i d u a l p h y s i c i a n s solving  (97)  (235)  and  (162).  this  focussed  Vaneslow  on  approach have s t r e s s e d  g r o u p p r o b l e m s and  (254)  quotes Slee  as  the  group  saying  anonymity  problem  that  some  m e d i c a l d i r e c t o r s have committed " p r o f e s s i o n a l s u i c i d e because they f a i l e d take, i n t o c o n s i d e r a t i o n  the w o r r i e s  consequences of a program of Far  less threatening  programs i s the as  a basis  clinical  for general  this and  the  two  revealed  p r o g r a m and that  the  reported  a  group engaged i n the  other  d i d not.  amount o f p r e p a r a t o r y  increase  i n the  experimental  change i n the  the  by  Results the  despite  Follow work  group.  amount o f d i s c u s s i o n  l e a r n e r group.  time u t i l i z e d  significantly  extra  there  to the  differ  material  At McMaster U n i v e r s i t y a time l o g i s kept to determine whether a progressive  groups d i d not  Cudmore (67)  case  extra  faculty versus  the  teacher  own  the  encouragement g i v e n  is  the p h y s i c i a n s '  r e s u l t s when one  physicians  possible  used i n community h o s p i t a l  compared the  p r i o r to a v i s i t i n g  u n d e r t a k e n by  therefore widely  T u p p e t t and  preparation  the  type."  discussion.  study that  interviews with  the m e d i c a l s t a f f r e g a r d i n g  conference using  preliminary  up  of  to  t i m e u s e d by  t o d a t e h a v e shown no  practising physicians  the  visiting  significant  participating in  program.  Demonstrations; Supervised In psychiatry  Clinical  a number o f  Practice:  courses are  reported  w h i c h combine the  case  71  conference  approach w i t h p a t i e n t demonstrations,  supervized  clinical  the use  of the  discussions  practice.  patient  (26)  (28)  by L e v i n s o n  (274).  (98)  Also reported  role playing  (140)  situations prior  Fleisher  programs feedback p r o v i d e d  two-way m i r r o r a n d / o r v i d e o t a p e  u s e s o f p s y c h o d r a m a and described  In these  return demonstration,  (26).  serve  as  from t h i s  field  successful  i n which the p h y s i c i a n p a r t i c i p a n t s re-enact  t o and  following their  clinical  experiences.  r e p o r t s t h a t at the U n i v e r s i t y of  Southern  California,  device  State College  been developed  further at Michigan  r o l e of p a t i e n t s .  of C o l o r a d o where p r e l i m i n a r y work i n d i c a t e s a f a i r l y o b j e c t i v i t y on  In  are  A t y p i c a l example i s t h a t  the  of student  the p a r t of  the a c t o r s , thereby  l e a r n i n g c o u l d be c o n t r a s t to the  and  reliable  suggesting  degree  t h a t an  f o r e g o i n g , K e r n e t a l (130)  T h i s has  same u n s t r u c t u r e d  been evaluated  suggest that t h i s t h e i r own of  favourable  roles,  i s capable  of  classroom  a visiting  teacher  Pennsylvania  to the  physicians  that used i n t r a i n i n g  ambiguous s i t u a t i o n  on  residents.  which  the p h y s i c i a n s  r e q u i r i n g frequent  fostering self-learning  and  for  changes  an a t t i t u d e  change.  A number o f p r o g r a m s r e p o r t e d from the  work as  i s placing responsibility  i n an  to implementing  field  p r o j e c t i n community p s y c h i a t r y  p h y s i c i a n s responses to questionnaires  technique  l e a r n i n g and,  s t y l e and  by  assessment  Hopkins  D e m o n s t r a t i o n Week" i n w h i c h p r a c t i s i n g  the  experimental  at Johns  u s i n g what they  "The  of  possible.  an  call  This  the U n i v e r s i t y  U n i v e r s i t y have d e s c r i b e d  experience  through  the b a s i s f o r group  p r o f e s s i o n a l a c t o r s have been t r a i n e d t o p l a y has  and  clinical  also provide  practice field.  p r o g r a m c o n d u c t e d i n one  i n which a consultant  e v i d e n c e o f a movement Richardson  (202)  described  s m a l l community h o s p i t a l i n  allergist visited  the  allergy  clinic  every  72  two  weeks.  At  t h i s v i s i t , s p e c i a l i z e d techniques  local physicians therapeutic local of  p r a c t i c e d the  plans  the  St. Justine's Children's  a c o n s u l t a t i o n s e r v i c e i n w h i c h two a community h o s p i t a l .  whom t h e  family physicians present  to Rosier medical  a l l cases.  (215),  this  education,  of a q u a l i f i e d  a l s o as  and  Federman  program i n which three  general  gency department of a t e a c h i n g clinical  i s of p a r t i c u l a r  other  (202). has  reported  fruitful,  a way  of p r o v i d i n g  (106)  have d e s c r i b e d  days  family physicians  f o r e x a m i n a t i o n and  the  p r a c t i t i o n e r s served hospital while  i n s t r u c t i o n on  While t h i s program i l l u s t r a t e s  lities  and  p e d i a t r i c i a n s s p e n d two  afternoon  t h e y see  in  and  outpatients  consultation. "not  aim  only  in  public with  According  continuing the  services  consultant."  Goldfinger  supervized  In the  experiment i s proving  but  visits  Hospital i n Montreal  to three  the  I t i s the  consultant  I n t h e m o r n i n g t h e y meet w i t h  do w a r d r o u n d s , r e v i e w i n g  sessions,  to l o c a l p h y s i c i a n s  The  formulated  treatment plans.  t h e number o f  t r a n s f e r of r e s p o n s i b i l i t y  Similarly,  Between c l i n i c  implement the proposed  program to decrease g r a d u a l l y  increase  u n d e r s u p e r v i s i o n and  for selected patients.  staff physicians  this  techniques  were demonstrated.  the  interest i s that  automatically defined h a n d , Brown  (33)  the  the  to r e t r a i n i n a c t i v e p h y s i c i a n s  the  conventional  t r a i n e e s h i p p r o g r a m was  not  only  l e a r n i n g needs.  course using  curriculum  for physicians  c l a s s should  what  On  the  experimental found  i n a d e q u a t e f o r a g r o u p who  didactic instruction.  in this  an  i n w h i c h i t was  r e l u c t a n t t o assume p a t i e n t r e s p o n s i b i l i t i e s , b u t review  techniques.  of the ward r e s p o n s i b i -  Center described  project designed  systematic  and  t r a i n e e s h i p i n most r e s p e c t s ,  emergency n a t u r e  Medical  emer-  lectures  i n t e n s i v e care  the p h y s i c i a n s ' r e a l  at P a c i f i c  refresher  as housemen i n t h e  receiving formal  latest  typical  a successful  required  that  were a  T h e y recommend t h a t  c o n s i s t of  two  phases:  an  the  73 intensive review  course  program o f s u p e r v i z e d  on b a s i c a s p e c t s  of c l i n i c a l  patient contact with a gradual  m e d i c i n e f o l l o w e d by a assumption o f r e s p o n s i -  bility. The  o n l y r e p o r t o f an ongoing i n s e r v i c e t r a i n i n g program  in  t h e l i t e r a t u r e was t h a t d e s c r i b e d  in  group p r a c t i c e , t h i s program u t i l i z e d  emphasis on c l i n i c a l patients.  cases, with Consultant  standing  two y e a r s  also felt  to referral  therapy  before  diagnostic studies."  a simulated  coronary  care u n i t a t t h e P a c i f i c Medical r e g u l a r l y scheduled  being under-  presentations  treatment  of heart  topics.  centers  the arrthymias;  c a r t r i d g e s ; and f i l m s t r i p s ) on t h e c a r e and  disease;  and computer programming on v a r i o u s these  preceptorships  programs  coronary  classes, consultative services are a r e arranged  T h i s program has been r a t e d so h i g h l y t h a t o t h e r or modified  classroom  conducting  film  and p o s t - g r a d u a t e  coronary  The equipment u s e d f o r  (slides;  In conjunction with  Center, the  c l a s s e s on  s i m i l a r programs i n c l u d e : tapes and m o n i t o r s f o r t e a c h i n g  similar  i n problem  o f t h e problems i n v o l v e d .  for m u l t i p r o f e s s i o n a l health personnel.  provided  ordered  and t h a t r e f e r r a l n o t e s d i s p l a y e d a f u l l e r  i n s t r u c t i o n and which i s a v a i l a b l e f o r l o a n t o other  care  with  t h a t b e t t e r p a t i e n t assessments were  W a s h i n g t o n / A l a s k a RMP i s c o n d u c t i n g  A.V,  sessions  indicated that, i n general,  l a b o r a t o r y and X-ray s t u d i e s were b e i n g  specialists  Using  care  S p o n s o r e d b y 60 p h y s i c i a n s  s m a l l group bedside  audit after  l e s s tendency t o i n i t i a t e  performed p r i o r  (124).  d i a g n o s i s a n d t h e management o f t h e p a r t i c i p a n t ' s own  A f o l l o w up m e d i c a l  "more a p p r o p r i a t e  by Jampol  encountered  for physicians  RMPS a r e r e p o r t e d  (261).  developing  (252) .  LARGE GROUPS Instruction provided  t o l a r g e groups must f o c u s  on t e c h n i q u e s  which  74  will  enhance p a r t i c i p a n t i n t e r a c t i o n .  groups, there descriptive with  are  few  studies  respect  to the  studies  selected use  of  of  i t s use  for this  the  Despite and  the w i d e s p r e a d use  effectiveness.  review are  The  particularly  of  large  two  informative  l a r g e group i n i n t e r p r o f e s s i o n a l c o n t i n u i n g  education. Harshbarger  (194)  i n v e s t i g a t e d a community m e n t a l h e a l t h  a t t e n d e d by  some 80  i n d i v i d u a l s from v a r i o u s  participant  o b s e r v e r s g a t h e r d a t a on  s m a l l b u z z g r o u p s and the  reports  that while sessions,  a c o m p a r i s o n was  s t i m u l a t i n g and t h e s e were not  reported  The  the v a r i o u s  total  issues  the  discussed  observers'  group.  Their  back to the  characterized t o be  total  most of  the  summaries  and  revealed  small  group  Instead,  reports.  c r e a t i v e f o r u m s f o r new  in  findings  group. the  had  ideas,  p r o f e s s i o n a l p a r t i c i p a n t s m u s t be  This  study  the  tradi-  disrupted."  r e c o m m e n d a t i o n s s t r e s s the need f o r more e f f e c t i v e f e e d b a c k mechanisms  s u c h as  that provided  essential  by  p a r t i c i p a n t o b s e r v e r s who  contrasting professional viewpoints  a s s e m b l y f o r f u r t h e r d i s c u s s i o n and Schlesinger s y m p o s i u m on  (221)  He  d i d a c t i c f o r m a t and the  audience.  objectives while  of the  general  reported  epilepsy presented  health workers.  and  pertinent  He  m e a n i n g f u l problems were r a i s e d i n the  " I f workshops are  t i o n a l r o l e s of  health professions.  made o f  from each buzz group t o the  "professional overpoliteness" concludes:  the  workshop  found that the He  would ensure that  w o u l d be  relayed  the  to the  larger  clarification.  a questionnaire  to a d i v e r s e the h i g h e s t  evaluation  of a three  group of p h y s i c i a n s  mean r a t i n g was  given  and to  day  other the  lowest to exchanges between s p e a k e r s , p a n e l i s t s ,  also  found that  p a r t i c i p a n t s and  the  t h e r e was  a discrepancy  content of  p r a c t i t i o n e r s were r e l a t i v e l y  the program.  satisfied with  between  the  Furthermore,  the.program,  75 specialists matter.  expressed  d i s s a t i s f a c t i o n w i t h the broad  The n u r s e p a r t i c i p a n t s e x p r e s s e d  topics y e t , the author noted,  r e l e v a n t to the nurses'  that the findings of t h i s  problems i n h e r e n t i n l a r g e  of subject  a high degree of i n t e r e s t  " t h e s u b j e c t m a t t e r was g e a r e d  and much o f i t w a s o n l y i n d i r e c t l y may i n f e r  coverage  study merely  i n a l l  to physicians  interests."  One  r e i t e r a t e one o f t h e b a s i c  l e a r n i n g g r o u p s — " H o w w i d e a n e t s h o u l d be  cast,  a n d how l a r g e s h o u l d t h e o p e n i n g b e ? "  MASS MEDIA The  radio,  t e l e v i s i o n , and t h e t e l e p h o n e  u b i q u i t o u s communication been used but  devices i n North America.  A l l three of these  t h a t they have been used  to provide systematic  T h e s e m e d i a p r o v i d e a way o f e x t e n d i n g t h e r a n g e  t o many g r o u p s a n d o b v i a t e t h e n e c e s s a r y group a t a s p e c i f i e d  instructional  l o c a t i o n w i t h an i n s t r u c t o r p r e s e n t i n person.  e d u c a t i o n t h a n w i t h any o t h e r s u b j e c t a r e a .  to l e a r n i s generally high.  I n some  i n continuing medical  T h i s i s d u e , no d o u b t ,  that the potential participants are clearly  instruc-  o f an i n s t r u c t o r  of forming a s p e c i f i c  r e s p e c t s , t h e s e m e d i a have been used more e x t e n s i v e l y  fact  have  f o r many y e a r s t o d i f f u s e new m e d i c a l i n f o r m a t i o n t o p h y s i c i a n s  i ti s only recently  tion.  a r e t h r e e o f t h e most  identified  to the  and t h e m o t i v a t i o n  U n f o r t u n a t e l y t h i s p a t t e r n o f i n s t r u c t i o n has  not been s t u d i e d a d e q u a t e l y . Radio  Conferences: A most n o t e w o r t h y  i n n o v a t i o n i n c o n t i n u i n g m e d i c a l e d u c a t i o n has been  t h e two-way r a d i o c o n f e r e n c e p i o n e e r e d b y W o o l s e y a t A l b a n y In t h e t y p i c a l program, p h y s i c i a n s gather around and  receiver set located  i n their  C o l l e g e i n 1955 ( 2 7 9 ) .  