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

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CONTINUING EDUCATION IN THE HEALTH PROFESSIONS: A LITERATURE REVIEW PERTINENT TO NORTH AMERICA by JUNE NAKAMOTO R.N. S t . P a u l ' s H o s p i t a l B.N. M c G i l l U n i v e r s i t y A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS _ ~- 1 ( A d u l t E d u c a t i o n ) We a c c e p t t h i s t h e s i s a s c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA AUGUST, 1972 In present ing th is thes is in p a r t i a l f u l f i l m e n t o f the requirements for an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e for reference and study. I fu r ther agree that permission for extensive copying of th is t h e s i s for s c h o l a r l y purposes may be granted by the Head of my Department or by h is representa t i ves . It is understood that copying or p u b l i c a t i o n of t h i s thes is fo r f i n a n c i a l gain sha l l not be allowed without my wr i t ten permiss ion . Department of ADULT EDUCATION The Un ive rs i t y o f B r i t i s h Columbia Vancouver 8, Canada D a t e ^J^V / %/p ^ i i ABSTRACT 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 p r o v i d e s a c o m p r e h e n s i v e and c o m p a r a t i v e r e p o r t on c o n t i n u i n g e d u c a t i o n i n t h e f o u r s e n i o r h e a l t h p r o f e s s i o n s , 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 f r o m 1960 t o 1970. F i n d i n g s d i s c l o s e t h a t w h i l e c o n t i n u i n g e d u c a t i o n 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 , e a ch o f t h e p r o f e s s i o n s r e v i e w e d i n t h i s r e p o r t a d m i t s t h a t i t has been f a r fr o m s u c c e s s f u l i n i t s i m p l e m e n t a t i o n . The pr 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 , a l t h o u g h i n d i f f e r i n g m easure, were found t o be: 1) t h e l a c k o f r e s o u r c e s — f u n d s , q u a l i f i e d a d u l t e d u c a t o r s , and c l i n i c a l f a c i l i t i e s ; 2) t h e need f o r more and b e t t e r a d u l t e d u c a t i o n r e s e a r c h ; and 3) t h e l i m i t a t i o n o f program g o a l s w i t h i n t h e c o n t e x t o f t h e r a p i d l y c h a n g i n g h e a l t h c a r e s y s t e m . Recent p u b l i c 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 c o n d i t i o n f o r p r a c t i c e , c o u p l e d 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 a d v a n c e s , i n d i c a t e t h a t c o n t i n u i n g e d u c a t i o n c a n no l o n g e r be r e l e g a t e d t o a s e c o n d a r y p l a c e i n p r o f e s s i o n a l e d u c a t i o 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 r e s e a r c h , s p e c i f i c recommendations were n o t p o s s i b l e . However, i t was s u g g e s t e d t h a t : 1) more e f f e c t i v e methods of d e f i n i n g l e a r n i n g needs be d e v e l o p e d and t e s t e d ; 2) more s t r e s s be p l a c e d on c l i n i c a l l y o r i e n t e d programs and t h o s e w i t h b u i l t i n e v a l u a t i o n schemes; and 3) r e g i o n a l c e n t e r s be e s t a b l i s h e d t o f a c i l i t a t e t h e development o f o n g o i n g , i n t e r r e l a t e d programs on b o t h a u n i p r o f e s s i o n a l and i n t e r p r o f e s s i o n a l b a s i s . ( 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 programs and e v a l u a t i o n p r a c t i c e s a r e i n c l u d e d . ) i i i ACKNOWLEDGEMENTS The w r i t e r w i s h e s t o e x p r e s s a p p r e c i a t i o n t o a l l t h o s e who c o n t r i b u t e d m a t e r i a l f o r t h i s r e v i e w . A l t h o u g h i t i s n o t p o s s i b l e t o s p e c i f i c