a combination  community h o s p i t a l s .  transmitter  Following a brief  76  l e c t u r e by m e d i c a l hospitals  take  Frequently, to  school personnel,  turns  i n submitting  s l i d e s and  other  questions  medical  England Medical  lecturers.  supplementary m a t e r i a l s d i s t r i b u t e d  i n advance  a limited  In the  f o u r t h year  c o l l e g e s and  Physicians i n a f f i l i a t e d  to  t o and  m a t e l y 1,298  colleges.  of o p e r a t i o n , Woolsey r e p o r t e d  h o s p i t a l s were p r o v i d e d questions  I n 1963,  Ebbert  felt  t o be  considerable.  The  m o r e t h a n one  h u n d r e d p r o g r a m s and  Woolsey a l s o d e s c r i b e s  with s i x medical as  schools  a medical  i n 15  the  a new  decided  on  these  participating  states.  This  h i s d i a g n o s i s and  treatment,  case"and presents  has  been completed, p h y s i c i a n s d i s c u s s the  the  h i s approach to the problem.  approxiradio  listened  This  to  fee  covers  materials  offered co-operatively program i s  case which the p h y s i c i a n s f i r s t a n a l y z e procedures.  the  participating  per h o s p i t a l .  program format being  the  communication.  to each  in  from  that  supplementary i n s t r u c t i o n a l  f o r m l i s t i n g a v a r i e t y o f p o s s i b l e t e s t s and  skilful  estimated  r e a c h e d by  cost  h o s p i t a l i n t h e A l b a n y N e t w o r k i s $700 p e r y e a r  p a n t has  (80)  New  opportunity  experts  I n a d d i t i o n , t h e number o f u n c o u n t e d p h y s i c i a n s who  t h e p r o g r a m s was  presented  w i t h an  to f a c u l t y  the  five  hospitals participating  p h y s i c i a n s i n 36 h o s p i t a l s w e r e b e i n g  conferences.  (277).  program.  s c a l e , 21 h o s p i t a l s w e r e l i n k e d w i t h  t o d i r e c t comments and  d i f f e r e n t medical  the  their affiliated  network. listen  participating  comments t o t h e  begun on  college.  i n the  and  the h o s p i t a l s are used i n c o n j u n c t i o n w i t h Initially  six  physicians  on  a special  A f t e r each  instructor When t h e  partici-  analyzes  presentation  c a s e management v i a two-way r a d i o  P r e l i m i n a r y s t u d i e s s u g g e s t t h a t p h y s i c i a n s become more  i n their diagnosis  after  experience  with  t h i s approach to  case  management. Farber a 500  mile  (95)  estimates  r a d i u s are  t h a t p r e s e n t l y - m o r e t h a n 800  participating  physicians within  i n t h e programs c o n d u c t e d by  the U n i v e r s i t y  77  of C a l i f o r n i a  School  lecture notes  and  hospitals. broadcast  at their  More than  convenience.  To  "the medical  i f any,  by R i c h a r d s o n  radio series  through  (201)  the use  of before  a c o n t r o l group c o n s i s t i n g show a s t a t i s t i c a l l y  The  d i f f e r e n c e f o r the medium o f r a d i o has  1968,  a series  to  s u c c e s s f u l , s o i t was  and  step with  proposed Multi-Media  e v a l u a t i o n s of the e f f e c t i v e n e s s  after had  attempted  control  planned  that a  t e s t s of knowledge g a i n . participated  g r o u p , and  no  i n the  program,  was  able  between  the  statistically  group.  s c a r c e l y been used i n Canada. was  was  to evaluate  o f 12 n o n - p a r t i c i p a n t s , R i c h a r d s o n  The  only  report  that from the U n i v e r s i t y of A l b e r t a .  of twenty-one r a d i o seminars  were o f f e r e d .  to extend  These were  the b r o a d c a s t s  Information Retrieval  Saskatchewan r e p o r t s plans in  practitioners.  have been a major  s i g n i f i c a n t mean s c o r e d i f f e r e n c e o f 1.6  of a v i a b l e program encountered  its  been from g e n e r a l  This study  second t e s t s f o r the experimental  significant  any  California  only o b j e c t i v e e v a l u a t i o n found  a s a m p l e o f 70 v o l u n t e e r p h y s i c i a n s who  and  hear  into outlying districts  meaningful  i n 1963.  be  has  concepts  undertaken  first  t h a t p h y s i c i a n s may  r a d i o conferences  The  to  participating  date, the f i n d i n g s of the  o f two-way r a d i o c o n f e r e n c e s .  and  speakers'  expenditure."  T h e r e have been few,  Using  copies of  e a c h week t o  the programs so  i n b r i n g i n g the most r e c e n t  a minimum o f  1,510  p r e s e n t a t i o n s are mailed  show t h a t t h e g r e a t e s t r e s p o n s e  concludes:  forward  case  Many h o s p i t a l s t a p e  experience Farber  of Medicine.  (7).  felt  As  part  System, the U n i v e r s i t y  to e s t a b l i s h a province-wide  In  of  of  radio-telephone  series  c o - o p e r a t i o n w i t h t h e C.B.C. ( 1 3 ) .  Medical Radio An Radio  Network:  experiment  Network has  i n the use  o f r a d i o i s r e p o r t e d by A i t k e n ( 4 ) .  been e s t a b l i s h e d i n Boston  which broadcasts  musical  A  Medical programs  78  into  the p a r t i c i p a t i n g physician's  interrupted the of  doctor  office  every hour by a f i f t e e n may l i s t e n , w i t h  t h e f o u r programs  three  twelve hours a day.  The m u s i c i s  t o t h i r t y minute m e d i c a l program t o which  opportunities  each day t o l i s t e n  t o each  offered.  Telelectures: A pilot telelectures described by The  project  to provide  education  to physicians v i a  o r a m p l i f i e d telephone a t t h e U n i v e r s i t y of W i s c o n s i n has been  by Meyer  (156).  Initiated  p r i v a t e telephone l i n e s general  continuing  i n 1965, seventy h o s p i t a l s a r e l i n k e d  to the University's Medical  program format f o l l o w s  including a b r i e f lecture with  t h a t used w i t h  s l i d e s followed  P a r t i c i p a t i n g h o s p i t a l s take turns  Communication  t h e two-way r a d i o  by d i s c u s s i o n  s u b m i t t i n g .questions  Center. conferences,  period.  and comments.  According  t o M e y e r , i n t h e 1967-1968 a c a d e m i c y e a r 80,000 i n d i v i d u a l h o u r s o f i n s t r u c t i o n were g i v e n  with  "neither  ties or their health  f a c u l t y n o r s t u d e n t s m o v i n g away f r o m t h e i r  care  responsibilities."  Fortney  (101) r e p o r t s  communithat the  M i s s o u r i RMP h a s e s t a b l i s h e d a s i m i l a r t e l e p h o n e n e t w o r k l i n k i n g many o f t h e remote h o s p i t a l s i n M i s s o u r i w i t h The  S o u t h C a r o l i n a RMP i s o f f e r i n g c o n s u l t a n t  of malignant diseases way  the u n i v e r s i t y ' s medical  of c h i l d r e n v i a statewide  t o make v i d e o t a p e s o f p a t i e n t s  peutic procedures which w i l l Simultaneous viewing  will  Y o r k RMP's e x p e r i m e n t w i t h problems discussed,  Plans  as w e l l as s p e c i a l d i a g n o s t i c  to ask questions.  and t h e r a -  (166) .  l i m i t e d s u c c e s s by t h e C e n t r a l  telephone networks. that  the conferences  New  Among t h e many t e c h n i c a l  faculty unfamiliar with  t h e method a r e o f t e n  u n c o m f o r t a b l e t a l k i n g t o a n unknown a u d i e n c e and t h a t p h y s i c i a n s reluctant  a r e under-  be s e n t t o each o f t h e p a r t i c i p a t i n g h o s p i t a l s .  (143) r e p o r t s  he n o t e s  conferences i n the f i e l d  telelectures.  t h e n be p o s s i b l e d u r i n g  In c o n t r a s t , Lyons  center.  are equally  He n o t e s f u r t h e r t h a t n u r s e s a n d m e d i c a l  79  t e c h n i c i a n s h a v e made g r e a t e r u s e  of the t e l e p h o n e network than have p h y s i c i a n s .  Television: During attention  t h e p a s t f i f t e e n y e a r s , t e l e v i s i o n has  t h a n any  o t h e r medium.  e d u c a t i o n , O h l i g e r (176) are blossoming  a l l over  states, t h e map,  Referring  to i t s use  "Mass m e d i a c o u r s e s but m a i n l y  proven  keeping d o c t o r s abreast of advances i n m e d i c a l  (111) has  circuit  systems,  so r e c e n t l y r e v i e w e d this  standard r e c e i v e r , s t u d i e s of t h e i r I n 1954 television  and  and w i d e s p r e a d  experimental  or encoded b r o a d c a s t  Bowers  station  Since  on c l o s e d o f open  television,  (259)  reported the f i r s t  use  and was  circuit,  along with  of open  circuit  t e l e c a s t over  i n S a l t Lake C i t y , w i t h a r e c e p t i o n range  used  and  p u b l i c i t y was  To p r o m o t e p a r t i c i p a t i o n ,  p h y s i c i a n s were encouraged  success of the experiment  was  restricted  an u n l i s t e d  t o p l a c e q u e s t i o n s by a t t e s t e d by  the l a y p u b l i c .  This resulted  a  public  to d i r e c t m a i l to  t e l e p h o n e was  collect  Their  that included  In order to minimize  installed  calls.  The  favourable physician ratings  p r o g r a m , h i g h p a r t i c i p a t i o n by more r u r a l p h y s i c i a n s , and from  (111).  i n postgraduate m e d i c a l e d u c a t i o n a t the U n i v e r s i t y of Utah.  v i e w i n g , o f f a i r t i m e was  cisms  use,  spread r a t h e r s l o w l y  l a r g e l y w i t h the use  75 p e r c e n t o f t h e p r a c t i s i n g p h y s i c i a n s i n U t a h .  and  in  effectiveness.  Warner and  the p h y s i c i a n s .  quotes  immensely u s e f u l  the published l i t e r a t u r e  program c o n s i s t e d of a s e r i e s of m e d i c a l c l i n i c s commercial  he  practice..."  is still  survey i s concerned scrambled  t o be  of t e l e v i s i o n has  M o r e o v e r , much o f w h a t i s i n u s e  Harris  f o r the medical p r o f e s s i o n  surrounding i t s varied  c l o s e r s c r u t i n y r e v e a l s t h a t the use (193).  i n continuing medical  i n t h e U n i t e d S t a t e s , " and  Moses as s a y i n g , " E d u c a t i o n a l t e l e v i s i o n has  D e s p i t e a l l the p u b l i c i t y  p r o b a b l y r e c e i v e d more  of  the  no  adverse  criti-  i n the r e g u l a r use  of open  circuit  80  television that of  for continuing  m e d i c a l e d u c a t i o n by  e x p e r i m e n t , Wayne S t a t e  O k l a h o m a , and  basis  frequently  (43)  the  University  University  of Utah.  of Texas, the  o t h e r s b e g a n t e l e c a s t i n g s i m i l a r p r o g r a m s on using  C o m m e n t i n g on Castle  University,  the  t a p e s made a t  the  teaching  the  University  of Utah  an  After University  experimental  (43).  techniques used i n these e a r l y  programs,  notes:  W h i l e t h e method o f p r e s e n t a t i o n has v a r i e d f r o m i l l u s t r a t e d l e c t u r e s , p a n e l d i s c u s s i o n s , q u e s t i o n and a n s w e r p e r i o d s , and d e m o n s t r a t i o n s o f p r o c e d u r e s and p a t i e n t s . . . t h e a p p r o a c h most f r e q u e n t l y u s e d has b e e n i n f o r m a l d i s c u s s i o n b e t w e e n two t e a c h e r s w i t h l i b e r a l u s e o f v i s u a l a i d s t o d e m o n s t r a t e and e m p h a s i z e s a l i e n t f e a t u r e s o f t h e presentation. A in  1963  slightly by  Michael  presentation i n one  (158).  studio  in Jacksonville  type of  i n the  c o n f e r e n c e was In P i t t s b u r g h  hospitals.  I n 1962  g r a n d r o u n d s and  of  area of  h a l f of  I n 1965,  include  63  answers  i t was  I n 1967,  Gladmin  panel  A  half  micro-  following  T h i s a p p r o a c h was and  of  other  at G a i n s v i l l e .  felt  concluded  regular  to  that  this  a b r i e f m e d i c a l n e w s c a s t was M o s e s and hospitals  (176)  local  weekly broadcasts c o n s i s t i n g  Wolfe  (167)  extending  reported  70  initiated  reported  of  "live"  in  29  an  expansion  throughout the  tri-state  S o u t h W e s t e r n P e n n s y l v a n i a , S o u t h E a s t e r n O h i o , and  Virginia.  a  the  p a r t i c u l a r e f f o r t s h a v e b e e n made t o i n v o l v e  closing with  t h i s program to  one  q u e s t i o n s and  studio.  reported  desirable.  a s e r i e s of  community h o s p i t a l s .  exchange  studio  bedside teaching"  highly  F l o r i d a was  a grand rounds type  s e r v e d as  i n the  Jacksonville  u n i v e r s i t y to the  of  of  some s i x t y - f i v e m i l e s a w a y , w i t h  f a c u l t y members l o c a t e d  a case presentation the  University  T h i s program c o n s i s t e d  system p r o v i d e d a s e r i e s of  "bring  the  i n which three l o c a l physicians  c o n s i s t i n g of relay  d i f f e r e n t approach at  hospitals  N o r t h e r n West  participating in this  network. A  t e l e v i z e d l e c t u r e s e r i e s c a l l e d " B o s t o n M e d i c a l R e p o r t s " was  launched  81 in  1964  t a k i n g a s one  medical  e d u c a t i o n b y means o f t e l e v i s i o n ,  proposed New  university without walls."  