a l l y l i s t e ach p e r s o n by name, s p e c i a l t h a n k s a r e ex t e n d e d t o t h e many n u r s e s who so w i l l i n g l y s h a r e d u n p u b l i s h e d r e p o r t s and 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 f i l e s . S p e c i a l t h a n k s a r e a l s o due Dr. C o o l i e V e r n e r f o r h i s c o n t i n u e d s u p p o r t and a s s i s t a n c e , and 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 t h i s m a n u s c r i p t . iv TABLE OF CONTENTS P a g e ABSTRACT i i ACKNOWLEDGEMENTS i i i LIST OF TABLES . ix P A R T O N E AN OVERVIEW 1 CHAPTER I INTRODUCTION . . . . . . . . . . . . . . . . . 2 BACKGROUND OF THE HEALTH PROBLEM 3 PURPOSE 5 CLARIFICATION OF TERMS 5 DESIGN AND LIMITATIONS 6 REFERENCES 8 P A R T TWO CONTINUING EDUCATION IN MEDICINE . 10 CHAPTER II THE PROFESSION AND CONTINUING EDUCATION . . . . 11 PHYSICIAN COMPOSITION AND DISTRIBUTION . . 11 Work Patterns 12 Changing Patterns of Practice . . . . 13 NEED FOR CONTINUING EDUCATION 15 Early Developments 16 CHAPTER III PARTICIPATION IN CONTINUING EDUCATION 21 Field of Practice 22 . J . U ^ k i . l . k . L L A t l ^ ^ l . ^ l I L J . . . . . . . . Location of Practice 24 Years of Practice 24 OPINIONS AND PREFERENCES 25 Deterrents to Attendance 25 Fees and Stipends 26 Scheduling of Programs 26 Sponsors 27 Instructional Processes 28 Felt Learning Needs 30 Other Information Sources 31 CHAPTER IV ORGANIZATION AND ADMINISTRATION 34 ORGANIZATION . . . . . 34 Numbers of Courses and Sponsors . . . 34 Course Content and E l i g i b i l i t y . . . . 36 Patterns of Course Organization . . . 37 SPONSORSHIP ROLES AND RESPONSIBILITIES . . 42 Medical Schools . 43 Community Hospitals . 45 Medical and Specialty Societies . . . 48 PROGRAM PLANNING AND ADMINISTRATION . . . 50 Administrative Arrangements 50 Instructors 51 Finances 53 Publicity and Promotion 53 Programming 54 V Page CURRENT AND RECURRING ISSUES AND TRENDS . . 58 Accreditation 58 National Plans 60 Incentives for Learning 61 CHAPTER V INSTRUCTIONAL PROCESSES ; 65 PATTERNS OF INSTRUCTION 66 SMALL GROUPS 68 Psychiatric Case Seminars 68 Cl i n i c a l Conferences 69 Demonstrations: Supervised C l i n i c a l Practice . . . 70 LARGE GROUPS 73 MASS MEDIA 75 Radio Conferences 75 Medical Radio Network 77 Telelectures 78 Television 79 Encodes or Scrambled Broadcast TV . . . 85 Slow-Scan TV 87 SUPPORTING DEVICES 87 Motion Pictures 88 Audio Tape Recordings 88 Mediphone 91 Correspondence: Programmed Instruction.. 92 Computer Assisted Instruction 93 ORGANIZATION FOR INSTRUCTIONAL TECHNOLOGY . 95 Regional 96 National 98 CHAPTER VI EVALUATION . . ." 101 SUBJECTIVE ASSESSMENT 101 OBJECTIVE EVALUATION 104 Testing for the Achievement of Learning 104 Measuring Change in Performance . . . . 110 Measuring Long Term Results of Care . . 112 Program Models with Built-in Evaluation 114 PROBLEMS OF EVALUATION 118 The Problem of Objectives 118 Design Problems 119 Costs 120 CHAPTER VII SUMMARY AND CONCLUSIONS " 122 SUMMARY ' 122 Participation 123 Organization and Administration . . . . 124 Instructional Processes 124 Evaluation 125 CONCLUSIONS 126 REFERENCES 129 v i Page P A R T T H R E E CONTINUING EDUCATION IN DENTISTRY 152 CHAPTER VIII THE PROFESSION AND CONTINUING EDUCATION . . . . 153 COMPOSITION AND DISTRIBUTION 153 Practice Arrangements 154 Patterns of Work 155 NEED FOR CONTINUING EDUCATION 156 CHAPTER IX PARTICIPATION IN CONTINUING EDUCATION 160 Location 161 Field of Practice 161 Patterns of Practice 162 Income, Age 162 Use of Information Sources . . . . . . 163 Reasons for Attending or Not 164 Sponsors 164 Scheduling of Programs . . . . . . . . . 165 Tuition Fees 165 Felt Learning Needs 165 Instruction 166 Instructors 167 CHAPTER X PROGRAM ADMINISTRATION AND ORGANIZATION . . . . 