Hampshire, Massachusetts  (176). for  of i t s p r i n c i p a l o b j e c t i v e s ,  One  noteworthy  the Boston  I n t h i s network were s t a t i o n s  ( 2 0 9 ) , and  Intended  of  e x p e c t i n g i t t o become a p a r t o f  a  i n Maine,  more r e c e n t l y , Rhode I s l a n d  e l e m e n t o f t h e s e r i e s was  Reports."  "the r e g i o n a l i z a t i o n  and  Vermont  the " P h y s i c i a n s ' Notebook  as a p r o m o t i o n a l a t t r a c t i o n , p r i o r  to  the  t e l e c a s t s a copy o f a t h r e e r i n g e d notebook w i t h i n f o r m a t i v e m a t e r i a l s  announcing  the s e r i e s ,  in  Maine.  i t s purpose,  Subsequently,  and  reference.  studies which could modify  mailed  to a l l p o t e n t i a l viewers  l i t e r a t u r e accompanying each l e c t u r e  to the notebook which  Another important  c o u l d t h e n s e r v e as a  e l e m e n t o f t h i s p r o j e c t was  "provided continuous  feedback  was  source  the e f f e c t i v e n e s s  t o p r o g r a m p l a n n e r s so t h a t  they  f u t u r e programs."  Although hampered by  was  supplementary  s e n t t o p h y s i c i a n s t o add of  format  attempts  limitations  Medical Reports  a t an o b j e c t i v e e v a l u a t i o n o f the s e r i e s  o f t h e r e s e a r c h d e s i g n s , i t was  d i d provide a review of medical  felt  t o p i c s and  "that  were Boston  f o r some v i e w e r s ,  9  significant launched i n New England  a s t r o n g movement t o w a r d  England,"  including  Dental Reports  pioneered of  l e a r n i n g d i d take p l a c e . "  an e f f o r t  M o r e o v e r , i t was  a g r e a t e r use  the i n i t i a t i o n  The  total  t h e E a s t e r n E d u c a t i o n a l T-V c o s t o f e a c h p r o g r a m was  per p o t e n t i a l viewer  and  b e t w e e n $10  and  Increasing r e g i o n a l d i s t r i b u t i o n decreases  techniques "New  In addition, i t  presently a special  package  Buffalo, Pittsburgh, i s  N e t w o r k t o i t s member  approximately  $12  series  series entitled  for Continuing Dental Education."  a t r e g i o n a l c o - o p e r a t i o n and  that "the  o f mass c o m m u n i c a t i o n  of a s i m i l a r  42 p r o g r a m s e n t i t l e d M e d i c a l R e p o r t s , B o s t o n ,  b e i n g o f f e r e d by  felt  $4,000 o r about  per a c t u a l viewer  c o s t s and  stations.  i n Maine.  the estimates of  the  $4  82  number o f v i e w e r s r a n g e f r o m 9 p e r c e n t potential physician participants. a u d i e n c e m u s t be and  weighed a g a i n s t  than other  be  placing this  responsibility  on  The  of and  the  first  contact  f o l l o w up  physician.  the  first  one  not  p r o g r a m was  appeared that in  10.4  the  committeein  and  The  percent.  achieved  their  involved  of continuing  the  concern to get  medical education."  tional objectives  This  job  as  the  f o r each program.  viewing  while  this any  telephone interviews i t Association  the  television development a v e r a g e member  sponsorship of other found  that  the  to i d e n t i f y  programs  program  were u n a b l e to adapt to the  failure  from  disclosed that  d i s t a n t from the  M o r e o v e r , i t was  role  questionnaires  sample drawn  done, p e r m i t t e d  the  broad-  to the  l a r g e numbers o f v i e w e r s ,  j u s t as  that  R e v i e w " was  made t h r o u g h m a i l  a representative  association.  continuing  o n l y , perhaps "because the  u s e d i n d i v i d u a l s who was  t h e i r own  e n t i r e membership o f the  the  the  television  hoped  maximum number o f p h y s i c i a n s  i n theory  E v e n more i m p o r t a n t ,  television,  productive  content relevant  physicians.  j u s t as h i e r a r c h i c p a t t e r n s  planners frequently  on  From r e s p o n s e s to the  involvement of  target  produce  a broadcast  Oregon M e d i c a l  A s t u d y was  o r g a n i z a t i o n a l s t r u c t u r e t h a t was  medium.  "The  focussed  a u d i e n c e o f 1,651  maintained.  p r o g r a m m i n g was  o f an  and  i n planning  f i v e programs a t t r a c t e d r e l a t i v e l y  i n t e r e s t was  to  educationally  i t s a c t i v e m e m b e r s h i p , i t was  telephone interviews, using  the p o t e n t i a l viewing  effort  s e v e n t e e n p h y s i c i a n members o f  series entitled  cast weekly from January to A p r i l  and  s p o n s o r e d i n 1966  p r a c t i t i o n e r s w o u l d become m o r e i n v o l v e d medical education.  concludes: " S i z e of  (211).  Association  a committee of  the  target audience i s s m a l l ,  less monitarily efficient  Oregon M e d i c a l  s e r i e s p r o d u c e d by  (211)  program of  c o s t , i n c l u d i n g t i m e and  i n s t r u c t i o n a l methods"  The  percent per  Robertson  b r o a d c a s t t e l e v i s i o n programs... I f the  a m a s s m e d i u m , may  By  t o 38  television  specific instruc-  I n c o n c l u s i o n , M e i g h a n and  Treseder  (153)  83  n o t e d : "The education  medium' p r o v i d e s  may  attractive  be  a means w h e r e b y p r o g r a m s o f  distributed widely;  features.  i t seems t o o f f e r some  However, f u r t h e r study  r e q u i r e d , t o show t h a t t h e s e o u t s t a n d i n g I n 1963, circuit  t h e New  t h i s p r o j e c t was  o f t e l e v i s i o n as a metropolitan opinions the  an  study no  a period  of  by  d i d not  felt  l e a r n i n g c o u l d be polls  F a h s and b r o a d c a s t i n the programs of a c c u r a c y and  the  continuing Miller  size,  the  t o 100  3)  and  In a d d i t i o n ,  v i e w e r s and  by 100  the  f i n d i n g s of  results indicated McGuiness only  (148) 305  this  that  indicated  o r 4.8  percent  a t t r a c t e d r e g u l a r l y to the s e r i e s . e x p e n s e and  described  the  effort  i t was  so s m a l l an  terminated  the relevance  in  of  audience 1968.  e v a l u a t i o n of a t e l e v i z e d s e r i e s In  their  from three p o i n t s of view:  scientific  Four panels of p h y s i c i a n s w i t h  in  i t s audience  While the  (147) .  The  education  t o e i g h t months a f t e r  an"audience averaging  s e r i e s were a n a l y z e d  and  open  composition,  p r o g r a m on  s t a t e o f M i n n e s o t a betxvreen 1 9 6 7 - 1 9 6 8 .  r e c o g n i t i o n of  communication;  the  series.  the p r o g r a m , so  (94)  the  administered  from f o u r  on  effectiveness  program were s t u d i e d .  impact of  demonstrated  revealed  that considering  justify  illusory."  a c c e p t a b i l i t y and  time v a r i a b l e s , the  t h e p o t e n t i a l v i e w e r s t h a t was  I t was  i n the  t e s t w h i c h was  w e r e somewhat c l o u d e d  specific  effectiveness i s  Seminars f o r p h y s i c i a n s .  polls,  of s e l e c t e d programs i n the  that cumulatively, of  participating  information  non-viewers covering presentation  Science  "to a s c e r t a i n the  sought to determine the  means o f an  of e d u c a t i o n a l  a t t r a c t i o n s are not  Through repeated  of physicans  study  outstandingly  a d d i t i o n a l medium f o r c o n t i n u a t i o n m e d i c a l  area".  medical  Y o r k Academy o f M e d i c i n e b e g a n p r e s e n t i n g  t e l e v i s i o n i t s weekly C l i n i c a l  purpose of  continuing  information;  2)  the  the programs to the  study, 1)  nine  the  success  in  care  patients.  of  e x p e r t i z e i n these areas were s e l e c t e d  to  84  make t h e viewing  evaluation.  A c o m p a r i s o n was  audience "with  information  i n s i g h t s came t o t h o s e who Since  a l s o made o f  on why  physicians  content  of  the  accurate.  With respect  attempts to evaluate  s e r i e s was  j u d g e d t o be  t o c o m m u n i c a t i o n and  of the p a n e l s were u n m i s t a k a b l y n e g a t i v e . gentlemen communicating w i t h d o n ' t c o n v i n c e me  that  each other  the p a n e l ,  unless  on  clearly  what  them.  defined,  the  In general,  the  adequate, r e l i a b l e ,  technical production,  As  one  p a n e l i s t put  a b o u t t h e i r own  I want t o e m u l a t e t h e i r  program c o u l d have been put  appearance of  potential  d i d n o t w a t c h and  o b j e c t i v e s f o r s p e c i f i c programs were not  scientific  a c t u a l and  watched."  p a n e l i s t s were hampered i n t h e i r  "One  the  style."  the  comments  "these  h a b i t s of p r a c t i c e j u s t Another  a u d i o a l o n e w i t h no  i t s p e r s o n a l i t i e s are  it,  and  concluded,  need f o r v i s i o n .  dynamic, i s l e s s  The  than  worthless." Comments f r o m v i e w i n g of program t e s t i n g o c c u r r e d , i n h i s p r a c t i c e , he watching. was  And  tried  viewing  were: not  watch, or being  too  the  news.  ten o'clock  and  suggested  w h e r e one  others.  of  the  Conversely,  series."  knowing of  busy. The  that  p r o g r a m was  The  "a c o n s i d e r a b l e u s e f u l to the  when r e c e i v e d no  t h e m o r e p r o g r a m s t h e p h y s i c i a n saw,  g e t t i n g something out  f o r not  physicians  the  physician  b e n e f i t he  c l e a r e r i t was  major reasons given  by  that  quit he  physician  the program's e x i s t e n c e , f o r g e t t i n g to  Some a l s o i n d i c a t e d t h a t t h e y p r e f e r r e d authors  amount  to watch  conclude:  No one d o u b t s t h a t c o n t i n u i n g m e d i c a l e d u c a t i o n t h r o u g h t e l e v i s i o n h a s p o t e n t i a l . H o w e v e r , few b e l i e v e t h a t i t s f u l l p o t e n t i a l i s p r e s e n t l y b e i n g u t i l i z e d , and v i r t u a l l y a l l a r e w i l l i n g t o e x p e r i m e n t t o some e x t e n t . T h i s e v a l u a t i o n r e a f f i r m s s u c h g e n e r a l i z a t i o n s and h o p e s t h a t c o n t i n u i n g e f f o r t be a p p l i e d t o b o t h new and o l d methods. A number o f m e d i c a l  centers  i n Canada have r e p o r t e d  some  experimentation  in  the use of broadcast  (119)  television  f o r continuing medical  ( 1 1 ) . The g e n e r a l i m p r e s s i o n g a i n e d  e d u c a t i o n (253)  from the l i t e r a t u r e  i s t h a t most  Canadian p r o d u c t i o n s have f o l l o w e d t h e t y p i c a l American format, l e c t u r e s o r p a n e l p r e s e n t a t i o n s f o l l o w e d by a b r i e f period.  As i n the United  relative  t o v i e w e r s h i p , and d i f f i c u l t i e s  viewers,  i n evaluating the worth of t e l e v i z e d  a s t h e m a j o r o b s t a c l e s i n t h e u s e and  r e a c t i o n s from l a y  the question of complete p r o f e s s i o n a l p r i v a c y i s s t i l l p r o f e s s i o n ( 2 6 3 ) , and t h i s has r e s u l t e d  s c h o o l s and a f f i l i a t i n g  encoded b r o a d c a s t Under t h i s  television  are s t i l l  relatively  or  (30) (165).  preventing public viewing.  by a m o d i f i e d r e c e i v e r .  expensive,  placed only i n the a f f i l i a t i n g advantages:  debated  i n a network of  s y s t e m , t h e p i c t u r e a p p e a r s on t h e s t a n d a r d  i s accomplished  being  h o s p i t a l s i n C a l i f o r n i a using scrambled  s c r e e n , b u t i n encoded form thus unscrambling  expansion  Television:  no s t u d i e s t o d a t e have r e v e a l e d s p e c i f i c  within the medical medical  costs  (119) (253).  Encoded o r Scrambled Broadcast While  q u e s t i o n and answer  S t a t e s , the problems of t e c h n i c a l p r o d u c t i o n ,  programs, have been i d e n t i f i e d o f t h e medium  namely,  Decoding or  Because these  i n the C a l i f o r n i a experiments hospitals.  television  decoders  they have been  T h i s i s b e l i e v e d t o have s e v e r a l  1 ) i t makes t h e c o m m u n i t y h o s p i t a l  the center f o r continuing  medical  e d u c a t i o n , 2) i t makes f e a s i b l e a n a c c u r a t e r e c o r d o f t h e number o f  viewers  o f e a c h p r o g r a m , and 3) i t makes i t p o s s i b l e f o r t h e u n i v e r s i t i e s  to  charge a t u i t i o n  fee for participation  i n t h e n e t w o r k , w h i c h i n t u r n makes  possible superior production techniques (30). The  success  with the University  o f an i n i t i a l of C a l i f o r n i a  number o f p a r t i c i p a t i n g  pilot  project linking  i n 1965, r e s u l t e d  15 c o m m u n i t y h o s p i t a l s  i n the expansion  of the  h o s p i t a l s and t h e m e r g i n g o f s i x m a j o r m e d i c a l  centers  86  and  their  television  facilities  for  t h e p r o d u c t i o n and  to form  the M e d i c a l T e l e v i s i o n Network  d i s t r i b u t i o n of t e l e v i z e d  programs.  second  y e a r o f b r o a d c a s t i n g , B r a y t o n r e p o r t e d (29)  in  w i t h an a d d i t i o n a l  MTN  t h e end  72 h o s p i t a l s  18 h o s p i t a l s p a r t i c i p a t i n g  s y s t e m w h e r e b y h o s p i t a l s r e c e i v e d t h e p r o g r a m s on one c o u l d t h e n be p l a y e d b a c k o n r e l a t i v e l y  At  of  t h e programs has been g r e a t l y  has  been lowered  r e a c h i n g some 750 hours of  substantially.  