168 ADMINISTRATION . . . 168 Administrative Arrangements 169 Instructors and F a c i l i t i e s 170 Finances 171 Publicity and Promotion . . . . . . . . 172 PROGRAM PLANNING 173 Study Clubs 174 Regional Programs . 176 Hospital Programs . 177 Professional Meetings 178 Television Programs 178 Correspondence, Programmed Instruction 181 Information Retrieval 182 CURRENT AND RECURRING ISSUES AND TRENDS. . 183 CHAPTER XI SUMMARY 186 PARTICIPATION . 186 ADMINISTRATION AND ORGANIZATION . . . . . 187 REFERENCES . . . . . . 188 v i i Page P A R T F O U R CONTINUING EDUCATION IN NURSING . 195 CHAPTER XII THE PROFESSION AND CONTINUING EDUCATION . . . . 196 NURSE COMPOSITION AND DISTRIBUTION . . . . 196 Trends in Composition and ; Distribution 197 Changing Patterns of Practice . . . . 199 CONCERN FOR CONTINUING EDUCATION . . . . . 202 Research Interests . . . . . . . . . . 205 CHAPTER XIII PARTICIPATION IN CONTINUING EDUCATION 208 CHARACTERISTICS OF PARTICIPANTS . . ... . 208 Location of Practice 208 Position in Nursing Service 209 Marital Status and Age 209 Educational Achievement . 210 Use of Other Information Sources . . . 210 REASONS FOR PARTICIPATION OR NOT 212 Scheduling . . . 213 Cost 213 Felt Learning Needs . . . . . . . 215 Methods and Techniques . . . . . . . . 218 CHAPTER XIV PROGRAM,ORGANIZATION AND ADMINISTRATION . . . . 220 SPONSORS AND PROGRAMS 220 Nursing Associations 220 Hospitals 222 Universities and their Schools of Nursing 225 ADMINISTRATION . . 227 Instructors 228 Finances 228 Publicity and Promotion . 229 Program Planning 229 SOME SAMPLE PROGRAMS 232 Regional and Sub-Regional Programs . . 233 Inservice Education . . . . 240 Mass Media and Self-Instructional Methods 244 RECURRING ISSUES AND TRENDS 249 CHAPTER XV SUMMARY 251 REFERENCES 254 v i i i Page P A R T F I V E CONTINUING EDUCATION IN PHARMACY 264 CHAPTER XVI THE PROFESSION AND CONTINUING EDUCATION . . . . 265 COMPOSITION AND DISTRIBUTION . . . . . . . 265 The Changing Nature of Practice . . . 268 Need for Continuing Education . . . . 269 CHAPTER XVII PARTICIPATION IN CONTINUING EDUCATION 272 REASONS FOR ATTENDING OR NOT 274 Scheduling of Programs 275 Fees 275 Felt Learning Needs 275 Instructional Processes 276 CHAPTER XVIII PROGRAM ORGANIZATION AND ADMINISTRATION . . . . 277 CURRENT COURSE OFFERINGS . . . . . . . . . 277 ADMINISTRATION . . . . . 282 Finances and Faculty 282 Promotion and Publicity 283 SOME SAMPLE PROGRAMS 284 Regional Programs 284 Mass Media 284 Home Study 285 ISSUES AND TRENDS 28o CHAPTER XIX SUMMARY 287 REFERENCES . . . 290 P A R T S I X CONTINUING EDUCATION IN THE HEALTH PROFESSIONS: MAJOR CONCLUSIONS • • • 293 CHAPTER XX MAJOR CONCLUSIONS 294 COMMON FINDINGS AND IMPLICATIONS 294 EDUCATIONAL PLANNING . . . . 294 Relevant Programs . . . . 295 A Health Team Approach 296 ORGANIZATION AND ADMINISTRATION 297 The Role of the University 298 The Role of the Hospital Services. . . 298 T Coordination of Programs 299 Financing and Promoting Continuing Education . 300 The Educator in Continuing Education. . 301 METHOD AND TECHNIQUES 302 EVALUATION 303 SUMMARY 304 REFERENCES . 306 i x L I S T OF TABLES Page TABLE I QUALITY OF CARE PROCEDURE IN GROUPS (CANADA, 1967) ' 23 TABLE I I CONTINUING MEDICAL EDUCATION COURSES LISTED 1961-1962 TO 1970-1971 35 TABLE I I I PERCENTAGE DISTRIBUTION OF CONTINUING EDUCATION COURSES BY TYPE OF COURSE 1964-65 TO 1969-70 . . 39 TABLE IV THE BI-CYCLE: RELATION OF PATIENT-CARE AND EDUCATION CYCLES 116 TABLE V ESTIMATED COST OF DIFFERENT EVALUATION TECHNIQUES FOR A HYPOTHETICAL ONE-WEEK SHORT COURSE . . . . 121 TABLE V I PERCENTAGE DISTRIBUTION OF EMPLOYED NURSES BY FIELD OF EMPLOYMENT IN CANADA 1930, 1960, 1968 . 