i n a v i d e o tape  facilities. and  inch videotape  Attendance  physician viewers  which  charged  d a t a shows t h a t MTN  e a c h w e e k and  Through  i s currently  Consequently,  the t u i t i o n  the  broadcasts  that approximately  target audience,  motivated  to p a r t i c i p a t e .  i n the narrower  I n 1968  Brayton  s p e c i a l t i e s being the (30) r e p o r t e d t h a t :  are  28,000 S i n c e most  i t i s not  t h e g r e a t e s t number o f v i e w e r s h a v e b e e n g e n e r a l p r a c t i t i o n e r s  internists, with specialists  quality  hospitals  o f i n s t r u c t i o n a r e p r o v i d e d i n t h e 38 p r o g r a m s o f f e r e d y e a r l y . their  the  distribution  inexpensive video recorders.  improved  t h e p r o g r a m s h a v e g e n e r a l i s t s as  that  and  of  participating  a c o n t r a c t w i t h t h e U n i t e d S t a t e s P u b l i c H e a l t h S e r v i c e , t h e MTN operating with a professional staff  (MTN)  surprising and  least  .  The MTN v i d e o t a p e r e d u p l i c a t i o n and d i s t r i b u t i o n s y s t e m h a s b e e n r e - o r g a n i z e d to combine the Southern C a l i f o r n i a t e l e v i s i o n r e s o u r c e s w i t h t h o s e o f a s i m i l a r e n c o d e d n e t w o r k i n San F r a n c i s c o f o r N o r t h e r n C a l i f o r n i a . . . T h e r e s u l t i n g v i d e o t a p e d i s t r i b u t i o n s y s t e m , now c a l l e d t h e C a l i f o r n i a M e d i c a l T e l e v i s i o n N e t w o r k w i l l r e d u p l i c a t e and p o o l t h e o u t s t a n d i n g p r o g r a m s b r o a d c a s t f o r m e d i c a l and p a r a m e d i c a l e d u c a t i o n i n e a c h a r e a and r e g u l a r l y d i s t r i b u t e t h e s e t o p a r t i c i p a t i n g h o s p i t a l s . . . I n t h i s way, t h e c o m b i n e d m e d i c a l f a c u l t i e s i n t h e m o s t p o p u l o u s s t a t e w i l l form the academic base f o r c o n t i n u i n g m e d i c a l and p a r a m e d i c a l e d u c a t i o n u s i n g the newest t e l e v i s i o n m o d a l i t y . D e s p i t e such optimism in  r e g a r d i n g the f u t u r e of encoded b r o a d c a s t  a r e c e n t r e p o r t of atf e v a l u a t i o n of f o u r programs sponsored  C a l i f o r n i a N e t w o r k , Mock (165)  by  the  television,  Northern  concluded:  W h i l e most o f t h e a s s e s s m e n t t e c h n i q u e s i n t h i s s t u d y e n c o u n t e r e d s e r i o u s s a m p l e d e p l e t i o n , g i v e n t h i s l i m i t a t i o n . . . v i r t u a l l y no measurable changes i n e i t h e r b e h a v i o u r or i n f o r m a t i o n l e v e l were found which c o u l d be d i r e c t l y a t t r i b u t e d t o t h e p r o g r a m s . . . I t was n o t e d t h a t two  87  h o s p i t a l s changed t h e i r i n f e c t i o n c o n t r o l p r o c e d u r e s , but does t h i s make t h e s e r i e s w o r t h w h i l e ? The a n s w e r t o t h i s q u e s t i o n w o u l d r e q u i r e an o b j e c t i v e c o m p a r i s o n b e t w e e n p o s t g r a d u a t e m e d i c a l t e l e v i s i o n and other teaching media. The s t u d i e s w h i c h w i l l p r o v i d e a n a n s w e r t o t h i s q u e s t i o n r e m a i n t o be done. More p o i n t e d l y , L a u l e r medium w i t h o u t the  leveraging  (55)  concludes:  "The  e x p l o i t a t i o n of a  i t s advantages i n j u x t a p o s i t i o n to other  t e l e v i s i o n medium t o f a i l u r e . . . T h e m a j o r l i m i t a t i o n o f  t e l e v i s i o n o r movie m a t e r i a l r e s i d e s  i n the  software  given  m e d i a doomed  the p r o d u c t i o n  of  aspect."  Slow Scan T e l e v i s i o n : An will  use  p r o j e c t c u r r e n t l y planned a t the U n i v e r s i t y of  s l o w s c a n t e l e v i s i o n c a r r i e d by  classroom with  experimental  at  the M e d i c a l  a t e l e p h o n e and  radio link  Wisconsin  from  the  Communications C e n t e r t o f o u r s m a l l community h o s p i t a l s  reception f a c i l i t i e s .  As  described  by M e y e r  (156):  U s i n g t h i s medium s t i l l s n a p s h o t s a r e t r a n s m i t t e d o v e r o r d i n a r y t e l e p h o n e w i r e s thus o b v i a t i n g the need f o r e x p e n s i v e c o - a x i a l or microwave r s l a y systems. S p e c i a l r e c e i v e r s s t o r e t h e p i c t u r e s and r e l e a s e them a p p r o x i m a t e l y e i g h t m i n u t e s l a t e r . . . T h u s t h e p a r t i c i p a n t s i n t h e c o m m u n i t y h o s p i t a l s h a v e t h e l i v e v o i c e s , t h e s l i d e s , and o t h e r v i s u a l s u s e d d u r i n g t h e c o n f e r e n c e as w e l l as t h e s t i l l p i c t u r e s . According attractive  to Meyer, other  a t t r i b u t e s w h i c h make s l o w s c a n  television  are:  I t s a b i l i t y f o r r a n d o m a c c e s s i n f o r m a t i o n r e t r i e v a l s o t h a t 5,000 h o u r s o f i n s t r u c t i o n and 1 0 , 0 0 0 v i s u a l s c a n be s t o r e s , r e t r i e v e d , and shown i n remote p o i n t s . In a d d i t i o n , i t h o l d s the a b i l i t y f o r h a r d c o p y p r i n t o u t a t remote l o c a t i o n s so t h a t . p r i n t e d i n f o r m a t i o n i n s e r t e d a t one end o f t h e s y s t e m c a n be f a i t h f u l l y r e p r o d u c e d a t t h e o t h e r without t e l e t y p e w r i t e r s , a s o r t of long d i s t a n c e Xerox Machine.  SUPPORTING D E V I C E S The technologies  supporting  devices  reviewed here are  w h i c h have found t h e i r  o r as a means of  self  instruction.  greatest  use  t h o s e newer as  quick  educational  information  sources,  88  Motion  Pictures; Probably  Videotapes: the most s i g n i f i c a n t  development i n the area of f i l m s  been the e s t a b l i s h m e n t of a S i n g l e Concept F i l m U n i v e r s i t y of Wisconsin.  and  a r e on  l o a n f o r s i x weeks.  contains only e s s e n t i a l  p i c t u r e and can view (155)  sound s t a r t  the f i l m  responses felt  Each f i l m  information.  immediately.  a second  time merely  reports that a series  i n Wisconsin.  films runs  on new  from  from p r a c t i s i n g  medical  techniques  s i x to ten minutes  When t h e u s e r p r e s s e s a l e v e r  Since the f i l m  i s self  the  re-winding,  he  by p r e s s i n g t h e l e v e r a g a i n . M e y e r  of s i x f i l m s  a r e i n c i r c u l a t i o n among 47  A r e c e n t s u r v e y b a s e d on a p p r o x i m a t e l y  1,600  hospitals  questionnaire  p h y s i c i a n s r e v e a l e d t h a t 93 p e r c e n t  of  respondents  t h a t the f i l m s p r o v i d e d u s e f u l m e d i c a l i n f o r m a t i o n . According  to Wenrich  a n u m b e r o f f i l m s and groups.  The  f i l m which  TV  (263)  kinescopes which  U p j o h n Company h a s  i s available  p h a r m a c e u t i c a l companies have a l s o  through  produced  education" which  a series  and  s e r v i c e i n o p e r a t i o n i s Audio  c a l l e d G r a n d R o u n d s on  one  half  Oakley  most e s t a b l i s h e d tape r e c o r d i n g  of medicine  mm  Roche  t o one  covered  subscription  D i g e s t , a n o n - p r o f i t s u b s i d i a r y of the (175)  r e p o r t s t h a t some 3 0 , 0 0 0 t a p e s overseas.  California  are sent These  each  tapes,  hour i n l e n g t h , r e p r e s e n t e d i t e d p o r t i o n s of  l e c t u r e s , p a n e l s , d i s c u s s i o n s , and areas  S i m i l a r l y , The  16  country.  m o n t h t o s u b s c r i b e r s i n t h e U n i t e d S t a t e s , C a n a d a , and ranging from  medical  Disc Services:  t h e o l d e s t and  Medical Association.  t o h o s p i t a l and  produced  f o r its- "network f o r c o n t i n u i n g m e d i c a l  i n c l u d e s h o s p i t a l s across the  Audio-Tape Recordings Probably  are loaned  i t s regional offices.  M e d i c a l Laboratory produces videotapes  The  the  Community h o s p i t a l s a r e p r o v i d e d w i t h a s m a l l  p o r t a b l e p r o j e c t o r along w i t h s i n g l e concept which  S e r v i c e o f f e r e d by  has  by  symposia p u b l i s h e d i n the c u r r e n t  this  literature.  service include general practice,  internal  89  medicine,  surgery, o b s t e t r i c s and gynecology, p e d i a t r i c s , anesthesiology,  and opthalmology.  Important meetings are also taped and sent to subscribers.  Wenrich (263) reports that Excerpta Medica has begun producing  "Voices of  Medicine" which provides weekly tape recordings of abstracted l i t e r a t u r e and feature presentations on selected subjects.  The American College of Cardiology,  i n c o l l a b o r a t i o n with the Radio Corporation of America, has begun a monthly tape service c a l l e d Access Library Service focussing on subjects which have the greatest relevance to the p r a c t i c e of cardiology (146). While the aim of these services i s to provide a way  that busy p r a c t i -  tioners can acquire information by l i s t e n i n g i n t h e i r homes or while d r i v i n g to work, reports by Aitken (4) and others (263)  (37) suggest  proportion of physicians are attracted to t h i s process.  that only a c e r t a i n  A study reported by  Aitken (4) found that of the 655 tapes requested and sent out i n 1961, who  took ten or more tapes each year used 513 of the t o t a l .  of i n t e r e s t was  29 users  Another finding  that 60 percent of the tapes requested went to general p r a c t i -  tioners i n the country or small towns.  In 1962,  the Canadian College set up  a disc service using twelve-inch long-playing discs i n which the members of the service retained t h e i r own recordings. popular, and by 1963  This method has proven extremely  a number of l i s t e n i n g groups had formed.  According to Harris (111) Smith and Hoist Incorporated i n C a l i f o r n i a have developed  a series of i l l u s t r a t e d medical lectures using both f i l m s t r i p s  and tape recordings produced by Loma Linda University School of Medicine. These lectures range from anesthesiology, i n t e r n a l medicine,  obstetrics,  cancer, and cariovascular disease to urology. Abrahamson and h i s colleagues (4) at the University of Southern C a l i f o r n i a report a recent evaluation of a s p e c i a l s e l f - i n s t r u c t i o n a l device  90  combining  a seven inch record  practitioners  s e l e c t e d by  served  experimental  as  the  programs were c i r c u l a t e d procedures included: questionnaires and  3)  l e a r n i n g of  as  no  stratified  participating  "communication behaviour" the p h y s i c i a n s  t o augment t h e d a t a . on  A n a l y s i s of  a l l programs; high  i n which physicians  c h a l l e n g i n g , Woolsey  physicians To  160  illustrate  integrated are  (277)  six-minute the  into  33  i s developing  1/3  rpm  the  projected.  Another i n t e r e s t i n g  feature w i l l  the m a t e r i a l presented  the machine.  at the  helpful;  Also being  be  o r no  considered  At  i t s c o n c l u s i o n , he w o u l d be  four multiple choice indicate his choice.  answers.  By  two  will  slot  be  hours of  inch color has  both  fun offer  instruction.  be  rating  evaluate  button  option  that  to get  button  I f h i s answer i s c o r r e c t , h i s q u a r t e r  the  it...very  appropriate  appropriate  which  return mail.  asked to  i n order  transparencies  with  asked a r e l e v a n t question  pushing the  study  a question  question  i n c l u s i o n o f an  i n the  approach,  education").  a n s w e r e d by  p u n c h i n g an  i s the  the  significant  p r o j e c t o r s have been  of each r e c o r d ,  h e l p , by  r e q u i r e the p h y s i c i a n to drop a q u a r t e r program.  16  the  that the user  conclusion  a  jukebox which w i l l  record  t h e n be  i t will  of  doctor  physician's  a d d r e s s , and  acceptability,  revealed  I f the  will  project  questionnaire  continuing  by  Assessment  (defined i n t h i s  totalling  two  Fifteen  study.  program  a medical  that  states  controls.  that l e a r n i n g should  the jukebox can't answer, a tape r e c o r d e r name a n d  as  i n the  data  general  11 W e s t e r n  acceptability  records,  t h e j u k e b o x mechanism so  slightly  and  100  pre-and-post  dial-access Carousel  and  study,  to v a l i d a t e  attempt to o b t a i n  s p o k e n w o r d , two  automatically synchronized  helpful;  2)  change i n "communication b e h a v i o u r "  In keeping with his basic philosophy and  served  1) p o s t t e s t s o f i n f o r m a t i o n ;  information  " t h e way  In t h i s  a n o t h e r 100  to the physicians  assessing  significant  strip.  random s a m p l i n g i n the  group w h i l e  i n t e r v i e w s of a sample of  r e s p o n s e s and  but  with a film  is  he  helpful; on  would  his and  offered  would  returned.  91 Mediphone  Services:  I n 1966, Access s e r v i c e . current  The  1)  2)  strictly  as  length.  When t h e  o b j e c t i v e s of  as  a quick  the  I n an  o r g a i n i n g new  used the  information  medical  over the  retrieval;  " W h e t h e r on  t o any  and  that  r a p i d growth."  Wisconsin Library using  their  On  have been r e c e i v e d  To  date,  230  rural  equal  and  3)  A  subjects and  appeal to  areas;  2)  a  p r o m o t i o n was  call  preliminary general  significant reinforced as  an  estab-  a s i g n i f i c a n t percent  of  library  that i s , review,  the b a s i s  of  library  or updating  knowledge  these f i n d i n g s , Meyer  d e g r e e o f e n t h u s i a s m f o r t h i s means  the d i a l  access l i b r a r y  M i n n e s o t a and own  separate  f r o m W i s c o n s i n and  communication  S a s k a t c h e w a n has  booklets  and  be  of expected  l i n k e d to  recently initiated  titles  scripts  the  systems.  s i x five-minute  listing  T w e n t y new  Saskatchewan s p e c i a l i s t s  c o n c e p t can  North Dakota are  " T h r e e h u n d r e d and  buted to a l l Saskatchewan p h y s i c i a n s . b e e n c o m p l e t e d by  in  the b a s i s of p o p u l a r i t y or e v a l u a t i o n data i t  In Canada, the U n i v e r s i t y of D i a l Access Service.  of the  telephone l i n e .  l o n g as  education,  i s a sufficient  retrieval  to s i x minutes  f r e e number d e s i g n a t e d ,  s u c h a l i b r a r y had  information.  Intended  twenty seconds a f t e r r e c e i p t of the  s e r v i c e as  for continuing  there  to experience  relevant  toll  i n emergency  information.  a s m a l l number o f p r a c t i t i o n e r s u s e d t h e  concludes:  appears that  the  i n b o t h u r b a n and  source of i n f o r m a t i o n  u t i l i z a t i o n was  (157)  f o r him  t h a t : 1)  specialist  number o f p h y s i c i a n s  lished  average of  f o r use  each tape i s f i v e  merely d i a l s  i s played  revealed  frequently while  medical  Dial  t o make a v a i l a b l e  t w e n t y f o u r h o u r s a day  p h y s i c i a n wishes information  tape requested  p r a c t i t i o n e r and  p r o j e c t were:  s o u r c e of r e f e r e n c e  tape.  s u r v e y i n 1968  this  a method of u p d a t i n g  i n t h e d i r e c t o r y , he  requests the  a non-computerized  authoritative information  s i t u a t i o n s , and  listed  the U n i v e r s i t y of W i s c o n s i n pioneered  a  messages  have been  distri-  f o r messages have  t w e n t y more a r e  in  preparation."  92  Utilization  of  The It differs According  M i s s o u r i RMP  and  has  t o Sawyer the  to test  (101),  the  s y s t e m by  development of a D i a l Access L i b r a r y . system i s  i n widely  s c a t t e r e d r u r a l and  A number o f m e d i c a l  required  telephone  (101).  more  efficient,  specialists  from a l l p a r t s of the  are viewpoint  U n d e r t h e A l a b a m a RMP  consultation services for  s e m i - r u r a l c o m m u n i t i e s and  C a l l e d MIST, t h i s p r o j e c t i s r e p o r t e d  to have served  the  area  physicians  their hospitals.  o v e r 900  consultation  s t a t e o v e r a s h o r t s i x month p e r i o d .  r e p o r t t h a t b o t h c o m m u n i t y p h y s i c i a n s and  s y s t e m b o t h f e a s i b l e and  computerized.  r e c e n t l y become t h e h e a d q u a r t e r s f o r a " w i d e  system" p r o v i d i n g l i v e  (32)  (13).  e v a l u a t i n g the messages from the e x p e r t s '  telephone  Uhl  to date  " t h i s makes t h e s e r v i c e c h e a p e r a n d  f a c t o r o f human e r r o r . "  U n i v e r s i t y o f Alabama has  and  the  L i b r a r y i n t h a t the  a d v i s i n g where c o r r e c t i o n s are  requests  satisfactory  sponsored  from the Wisconsin  eliminating helping  the s e r v i c e i s r e p o r t e d  Brown  f a c u l t y have found  the  useful.  C o r r e s p o n d e n c e ; Programmed I n s t r u c t i o n : I n 1962  the j o u r n a l Spectrum p u b l i s h e d  a l o n g w i t h a p r o g r a m m e d s e q u e n c e on how cardial United  infarction.  The  i s s u e was  to read  circulated  As  a result,  a longer  p r o g r a m on  made a v a i l a b l e t o p h y s i c i a n s on r e q u e s t . i n use  i n 74  I n 1964 on D i a b e t e s Of  the  article  an  of the  t o 225,000 p h y s i c i a n s  S p r e i g e l (234)  Control taught  78 p h y s i c i a n s who  program.  by  reported  and  (18)  the  on  myo-  in  endorsement of  the  the  h y p e r s e n s i t i v i t y was  reports  that this  program  schools.  a s u b j e c t i v e e v a l u a t i o n of a  programmed i n s t r u c t i o n on  completed  In comparing t h i s  allergy  Balson  91 A m e r i c a n m e d i c a l  on p r o g r a m m e d l e a r n i n g  electrocardiogram  S t a t e s , o f whom 5 0 , 0 0 0 r e p l i e d w i t h a " b l a n k e t  program."  is  an  course,  device with other  a l l felt  a teaching i t was  educational  a  course  machine.  meaningful  techniques,  the  93  physicians strongly endorsed the teaching machine approach.  On the basis of  post program interviews and follow-up mail questionnaires, i t was two thirds to three quarters of the physicians who  estimated  that  completed the program have  modified, or w i l l modify, t h e i r diagnostic and/or treatment practices with diabetes as a r e s u l t of having p a r t i c i p a t e d i n the course.  Programmed  i n s t r u c t i o n l i k e correspondence studies, appears to have found i t s greatest use as a supplementary device used i n conjunction with other forms of i n s t r u c t i o n (54) (59)  (61).  Computer Assisted I n s t r u c t i o n : Computer assisted i n s t r u c t i o n (CAI) i n medical education i s s t i l l i n its  infancy.  Paxton (180) reports that a number of d i v e r s i f i e d medical cases have  been computer programmed by the University of I l l i n o i s .  A physician with an  i n t e r e s t i n g case can question the computer i n h i s own words and the r i V A r r  m - m -? T-> r>  j> J- Vy ^ i- Uuuua.iijj  for  /z> n M  O n  +-V»/^  UJ.I.UJX^U  /">m -r-\ i »  y  V.1.XV- v v i i i ^ U w C i  TN  k. \ J  -T /-Or-  -t- V- iv  1r/>Ti  UUL  iv*—_y  v.-»/-\ -v A r*> -An  WWJ-UkJ  which i t then provides the appropriate answer.  several computerized s e l f - t e s t i n g  programs.  J.11  +-T-i/>  tilt-  ^3 /-»»-» 4-  imaginative  e-\ -y- ^ r i  uOLv-VJL  i^f i _ * i_>  o + * r i n i o n f  U-Cl.k-Vl-lHV--l-l.V-  Also under development are  Although these are s t i l l experi-  mental, i t i s planned that they w i l l be expanded to include continuing  education  hookups with some outlying h o s p i t a l s . Ohio State University has some t u t o r i a l evaluation programs r o u t i n e l y available to medical students and by telephone hospitals.  l i n e s to physicians i n ten area  The equipment i s less elaborate i n that i t uses teletypewriter  terminals instead of TV display screens. s l i d e projector with coloured s l i d e s . to view a p a r t i c u l a r s l i d e .  The t e l e p r i n t e r i s augmented by a  The computer i n s t r u c t s the user when  The learner takes as long as he l i k e s to examine  i t then types the response c a l l e d for by the program. The University of Oklahoma tested a v a r i e t y of computerized teaching programs between 1965  and 1968.  Harless et. a l (110) report the findings of  94 one s t u d y i n v o l v i n g f o u r t e e n p r a c t i s i n g p h y s i c i a n s who a t t e n d e d a one week course i n c l i n i c a l anestehesiology Data showed t h a t the p h y s i c i a n s '  i n w h i c h a one hour CAI l e s s o n was i n c l u d e d . attitudes  toward C A I , e d u c a t i o n a l  and programmed i n s t r u c t i o n t e x t s were comparable b e f o r e exposure A f t e r the CAI l e s s o n , t h a n were a t t i t u d e s  attitudes  television,  to C A I .  toward CAI were s i g n i f i c a n t l y more  towards e i t h e r  positive  e d u c a t i o n a l t e l e v i s i o n o r programmed  instruction. At the U n i v e r s i t y of Southern C a l i f o r n i a , Abrahamson and Denson have produced a c o m p u t e r i z e d l e a r n i n g a i d c a l l e d Sim One, a r e a l i s t i c upon w h i c h p h y s i c i a n s may l e a r n how to c a r r y out e n d o t r a c h e a l  (3) mannequin  intubation.  The  computer i s programmed so t h a t the mannequin r e a c t s p h y s i o l o g i c a l l y to v a r i o u s drugs o r t r e a t m e n t s w h i c h may be a d m i n i s t e r e d . show the changes i n b l o o d p r e s s u r e , r e s p o n s e s to t r e a t m e n t .  Continuous graphic  pulse r a t e , e t c . ,  W i r e s from the s t r a t e g i c a l l y  d e p i c t i n g the  progress  mannequin's  p l a c e d magnets and s e n s o r s  r u n from Sim One t h r o u g h a l a r g e c a b l e t o the computer and to the at a c o n t r o l c o n s o l e ,  displays  instructor  so t h a t the i n s t r u c t o r i s k e p t p o s t e d on the  physician's  i n learning.  I n one s t u d y of s k i l l a c q u i s i t i o n , the l e a r n i n g r a t e of t e n new anesthesiology  r e s i d e n t s was compared, f i v e of whom took the  conventional  i n s t r u c t i o n , and f i v e of whom l e a r n e d the t e c h n i q u e u s i n g the mannequin. F i n d i n g s r e v e a l e d t h a t t h o s e who used Sim One took an average of 30 a t t e m p t s o v e r a p e r i o d of 45.6  days to a c h i e v e n i n e out of t e n p r o f e s s i o n a l l y  competent  i n t u b a t i o n s as compared w i t h 60 a t t e m p t s i n 77 days f o r the c o n t r o l g r o u p . Abrahamson and Denson p l a n to d e v e l o p r e f i n e m e n t s other s p e c i f i c indicates  techniques  of Sim One f o r  to m e d i c a l and p a r a m e d i c a l w o r k e r s .  teaching  Paxton  (180)  t h a t the Sims " c a n s h o r t e n the time r e q u i r e d t o t e a c h manual p r o c e -  dures i n almost e v e r y phase of  medicine."  95  A l l e n and  Ottem  (5) r e p o r t t h r e e e x p e r i m e n t a l  response computer s e r v i c e s . input "yes",  One  t h e o u t p u t one  " c o n d i t i o n a l " , or"unknown."  The  program which c a l c u l a t e s the proper i n i t i a l fluid is  required i n treatment.  a u g m e n t e d by A  s i m i l a r but  operation at cathode ray  The  diagnostic data  third  i n the  (T.V.) i n p u t - o u t p u t  The estimate  the  four compatabilities:  second program i s a burn  q u a n t i t i e s of e l e c t r o l y t e s  formula and that  literature.  more s o p h i s t i c a t e d c o m p u t e r p r o g r a m i s r e p o r t e d This  program, c a l l e d  terminals.  a b s e n c e o f p r i n t e d o u t p u t w h i c h c o u l d be patient's  of  i s a symptom d i a g n o s i s p r o g r a m  the U n i v e r s i t y of M i s s o u r i . tube  audio  i s a drug c o m p a t a b i l i t y program i n which  i s a p a i r o f d r u g c o d e s and "no",  programs u t i l i z i n g  The  in  Consider  major weakness i s  uses the  r e q u i r e d f o r l e g a l reasons or f o r  a  record. cost of  these  programs i s r e p o r t e d  as  reasonable.  A l l e n and  Ottem  that  The i n t r a v e n o u s a d d i t i v e p r o g r a m c o s t s u n d e r 35 c e n t s f o r e a c h r u n p l u s $10 p e r m o n t h f o r p r o g r a m and d a t a s t o r a g e . The b u r n f o r m u l a p r o g r a m w h i c h i s p u r e l y c o m p u t a t i o n a l , c o s t s r o u g h l y 50 c e n t s p e r u s e p l u s $1 p e r m o n t h f o r r e q u i r e d s t o r a g e . The d i a g n o s t i c a s s i s t a n c e p r o g r a m c o s t s a b o u t 40 c e n t s * p e r c a l c u l a t i o n p l u s $2 p e r m o n t h f o r storage. They s u g g e s t t h a t a f e a t u r e w h i c h w o u l d g r e a t l y i m p r o v e computer would  programs  be Access to data bases from v a r i o u s a u t h o r i t i e s f o r c o n t r o v e r s i a l subject areas. T h i s f e a t u r e w o u l d g i v e a c o m p u t e r n e t w o r k some o f t h e f l e x i b i l i t y now o f f e r e d t o t h e p h y s i c i a n by h a v i n g s e v e r a l m e d i c a l t e x t b o o k s , j o u r n a l a r t i c l e s , and s c i e n t i f i c d o c u m e n t s a v a i l a b l e o n particular topics.  ORGANIZATION FOR A number o f r e c e n t p r o p e r f a c i l i t i e s and  INSTRUCTIONAL TECHNOLOGY  articles  provide  environments f o r the  evidence of attempts to e f f e c t i v e use  create  o f mass m e d i a i n  96  continuing medical centralized  education.  Also being  systems to expedite  i n s t r u c t i o n a l m a t e r i a l s and  d i s c u s s e d and  t h e d e v e l o p m e n t and  devices  on b o t h  implemented  are  d i s t r i b u t i o n of  the  t h e r e g i o n a l and  national levels.  Regional: In be  1959  shipped  medical  the U n i v e r s i t y of Utah developed  to p h y s i c i a n s i n r u r a l  d i s c u s s i o n s on  slides.  to  Contained  Van  (232) .  Service  The  (164).  professions i n B r i t i s h  U n i v e r s i t y of B r i t i s h  a multi-media  members o f  Columbia, p a r t i c u l a r l y  developed  the a l l i e d  t h o s e who  find  A l a s k a / W a s h i n g t o n RMP  i s developing  approach  health  i t difficult  a u n i t which w i l l  co-ordinate a l l educational materials for projects i n two  state region.  