198 TABLE V I I THE FREQUENCY WITH WHICH RN's WOULD BE WILLING TO ATTEND SHORT TERM REGIONAL PROGRAMS 214 TABLE V I I I PERCENTAGE DISTRIBUTION OF PHARMACISTS BY FIRST AND CURRENT EMPLOYMENT, 1962 266 TABLE I X A COMPARISON OF PARTICIPANTS IN AND THE PROMOTION OF COURSES OFFERED BY PHARMACY SCHOOLS IN 1967 AND 1968 BY SPECIALTY OF THE PARTICIPANTS 273 TABLE X COURSES SPONSORED BY SCHOOLS OF PHARMACY 1966-1968 CLASSIFIED BY LOCATION AND CONTACT HOURS . . . . 278 TABLE X I COURSES SPONSORED JOINTLY BY SCHOOLS OF PHARMACY AND PROFESSIONAL ASSOCIATIONS 1966-1968 BY LOCATION AND CONTACT HOURS 280 TABLE X I I NUMBER OF COURSES OFFERED BY SUBJECTS IN 1967 AND 1968 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 o f o u r automated w o r l d b e cause i t g i v e s meaning and c o n t e n t t o t h e human r e s o u r c e s o f t h e n a t i o n . L a u r e n e E. G i l m o r e , R.N. Everywhere a c r o s s t h e c o u n t r y a d u l t s o f a l l ages and i n a l l w a l k s o f l i f e a r e c o n t i n u i n g t h e i r e d u c a t i o n . A l t h o u g h r e l i a b l e s t a t i s t i c s a r e n o t a v a i l a b l e , e s t i m a t e s a r e t h a t some 35 t o 50 m i l l i o n a d u l t s engage i n some k i n d o f a p l a n n e d l e a r n i n g e x p e r i e n c e a n n u a l l y and a l m o s t e v e r y s o c i a l i n s t i t u t i o n and agency i s i n v o l v e d i n one way o r a n o t h e r i n m e e t i n g t h e many and d i v e r s e e d u c a t i o n a l r e q u i r e m e n t s o f t h e s e m i l l i o n s o f a d u l t l e a r n e r s ( 7 ) . De Crow (6) s t a t e s t h a t : 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 u n o b s e r v e d , 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 h a p p e n i n g o f n e c e s s i t y , a l m o s t as a r e f l e x m o t i o n o f a s o c i e t y g r a p p l i n g w i t h s o c i a l f o r c e s w h i c h a r e r e m o u l d i n g a n a t i o n t o c o n f r o n t t h e c h a l l e n g e s o f a r a p i d l y c h a n g i n g w o r l d . C o t t o n (4) n o t e s t h a t t h e dominent theme i n r e c e n t y e a r s i s r e l a t e d t o t h e " a c c e l e r a t i n g r a t e o f s o c i a l c h a n g e . . . t h e knowledge e x p l o s i o n . . . a n d t h e f a c t t h a t s c i e n t i f i c 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 so r a p i d l y t h a t we must c o n t i n u e t o l e a r n o r we w i l l become o b s o l e t e . " I n d e f i n i n g t h e r o l e o f a d u l t e d u c a t i o n i n t h i s e r a o f r a p i d change, H a l l e n b e c k (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 t h i s s u r v e y . He s a y s : 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 t o l e a r n t o l i v e i n a s t a t i c w o r l d . When one comes t o a d u l t h o o d and f i n d s t h a t he 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 as we s a y , " t h e h a r d way." But o u r k i n d o f s o c i e t y can 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 has t o l e a r n " t h e h a r d way" o n l y once. The j o b o f a d u l t e d u c a t i o n i s t o h e l p p e o p l e t o u n d e r s t a n d t h e i r p r o b l e m s , 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 and t o r e a c h t h e i r g o a l s under c u r r e n t c i r c u m s t a n c e s . 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 , t h e decade of t h e s i x t i e s has w i t n e s s e d an i n c r e a s e d emphasis on c o n t i n u i n g e d u c a t i o n i n a l l o f t h e h e a l t h p r o f e s s i o n s . 