and  c o n s i d e r a b l e money s a v e d b y  m a t i o n t o t h e more i s o l a t e d technology  to  the  centralized production.  this unit w i l l  be  More  o f modern  be  achieved  particularly,  t o " p r o v i d e up  r u r a l p h y s i c i a n b y way  and  to date  infor-  communications  (138).  Cooper Education  produce  I t i s anticipated that greater e f f i c i e n c y w i l l  however, the main emphasis of  (63)  r e p o r t s the establishment  i n the H e a l t h  Sciences'  Center  the U n i v e r s i t y ' s m u l t i - d i s c i p l i n a r y  o f an O f f i c e o f  Audio-Visual  at the U n i v e r s i t y of Colorado. student  laboratories (unit  the newly c o n s t r u c t e d O f f i c e of Research i n H e a l t h  Education,  serve  i t will  as a c e n t r a l  e v a l u a t i o n of multimedia  source  for production,  Together  teaching  l a b o r a t o r i e s ) , and  and  a  their practices." The  with  coloured  Columbia i s developing  I t s purpose i s "to provide  f o r p h y s i c i a n s and  could  i n the k i t were  l o n g p l a y r e c o r d s , a c c o m p a n y i n g s c r i p t s ; and  continuing education  leave  communities.  T h i s m a i l s e r v i c e p r o v e d s u c c e s s f u l so o t h e r o r g a n i z a t i o n s  s i m i l a r programs Mobile  an A u d i o - V i s u a l K i t w h i c h  Science  distribution,  p r o g r a m s f o r t h e C o l o r a d o / W y o m i n g RMP.  Among  the  97  many e d u c a t i o n a l projects  approaches w h i c h have been e x p l o r e d ,  are of p a r t i c u l a r i n t e r e s t .  among h o s p i t a l s w i t h i n made b y t h e c l i n i c a l The  second w i l l  The f i r s t  be t h e p r o d u c t i o n o f a s e r i e s o f s i n g l e - c o n c e p t  on o r a l c a n c e r , t h e a u d i o p o r t i o n s  alteration  i n s u c h a way t h a t  hygenists,  nurses, physicians,  for  University  the next several  of which w i l l  years w i l l  (13) has d e c i d e d  and e f f i c i e n t  that  i t s major  dental  focus  outlined:  i n t h e i r e f f o r t s t o provide improved  expansion of d i r e c t telephone consultations,  to provide r a p i d  serve  s t a g e program has been  2) t o e n c o u r a g e a n d a s s i s t p h y s i c i a n s  m a n u a l and automated means.  be c a p a b l e o f  be on t h e development and p r o m o t i o n o f improved  1) t o a s s i s t c o m m u n i t y h o s p i t a l s  facilities;  basis.  dentists, or patients (63).  of Saskatchewan  Telephone L i b r a r y  recordings  f i l m s and  t h e same f i l m s a n d f i l m s t r i p s w i l l  " I n f o r m a t i o n R e t r i e v a l " methods, and a f o u r  facilities;  whereby v i d e o t a p e  be exchanged on a w e e k l y  filmstrips  The  pilot  i s a v i d e o t a p e exchange program  t h e Colorado/Wyoming r e g i o n  s t a f f of hospitals w i l l  two p r o p o s e d  i n t h e improvement and  3) t o e s t a b l i s h D i a l  and 4) t o a s s i s t b a s e l i b r a r i e s subject  library •  Access  i n their efforts  and b i b l i o g r a p h i c r e t r i e v a l by b o t h  E f f o r t s t o develop each phase ace p r o c e e d i n g  simultaneously. I n t h e A l b a n y RMP, c o m m u n i t y h o s p i t a l s learning  c e n t e r s f o r t h e u s e o f media and newer i n s t r u c t i o n a l t e c h n o l o g y .  T h e s e a r e b e i n g s e t up i n t h r e e s i z e s : staffs  a r e being developed as p r o t o t y p e  the smallest  o f up t o t w e n t y d o c t o r s a n d f e a t u r e  programs, radio  receivers  which w i l l  allow  related visual materials.  The medium s i z e d  twenty t o f i f t y  will  physicians  largest hospitals w i l l  include  are f o r hospitals  sound t a p e s , t e l e p h o n e d i a l two-way r a d i o  have v i d e o t a p e p r o j e c t o r s  access  c o n f e r e n c e s , and o t h e r  centers f o r hospitals  i n addition  with  o f from  the medical, jukebox.  as w e l l .  These  learning  The  98  centers are being library  e s t a b l i s h e d e i t h e r as an i n t e g r a l p a r t o f the  or are located adjacent  supervision of l i b r a r y  to a l i b r a r y  personnel.  According  medical  and a r e u n d e r t h e to Woolsey  continuous  (277),  M e d i c a l l i b r a r i e s c a n no l o n g e r e x i s t j u s t f o r t h e s t o r i n g a n d r e t r i e v a l o f p r i n t e d i n f o r m a t i o n . To b e r e a l l y u s e f u l , a m e d i c a l l i b r a r i a n s h o u l d be on hand as an i n s t a n t c o n s u l t a n t . I f what y o u need i s not i m m e d i a t e l y a v a i l a b l e , the l i b r a r i a n s h o u l d d i g i t out q u i c k l y o r t h e i m p u l s e t o l e a r n may b e l o s t . Similarly, helped  C a s t l e (41) r e p o r t s t h a t t h e I n t e r - m o u n t a i n  to organize  the following  learning resources  RMP  staff  i n the major  have  community  hospitals: C o n f e r e n c e Room E q u i p p e d W i t h :  Established  Usual teaching aids Audio playback T e l e v i s i o n playback f a c i l i t i e s  18 10 4  Two-Way R a d i o C o n n e c t i o n M e d i c a l Center  32  w i t h the U n i v e r s i t y  M e d i c a l L i b r a r y and Exchange Resources  System w i t h  University  A u d i t e d M e d i c a l Records System, I n t e g r a t e d w i t h E d u c a t i o n a l P r o g r a m s (PAS MAP)  9  Medical Education  5  C o - o r d i n a t i o n , or Core F a c u l t y  National: As t h e v a r i o u s m e d i c a l producing  c e n t e r s became i n c r e a s i n g l y  t e l e v i z e d programs, the f e a s i b i l i t y  agency t o c o - o r d i n a t e programs in  the establishment  Broadcasters are:  i n 1965  i n Utah.  the use o f b r o a d c a s t  e d u c a t i o n , a n d 2) e n c o u r a g e w i d e r and d i s t r i b u t i o n  (209).  of e s t a b l i s h i n g  e x c h a n g e s was  a  centralized  explored.  This  of a N a t i o n a l A s s o c i a t i o n of Medical  w i t h headquarters  1) t o p r o m o t e  and f i l m  involved i n  The  culminated  Television  o b j e c t i v e s of t h i s A s s o c i a t i o n  t e l e v i s i o n a s a medium f o r c o n t i n u i n g  c o - o p e r a t i o n i n program p l a n n i n g , p r o d u c t i o n ,  A t t h e moment, v i d e o t a p e s  are readily  available  through  99 the  services of this Association  medical school with  or organization  series at minimal  The lends  National Medical  to Brayton  ( 2 9 ) , "any  h a v i n g a c c e s s t o a n ETV s t a t i o n o r l i n k  s u c h s t a t i o n s c a n now i n i t i a t e  broadcast  i t s own p o s t g r a d u a t e m e d i c a l  up  television  cost." Audiovisual  Center  (NMAC) i n A t l a n t a ,  Georgia,  m o r e t h a n 9 3 , 0 0 0 a u d i o v i s u a l i t e m s e a c h y e a r t o members o f t h e h e a l t h  professions.  The C e n t e r i s s a i d t o h a v e t h e w o r l d ' s l a r g e s t m e d i c a l  visual collection. materials for  (AMTVB) a n d a c c o r d i n g  I n a d d i t i o n , t h e NMAC p r o d u c e s a l l t y p e s o f a u d i o v i s u a l  f o rhealth professions  biomedical The  audio  audiovisual  Medical  and s e r v e s as an i n t e r n a t i o n a l  clearinghouse  information.  Literature Analysis  and R e t r i e v a l System  (MEDLARS) i s a  computerized b i b l i o g r a p h i c system developed by t h e N a t i o n a l L i b r a r y o f M e d i c i n e . In use since  1964, t h i s  computer to s t o r e the  system indexes the major medical j o u r n a l s  the information.  If  request.  now f o r m u l a t e d  searches are being  section of this  retrieve the literature  Lancaster  (136) r e p o r t s  annually  at the National  that  Library of Medicine.  h a n d l e d a t r e g i o n a l MEDLARS c e n t e r s  United  its  l i m i t a t i o n s , MEDLARS o f f e r s t h e m o s t e x t e n s i v e  The 1965.  a v a i l a b l e on m e d i c a l  university disciplines resources  i n higher  equally  education.  toh i s  Additional States,  Although not without  and q u i c k e s t  indexing  literature.  I n t e r u n i v e r s i t y Communications C o u n c i l not only  searcher  searches  i n the United  K i n g d o m , Sweden, and more r e c e n t l y i n C a n a d a . "  I t represents  from  a  relevant  " o v e r 3,000 demand  the  service presently  listing,  a  o f i n t e r e s t i s a d e q u a t e l y c o v e r e d b y MEDLARS.  s o , t h e c o m p u t e r i z e d MEDLARS w i l l  specific are  Index Medicus i s p r i n t e d d i r e c t l y  computer, thus by s c a n n i n g t h e s u b j e c t  may d e t e r m i n e w h e t h e r h i s f i e l d  using  (EDUCOM) was o r g a n i z e d  the health professions,  but also a v a r i e t y of  interested i n developing Although beginning  i n  with  and s h a r i n g  educational  representatives  from  100  eight universities, M i l l e r universities of a  i n 1968.  (163) r e p o r t e d  Future  plans  eighty-eight  participating  o f t h i s o r g a n i z a t i o n i n c l u d e the development  multimedia e l e c t r o n i c network which w i l l  facilitate  sharing of  and a c c e l e r a t e i n f o r m a t i o n p r o c e s s i n g .  In medicine this w i l l  access to s p e c i a l i s t s  when t h e i r  four c r i t e r i a  followed  and o t h e r  experts  i n developing  advice  resources  provide  i s needed.  rapid The  the network a r e :  1.  T h a t i t be i n t e r d i s c i p l i n a r y health sciences.  fora l l fields  and n o t o n l y  f o r the  2.  That i t s s e r v i c e s be a v a i l a b l e e v e r y w h e r e i n t h e U n i t e d and e v e n t u a l l y , by e x t e n s i o n , e v e r y w h e r e i n t h e w o r l d .  3.  That i t be a multimedium network, n o t l i m i t e d t o computers o r f a c s i m i l e t r a n s m i s s i o n o f documents o r t e l e v i s i o n o r c o m p u t e r i z e d program i n s t r u c t i o n , b u t i n c l u d i n g a l l media o f e d u c a t i o n a l v a l u e w h i c h c a n be p u t on an e l e c t r o n i c n e t w o r k .  4.  T h a t whenever f e a s i b l e , a l l m a t e r i a l s be a v a i l a b l e r a p i d l y on demand, when d e s i r e d b y t h e u s e r .  States,  101  CHAPTER V I EVALUATION  Since the primary o b j e c t i v e of c o n t i n u i n g e d u c a t i o n i n medicine is  the achievement  it  i s necessary  of l e a r n i n g  that w i l l result  i n improved  to e v a l u a t e program a c t i v i t i e s .  As A b r a h a m s o n  s t a t e d , e v a l u a t i o n i s a "continuous process based developed,  and  i s concerned  the l e a r n e r s . "  of  continuing education i n medicine  concern. found from  There has  In these terms,  largely  has  changes i n b e h a v i o r  n o t been an i n t e g r a l  a l t h o u g h i t i s now  part  becoming a matter  of  b e e n an i n c r e a s e i n t h e number o f e v a l u a t i o n s t u d i e s  i n the l i t e r a t u r e inadequate  e v a l u a t i o n has  (2)  care,  upon c r i t e r i a c o - o p e r a t i v e l y  w i t h t h e s t a t u s o f , and  of  patient  o v e r t h e p a s t few y e a r s b u t most o f t h e s e  d e s i g n and  measurement so t h a t the r e s u l t s  suffer  achieved  are  inconclusive. Such e v a l u a t i o n as has  been r e p o r t e d i s p r i n c i p a l l y  there i s a promising increase i n attempts  subjective  at the o b j e c t i v e assessment  but of  learning. S U B J E C T I V E ASSESSMENT Next to attendance e v a l u a t i o n i s t h e f o l l o w up w i t h regard to a program i n c l u d e s why to  r e c o r d s , t h e m o s t commonly r e p o r t e d f o r m questionnaire which  (220)  (2)  (241).  physicians attended, their  The  solicits  v a r i o u s a s p e c t s o f t h e p r o g r a m , and w h e t h e r t h e y  their  objectives.  Since these instruments s o l i c i t  o p i n i o n s a b o u t an e d u c a t i o n a l e v e n t  participant opinion  information usually  i m p r e s s i o n s and felt  of  sought  opinions with respect they  unverified  they are o f t e n r e f e r r e d  achieved subjective  t o as a  "happiness  102 index" or opinionnaire. W h i l e such i n s t r u m e n t s may be u s e f u l i n p l a n n i n g f u t u r e c o u r s e s , p r o v i d e no e v i d e n c e t h a t l e a r n i n g r e a l l y took p l a c e . (77)  r e p o r t an experiment which i l l u s t r a t e s t h i s  they  D o n n e l l y and N a t f u l i n  point:  We r e c e n t l y conducted a somewhat l i m i t e d s t u d y of the v a l i d i t y o f the s o - c a l l e d h a p p i n e s s i n d e x . An a c t o r was h i r e d and programmed to speak i n c o h e r e n t l y on a t o p i c of i n t e r e s t to m e d i c a l e d u c a t o r s . . . H i s name, e r r o n e o u s t i t l e s , and degrees were i n c l u d e d on the program s e m i n a r . He gave a h i g h l y t e c h n i c a l p r e s e n t a t i o n w h i c h c o n s i s t e d of n o t h i n g more than mere d o u b l e talk. He spoke on a s u b j e c t about w h i c h he knew n o t h i n g . An a n a l y s i s of the s u b s t a n c e of h i s p r e s e n t a t i o n i n d i c a t e d t h a t i t c o n s i s t e d p r i m a r i l y of u n r e l a t e d examples and a few good j o k e s . F o l l o w i n g t h i s v e r y " e n t e r t a i n i n g " l e c t u r e , the a u d i e n c e ( c o n s i s t i n g p r i m a r i l y of i n s t r u c t o r s . . . ) was a d m i n i s t e r e d a r e p l i c a of one of the h a p p i n e s s q u e s t i o n n a i r e s . . . W i t h o u t e x c e p t i o n the group r a t e d the l e c t u r e and e n s u i n g q u e s t i o n and answer p e r i o d h i g h l y i n e v e r y r e s p e c t . They.found i t i n t e r e s t i n g , i n f o r m a t i v e , and s t i m u l a t i n g . . . I n o t h e r w o r d s , the m e d i c a l e d u c a t o r s i n a t t e n d a n c e were v e r y happy w i t h the i n s t r u c t i o n a l e x p e r i e n c e  d e s p i t e the f a c t t h a t the programmers had  m i n i m i z e d the l e a r n i n g component.  W h i l e t h i s i s o b v i o u s l y an extreme  example, most w r i t e r s a g r e e t h a t i t i s not s u f f i c i e n t to c o n s i d e r a program s u c c e s s f u l s i m p l e "because a t t e n d a n c e  i s h i g h and c o m p l a i n t s a r e l o w "  (27).  More r e c e n t l y , v a r i o u s m o d i f i c a t i o n s of the h a p p i n e s s i n d e x h a v e been reported.  L e v i n s o n (140)  e v a l u a t e s h i s one-week h e a l t h seminars by h a v i n g  p a r t i c i p a n t s r a t e each l e c t u r e and a l l o t h e r a s p e c t s of the seminar on a five-point scale.  They are a l s o asked to comment f r e e l y about the  experience  and t o add a d d i t i o n a l comments to the e v a l u a t i o n s h e e t a t the end of week.  S i x months l a t e r ,  the  t h r o u g h a m a i l q u e s t i o n n a i r e , each p a r t i c i p a n t  a g a i n asked to e v a l u a t e the e x p e r i e n c e .  is  T h i s time he i s asked what he t h i n k s  he l e a r n e d a t the seminar t h a t was most u s e f u l to h i m , what was l e a s t  useful,  how he a p p l i e d what he l e a r n e d , and what problems he had i n t h e i r a p p l i c a t i o n .  103  Although he  Levinson  i s not e n t i r e l y  r e p o r t s c o n s t r u c t i v e feedback  s a t i s f i e d w i t h t h i s procedure and s p e c i f i c  p r a c t i c e which p h y s i c i a n s have a t t r i b u t e d From t h e f i e l d  of evaluation,  examples o f changes i n m e d i c a l  to course  of p u b l i c h e a l t h , P a r l e t t e  attendance.  (179) r e p o r t s  experimental  s t u d i e s u s i n g p a i r e d q u e s t i o n n a i r e s , one answered by t h e p a r t i c i p a n t  concerning  change i n h i m s e l f as he p e r c e i v e s i t , and t h e o t h e r , by h i s s u p e r i o r . hypothesis change w i l l  i s , "that the deeper the i n d i v i d u a l occur  The  i n s i g h t s a r e , t h e more  likely  and be r e c o g n i z e d by h i s s u p e r i o r s and t h e r e f o r e t h e  p a r t i c i p a n t ' s r e p o r t e d change i s more  valid."  Another v a r i a t i o n of the o p i n i o n n a i r e i s the use of a personal view w i t h s m a l l randomly s e l e c t e d groups o f p a r t i c i p a n t s p r i o r each s e s s i o n o f the program. "this  technique  Dohner  Meyer i s quoted by Vaneslow as s a y i n g  i s exceedingly useful i n e l i c i t i n g  comments f r o m p a r t i c i p a n t s "  (75) has d e v i s e d an i n s t r u m e n t  w h i c h c a n be used as an  The i n s t r u m e n t  o r m o t i v a t i o n as judged  of t h e g e n e r a l v a l u e and r e l e v a n c e o f c o u r s e their  l e a r n i n g heeds.  Evidence  each scored  questionnaire responses.  Although  u s e d was a m o t i v a t i o n  participant's  of the instrument  i t e m on t h e s c a l e w i t h the results  i n meeting was  participants'  from one p r e l i m i n a r y s t u d y could provide a v a l i d  t o which t h e s c a l e p r e d i c t s a c t u a l changes i n a  subsequent behavior  Although  to assess the  o b j e c t i v e s and c o n t e n t  i n d i c a t e that the scale with f u r t h e r refinement the extent  index  by t h e l e a r n e r s ' p e r c e p t i o n s  of the r e l i a b i l i t y  p r o v i d e d by c o r r e l a t i n g  instrument,  that  p e r t i n e n t and c a n d i d  c o n s i s t i n g of a s e t of b i - p o l a r a d j e c t i v e s designed  degree o f enthusiasm  following  (254).  of the e f f e c t i v e n e s s of short courses. scale,  t o and  inter-  the "happiness  h a s y e t t o be v a l i d a t e d .  i n d e x " o r o p i n i o n n a i r e h a s no v a l i d i t y  or  104 reliability, those  i t i s p o s s i b l e t o enhance i t by  reported  above.  This  could  I t w o u l d be  t h e i r programs. w a s t e d on  This  invalid  r e a l value  advantageous i f those  d e v e l o p some s t a n d a r d  s c a l e d responses such  form of e v a l u a t i o n i s exceedingly  p r o g r a m d i r e c t o r s e v e n t h o u g h i t i s o f no program.  using  done w i t h  with  a j u d g e m e n t on  i n continuing medical  objective instruments  c o u l d be  as  popular  to assess  l e s s t r o u b l e and  as  a  education  opinions  about  expense than i s  now  s u b j e c t i v e measures.  O B J E C T I V E EVALUATION The  use  measures can  provide  o b j e c t i v e s and the to  of o b j e c t i v e measures f o r e v a l u a t i o n i s i n c r e a s i n g . hard  data  to assess  enable program planners  e v a l u a t i o n has  some v a l i d i t y .  measure s p e c i f i c  content  whether programs are  to work w i t h g r e a t e r  Objective  instruments  material acquired,  achieving  their  security that  have been  constructed  a t t i t u d e development  change, f e e l i n g s about i n s t r u c t i o n a l a c t i v i t i e s ,  Such  or  j o b p e r f o r m a n c e , and  patient  care. Testing  f o r the Achievement of The  fairly that  p r e - and  Learning  post- design  u s i n g p a p e r and  common i n c o n t i n u i n g m e d i c a l  the p r a c t i c e i s reasonably  Since most of  these  t e s t s are  the p r a c t i t i o n e r s are  expected  education.  w e l l accepted  t e a c h e r - m a d e and  p e n c i l t e s t s has  become  A number o f w r i t e r s by  physicians  b a s e d on  to l e a r n , the r e s u l t s  (244)  specific  i n no way  consider  (271)(74) . information,  identify  t h e p h y s i c i a n s a c t u a l l y do  l e a r n (205).  n e i t h e r knowledge g a i n nor  s a t i s f a c t i o n n e c e s s a r i l y ensure d e s i r a b l e changes  in  Furthermore, s t u d i e s have found  what that  behavior. An  e v a l u a t i o n o f an  i n t e n s i v e p s y c h i a t r i c and  neurology  review  course  105  r e p o r t e d b y N a t f u l i n and  Ware ( 1 7 0 )  i s interesting  study, the experimental p o p u l a t i o n consisted enrolled  certification  through  techniques used were: choice examinations;  traditional  In  this  psychiatrists  a c o n t r o l g r o u p who  1) s i m u l a t e d A m e r i c a n 3) i n t e r v i e w s ;  and  the board  s a t i s f a c t i o n w i t h t h e i r board p r e p a r a t i o n . t h e mean s c o r e s f o r t h o s e b o a r d On  Board  board  were s t u d y i n g  The  four evaluation  examinations;  2)  multiple  4) s a t i s f a c t i o n q u e s t i o n n a i r e s .  a t e l y h i g h e r r a t e t h a n d i d t h e c o n t r o l s , and  tests.  of twenty-eight  s e l f - s t u d y methods.  h y p o t h e s i z e d , those i n the course passed  in  regard.  i n a program; twelve of the group were s t u d y i n g f o r s p e c i a l t y  examinations w h i l e another ten c o n s t i t u t e d for  i n this  examiners  examinations at a  proportion-  expressed a higher l e v e l T h e r e was and  no  significant  e x p e r t s who  also  As  of change  took  the  the b a s i s of these f i n d i n g s , these r e s e a r c h e r s conclude:  While the debate over peer r e v i e w , mandatory c o n t i n u i n g e d u c a t i o n , r e - c e r t i f i c a t i o n , a n d s e r i a l c e r t i f i c a t i o n p r o g r a m s become h o t t e r , m e d i c a l e d u c a t i o n ..must d e v e l o p m o r e e f f e c t i v e e v a l u a t i o n o f t h e r e l a t i o n s h i p s a m o n g - c o n t i n u i n g e d u c a t i o n , s p e c i a l t y s k i l l s , and c l i n i c a l competence. I f continuing education interests correlate w i t h c l i n i c a l n e e d s i n b o t h g e o g r a p h i c and s p e c i a l t y a r e a s o f m e d i c a l p r a c t i c e , more a g r e e m e n t may be r e a c h e d a s t o w h a t c l i n i c a l competence i s . . . In clinical 1,700  this  respect, Miller  competence p e r t a i n i n g  critical  competencies  incidents  are relevant  r e f i n e m e n t c o u l d be u s e d objectives  i n most f i e l d s  (162)  identified  t h e c r i t i c a l components o f  t o o r t h o p e d i c s t h r o u g h an a n a l y s i s o f  c o n t r i b u t e d by p r a c t i s i n g o r t h o p e d i s t s . t o m o s t a r e a s o f m e d i c i n e , and w i t h  over  Since  additional  as t h e b a s i s f o r d e f i n i n g m e a s u r a b l e b e h a v i o r a l of p r a c t i c e ,  they are re-stated  here:  1.  S k i l l i n gathering c l i n i c a l information: a. Eliciting historical information b. O b t a i n i n g i n f o r m a t i o n by p h y s i c a l e x a m i n a t i o n  2.  E f f e c t i v e n e s s i n u s i n g s p e c i a l d i a g n o s t i c methods: a. O b t a i n i n g and i n t e r p r e t i n g x - r a y f i l m s b. O b t a i n i n g a d d i t i o n a l i n f o r m a t i o n b y o t h e r means  these  106  Competence i n d e v e l o p i n g a d i a g n o s i s : a. Approaching diagnosis o b j e c t i v e l y b. Recognizing conditions  4.  J u d g e m e n t i n d e c i d i n g on a p p r o p r i a t e c a r e : a. Adapting treatment to i n d i v i d u a l cases b. D e t e r m i n i n g e x t e n t and i m m e d i a c y o f t h e r a p e u t i c  5.  J u d g e m e n t and s k i l l i n i m p l e m e n t i n g treatment: a. P l a n n i n g the o p e r a t i o n b. Making necessary preparations f o r operation c. M o d i f y i n g o p e r a t i v e p l a n s a c c o r d i n g to s i t u a t i o n  6.  E f f e c t i v e n e s s i n t r e a t i n g emergency p a t i e n t s : a. Handling patients b. P e r f o r m i n g emergency t r e a t m e n t  7.  Competence i n p r o v i d i n g c o n t i n u i n g a. Attention postoperatively b. Monitoring patient's progress  8.  E f f e c t i v e n e s s of p h y s i c i a n - p a t i e n t r e l a t i o n s h i p s : a. S h o w i n g c o n c e r n and c o n s i d e r a t i o n b. R e l i e v i n g a n x i e t y o f p a t i e n t and f a m i l y o A c c e p t i n g r e s p o n s i b i l i t y f o r the w e l f a r e of the p a t i e n t : a. R e c o g n i z i n g p r o f e s s i o n a l c a p a b i l i t i e s and l i m i t a t i o n s b.  Using review  Relating effectively this  scheme, M i l l e r  o f b o t h t h e o r a l and  American Board of Orthopedic s u b j e c t m a t t e r and a new  needs  to other medical  and  his colleagues  written parts Surgeons.  professional skills  c e r t i f i c a t i o n p r o g r a m was  care:  persons then undertook a  of c e r t i f y i n g  This  study  developed using  examinations f o r  revealed  were incomplete  systematic  and  the  that t e s t s i n both spotty.  these  defined  (149)  illustrates  Accordingly,  competencies  as  the b a s i s f o r t e s t c o n s t r u c t i o n . The  study  by M c G u i r e and  her  w e l l known p r o b l e m o f e d u c a t i o n a l always occurs Using  one  unless  c o n t r o l and  colleagues  t e s t i n g , namely: t h a t l o s s of s k i l l s  p e r i o d i c reinforcement four experimental  e t a l s o u g h t t o d e t e r m i n e g a i n and  another  i s provided  groups of  30  to maintain  the  almost skill.  t o 40 p h y s i c i a n s , M c G u i r e  r e t e n t i o n of a u s c u l t a t o r y s k i l l s  in  107  physicians following i n s t r u c t i o n , both  a twelve  t o twenty  hour i n t e n s i v e course.  Prior to  t h e c o n t r o l and e x p e r i m e n t a l groups were p r e - t e s t e d on t h e  i d e n t i f i c a t i o n o f f i f t e e n unknown h e a r t s o u n d s .  Immediately  following the  i n s t r u c t i o n a l program, t h e f o u r e x p e r i m e n t a l groups were r e - t e s t e d . time, a review of h o s p i t a l one  c h a r t s was u n d e r t a k e n  e x p e r i m e n t a l group t o a s s e s s  the course,  On t h e t e s t  immediately  following  significant  g a i n s compared t o t h e c o n t r o l g r o u p . different  Moreover, chart reviews of both  g r o u p s showed n o s i g n i f i c a n t Richardson  on p a t i e n t s administered  t h e e x p e r i m e n t a l g r o u p s showed  t h e mean s c o r e s w e r e n o t s i g n i f i c a n t l y pre-test.  f o r t h e c o n t r o l group and  the information recorded  h o s p i t a l i z e d w i t h c a r d i o - v a s c u l a r problems.  A t s i x months, however, from  t h e mean s c o r e o f t h e  t h e c o n t r o l s and e x p e r i m e n t a l  similar  g r o u p s o f p h y s i c i a n s (N=16 a n d 1 5 ) , a n d w i t h a t h i r d  mean g a i n o f f r o m differential  6.4 t o 12 s i x m o n t h s a f t e r  findings  to the intermittent  findings.  i n design to that of the  M c G u i r e g r o u p , was a b l e t o d e m o n s t r a t e some a u s c u l t a t o r y s k i l l two  statistically  difference i n the recording of cardiac  (149), using a study  At this  training.  training  group,  r e t e n t i o n -with (N=15), a  He a t t r i b u t e s  schedule  these  used i n h i s study  as compared w i t h t h e i n t e n s i v e one s e s s i o n c o u r s e p r o v i d e d i n t h e M c G u i r e study. A number o f e x p l o r a t o r y s t u d i e s u s i n g t h e p r e and p o s t to measure a t t i t u d e  change a r e r e p o r t e d from  her r e v i e w , Lucy Zabarenko s u g g e s t i v e b u t f a r from  (281) concluded  coherent."  Tucker  t u d i n a l s t u d y o f 219 v o l u n t e e r f l i g h t measure a t t i t u d e  the f i e l d  design  of psychiatry.  In  that "the results are tantalizingly and R e i n h a r d t  (277) i n a  longi-  surgeons used s c a l e d q u e s t i o n n a i r e s t o  change f o l l o w i n g a s i x month p o s t g r a d u a t e  o f 48 l e c t u r e s a n d 8 t h r e e - h o u r  test  interviewing sessions.  a d m i n i s t e r e d a t t h e b e g i n n i n g and a t t h e c o m p l e t i o n  course  consisting  The q u e s t i o n n a i r e s ,  o f t h e c o u r s e , and a g a i n  108  eighteen months l a t e r , were designed to e l i c i t responses to some 44 frequently heard statements  about psychiatry which were scored on a four point scale.  The c r i t e r i a used to score the responses were established by four independent psychiatrists.  The most s i g n i f i c a n t findings were that "while the physicians'  attitudes toward p s y c h i a t r i s t s , psychotherapy  and mental i l l n e s s changed  very l i t t l e over time, they f e l t more confident and competent i n treating p s y c h i a t r i c p a t i e n t s . " These findings represent a sampling of opinions and attitudes of a group of student f l i g h t surgeons with regards to c e r t a i n statements  about psychiatry, and i n no way provide conclusive evidence that  any behavioural change occurred which was a t t r i b u t a b l e to course Pearson and Young (181)used  attendance.  four s p e c i a l l y devised scales to evaluate  eight short term p s y c h i a t r i c seminars f o r general p r a c t i t i o n e r s i n eight d i f f e r e n t communities.  Sponsored by WTCHE, the programs were a l l s i m i l a r i n  format and used mainly a non-directive approach. designed to measure 1) r o l e tolerance; a p o s t o l i c function;  The scales used were  2) p s y c h i a t r i c o r i e n t a t i o n ;  and 4) s o c i a l distance.  3)  The c r i t e r i a used to score the  scale were the scores achieved by the p s y c h i a t r i s t i n s t r u c t o r s .  The scales  were administered as pre and post tests to a t o t a l of 79 physicians.  Although  the findings were somewhat varied on the i n d i v i d u a l scales, s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p s were found between one or more scales and, on the basis of t h i s , these researchers conclude that the course achieved  "attitude  change i n the desired d i r e c t i o n . " On the other hand, Chassy and Heslin (181), using a s i m i l a r research design, were unable to confirm a t t i t u d e change i n t h e i r study of 79 general p r a c t i t i o n e r s who had attended another ten WICHE seminars. studies, Smith (181) states:  Commenting on these  109  To d e c i d e s e m i n a r g o a l s i s a d i f f i c u l t e n o u g h m a t t e r b u t t o d e c i d e i n an o b j e c t i v e f a s h i o n w h e t h e r t h e g o a l s have b e e n a c h i e v e d i s i n my j u d g e m e n t , c o n s i d e r a b l y m o r e d i f f i c u l t . Perhaps t h e m o s t s a t i s f a c t o r y means o f e v a l u a t i o n i s v i a o b j e c t i v e measuring instruments. However l a u d a b l e the e v a l u a t i o n e f f o r t s o f my WICHE c o l l e a g u e s h a v e b e e n i n t h i s d i r e c t i o n , t h e y a r e t h e f i r s t to admit t h a t t h e i r attempts have a s t r o n g element of s u p e r f i c i a l i t y i n them. Can a q u e s t i o n n a i r e e v e r be d e v i s e d t o i n d i c a t e t h a t a p h y s i c i a n i s more p s y c h o l o g i c a l l y m i n d e d , h a s m o r e human u n d e r s t a n d i n g , and h a s t h e t h e r a p e u t i c a b i l i t y t o h e l p h i s p a t i e n t toward f u r t h e r u n d e r s t a n d i n g of h i m s e l f ? I feel t h a t t h e s e a r e e x t r e m e l y d i f f i c u l t t h i n g s t o m e a s u r e and t o a s s e s s . F o r m a n and following patient 17  of  the  a pre-test  two  p r o c e d u r e was  a t t e m p t e d t o t e s t a t t i t u d e change  to the  repeated at The  physicians  the  end  in  s p i t e of  of  the  t e s t s i t u a t i o n and  c o u r s e and and  inter-  the  results  questionnaires  A l t h o u g h i t was  i n the p h y s i c i a n s '  Adler  (281)  felt  u n d e r s t a n d i n g and  have d e f i n e d  the  goals  degree  interest in  psychiatry,  criterion  more c l e a r l y , ,  and,  results.  atric  case conferences i n producing cognitive learning gain, a before  after  design  Of two  the  used, employing unstructed  interviews.  physicians  The  criteria  were r a t e d were the  three  e f f e c t i v e n e s s of a s e r i e s of  In  (90)  filmed  to measure the  group.  study  was  against  responses to three  which the  responses of  at a b e t t e r  t h a n an  ten  one  psychiand  simulated  fourteen p a r t i c i p a t i n g  the p s y c h i a t r i s t i n s t r u c t o r s .  major hypotheses t e s t i n g attainment of  were s u b s t a n t i a t e d  were  that a f a i r  a l i m i t e d s a m p l e , t h e y r e p o r t more c o n c l u s i v e designed  recorded  r e l a t e d to these  same r e c o r d i n g s  r e s u l t s w e r e i n c o n c l u s i v e as measured a g a i n s t E n e l o w and  (6 i n one  tape  c r i t e r i o n group c o n s i s t i n g of p s y c h i a t r i c r e s i d e n t s  psychiatric staff physicians.  of change occurred  the  simulated  t o answer q u e s t i o n s  t e s t s were compared.  also presented and  As  o t h e r ) , were r e q u i r e d  This  (100)  term p s y c h i a t r i c seminars u t i l i z i n g  interviews.  i n the  views.  short  h i s co-workers  .05  the  stated  objectives,  l e v e l of s i g n i f i c a n c e .  110 A n o t h e r s t u d y i s r e p o r t e d by Enelow and A d l e r (87)  of a t t i t u d e  change  f o l l o w i n g an advanced s u p e r v i s o r y p s y c h o t h e r a p y c o u r s e c o n s i s t i n g of 32 f o u r hour s e s s i o n s .  They used f o u r Guttman s c a l e s t o measure the f o u r d i m e n s i o n s  of the p h y s i c i a n ' s r o l e i n the d o c t o r - p a t i e n t r e l a t i o n s h i p ( a u t h o r i t y ;  self-  i n v o l v e m e n t ; e x p r e s s i o n of c o n c e r n ; and i n s t r u m e n t a l ) .  These were a d m i n i s t e r e d  to s i x p h y s i c i a n s b e f o r e and a t the end of the c o u r s e .  A c o m p a r i s o n of  two s e t s of s c o r e s r e v e a l e d t h a t d u r i n g the c o u r s e the p h y s i c i a n s ' of the d o c t o r - p a t i e n t r e l a t i o n s h i p became more c o n s i s t e n t  the  conception  i n s u p p o r t , moderate  i n r e l i a n c e on t e c h n i c a l p r o c e d u r e s , and h i g h i n s e l f - i n v o l v e m e n t .  A follow  up i n t e r v i e w u n d e r t a k e n s e v e r a l y e a r s l a t e r r e v e a l e d t h a t a l l s i x p h y s i c i a n s had changed t h e i r s t y l e of i n t e r v i e w i n g p a t i e n t s , w i t h more emphasis on the patient's referrals.  b e h a v i o r and l e s s dependency on p s y c h o t r o p i c drugs and p s y c h i a t r i c Enelow and Myers (91)  conclude that  "change i n a t t i t u d e and p r a c t i c e  w i l l o c c u r f o r p h y s i c i a n s who t a k e two o r t h r e e y e a r s of p s y c h i a t r i c c u l m i n a t i n g i n the advanced s u p e r v i z e d p s y c h o t h e r a p y  courses  course."  M e a s u r i n g Change i n P e r f o r m a n c e : B e l k i n elt a l (21) program d e s i g n e d to a s s i s t  attempted t o a s s e s s the e f f e c t s of a s h o r t t r a i n i n g the s t a f f of the C h i l d H e a l t h S t a t i o n i n New Y o r k  C i t y to i n t e g r a t e m e n t a l h e a l t h p r i n c i p l e s i n t o t h e i r d a i l y p r a c t i c e .  Using a  b e f o r e and a f t e r e x p e r i m e n t a l d e s i g n , 48 p a r t i c i p a t i n g p h y s i c i a n s were randomly a s s i g n e d to an e x p e r i m e n t a l group and a c o n t r o l g r o u p .  The e x p e r i -  m e n t a l group was observed and s c o r e d i n d e t a i l w h i l e c o n d u c t i n g the h e a l t h conference one month a f t e r  by two d i f f e r e n t o b s e r v e r s  completing t r a i n i n g .  child  p r i o r t o the c o u r s e and a g a i n  The c o n t r o l g r o u p , w h i c h had not gone  t h r o u g h the p r o g r a m , was s i m i l a r l y o b s e r v e d .  In order to v a l i d a t e  the  i n s t r u m e n t , o b s e r v e r s were not t o l d whether the d o c t o r b e i n g o b s e r v e d was i n  Ill the e x p e r i m e n t a l o r c o n t r o l g r o u p , and the d o c t o r s were not t o l d why the o b s e r v e r s were p r e s e n t . q u e s t i o n n a i r e responses  The s e r i e s of o b s e r v a t i o n s  of performance and  i n d i c a t e d t h a t w h i l e the t r a i n i n g program was r e l a -  t i v e l y s u c c e s s f u l i n i n s t i l l i n g a knowledge o f m e n t a l h e a l t h p r i n c i p l e s and t e c h n i q u e s of c o u n s e l l i n g , a comparison of e x p e r i m e n t a l and c o n t r o l groups suggested t h a t the program was l e s s s u c c e s s f u l i n a l t e r i n g p h y s i c i a n s ' b e h a v i o u r by the a p p l i c a t i o n of the l e a r n i n g i n p r a c t i c e . Ro.ney and Roark (212)  used p a t i e n t r e c o r d s as the p r i m a r y s o u r c e  d a t a to e v a l u a t e the e f f e c t i v e n e s s o f a c i r c u i t c o u r s e . of 1,092  The sample  of  consisted  p a t i e n t r e c o r d s of 41 p r a c t i s i n g p h y s i c i a n s , 24 of whom had a t t e n d e d  one o r more s e s s i o n s of the c o u r s e .  The p h y s i c i a n s were asked to respond  to s t a t e m e n t s c o n c e r n i n g 12 h e a l t h problems t h a t r e f l e c t e d the c o n t e n t of course being s t u d i e d .  They a l s o s e l e c t e d  p r o c e d u r e s p e r t i n e n t to the manage-  ment of t h e s e h e a l t h problems from t h e i r m e d i c a l r e c o r d s . p r o c e d u r e s as i n d i c a t e d by t h e p a t i e n t  responses  The use of  r e c o r d s was then compared f o r  and n o n - p a r t i c i p a n t s b o t h b e f o r e and a f t e r the c o u r s e . correct  t h a t p h y s i c i a n s a t t e n d i n g the c o u r s e were somewhat more competent  participants  suggested i n the  management of s e l e c t e d h e a l t h problems i n d i c a t e d by p a t i e n t r e c o r d s , d i f f e r e n c e between t h e two groups was not s t a t i s t i c a l l y (102)  the  significant.  a l s o used p a t i e n t r e c o r d s as a s o u r c e of  to e v a l u a t e a v i d e o t a p e d program on the use of d i u r e t i c s .  data  Two matched  h o s p i t a l s were u s e d , one s e r v i n g as the e x p e r i m e n t a l and the o t h e r as c o n t r o l group.  these  B o t h groups gave  t o the q u e s t i o n n a i r e and a l t h o u g h t h e f i n d i n g s  F o s t e r and L a s s  the  the  O b s e r v a t i o n s were made of p a t i e n t r e c o r d s i n b o t h h o s p i t a l s  f o r t h r e e weeks p r i o r to and t h r e e weeks f o l l o w i n g the showing of the v i d e o tape i n the e x p e r i m e n t a l h o s p i t a l .  The i n f o r m a t i o n sought was the e x t e n t  to  112 w h i c h t h e r e would be an i n c r e a s e  i n serum p o t a s s i u m and sodium d e t e r m i n a t i o n s  i n the e x p e r i m e n t a l h o s p i t a l as a r e s u l t of the v i d e o t a p e d program. a n a l y s i s of p a t i e n t r e c o r d s found no s i g n i f i c a n t d i f f e r e n c e s .  The  The d a t a d i d  r e v e a l t h a t p h y s i c i a n s i n the e x p e r i m e n t a l h o s p i t a l were f u n c t i o n i n g a t  a  s i g n i f i c a n t l y h i g h e r l e v e l t h a n the c o n t r o l group p r i o r to the program. A c c o r d i n g l y , as n o t e d by Abrahamson ( 1 ) ,  "One can say t h a t the  objectives  f o r u s i n g t h a t program were i n a p p r o p r i a t e . . . i n a p p r o p r i a t e c e r t a i n l y f o r  the  p r a c t i c e needs of t h o s e p h y s i c i a n s " . M e a s u r i n g Long Term R e s u l t s of  Care:  W h i l e the u l t i m a t e g o a l o f a l l c o n t i n u i n g m e d i c a l e d u c a t i o n i s improvement o f m e d i c a l c a r e , e f f o r t