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 a c c e n t u a t i n g t h i s need have been w e l l documented i n many government h e a l t h manpower r e p o r t s (22) (21) (24) ( 1 9 ) , and as w e l l , by numerous l e a d e r s i n t h e h e a l t h f i e l d Among t h e f o r c e s 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 t h e tremendous r a t e a t w h i c h b i o - m e d i c a l r e s e a r c h i s p r o d u c i n g new knowledge i n t h e h e a l t h f i e l d . Modern s c i e n c e has 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 u n d e r s t a n d i n g , p r e v e n t i o n , 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 l i f e e x p e c t a n c y t w o - f o l d . A t t h e same t i m e , i t has 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 and b e t t e r means must be found 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 improvement o f h e a l t h c a r e . The need t o cope w i t h t h i s p r o b l e m has been h e i g h t e n e d i n r e c e n t 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 o f t h e s e new m e d i c a l d i s c o v - e r i e s and demands them. F u r t h e r m o r e , h i g h e r e d u c a t i o n , h i g h e r e a r n i n g s , and expanded h e a l t h i n s u r a n c e c o v e r a g e a r e r a p i d l y s h i f t i n g t h e r o l e o f consumer 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 p o s i t i o n t o demand more and b e t t e r h e a l t h s e r v i c e s . I n a d d i t i o n , a g r o w i n g e g a l i t a r i a n p h i l o s o p h y now v i e w s h e a l t h as a b a s i c human r i g h t w h i c h s h o u l d be a v a i l a b l e t o a l l p e o p l e w i t h e q u a l q u a l i t y and w i t h o u t r e f e r e n c e t o a b i l i t y t o pay. The e v e r e x p a n d i n g r o l e o f government i n t h e p r o v i s i o n and s u r v e i l l a n c e o f h e a l t h s e r v i c e s r e f l e c t s t h i s v i e w . I n r e s p o n s e t o t h e s e new c i r c u m s t a n c e s , t h e u n i v e r s i t i e s and p r o f e s - 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 e m p l o y i n g i n s t i t u t i o n s and v o l u n t a r y h e a l t h a g e n c i e s , have a t t e m p t e d t o p r e v e n t p r o f e s s i o n a l o b s o l e s c e n c e by i n c r e a s i n g t h e i r commitment t o c o n t i n u i n g e d u c a t i o n . These a c t i v i t i e s have t a k e n a v a r i e t y of f o r m s , n e v e r t h e l e s s , e v e r ywhere a p p a r e n t i s t h e g r o w i n g c o n c e r n t h a t c o n t i n u i n g e d u c a t i o n i s a r e s p o n s i b i l i t y w h i c h i s n o t b e i n g s a t i s f a c t o r i l y d i s c h a r g e d (14) (10) (19) (12) ( 2 0 ) . M o r e o v e r , as n o t e d by H o u l e ( 1 1 ) : Even more d i s c o n c e r t i n g i s t h e 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 ecause of t h e 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 w h i c h 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 e d u c a t i o n m i g h t have h e l p e d t o p r e v e n t . A l t h o u g h t h e c a s e i s n o t c r e a r , t h e v i e w i s w i d e l y e x p r e s s e d t h a t c o n t i n u i n g e d u c a t i o n i n t h e h e a l t h s c i e n c e s has been hampered by l a c k o f p u r p o s e , l i m i t a t i o n s o f t e a c h e r s , and l a c k o f p r o f e s s i o n a l i n t e r e s t . There i s a l s o w i d e s p r e a d t h e i m p r e s s i o n t h a t programs o f c o n t i n u i n g e d u c a t i o n a r e n o t " c o n t i n u i n g " b u t l a r g e l y "ad h o c , " " p i e c e m e a l , " and b u i l t on a model d e s i g n e d f o r t h e e d u c a t i o n o f y o u t h r a t h e r t h a n a d u l t l e a r n e r s . whatever t h e c r u x o f t h e p r o b l e m , t h e g e n e r a l c o n s e n s u s i s t h a t p r e s e n t methods have many s h o r t c o m i n g s , and t h a t new and more e f f e c t i v e a p p r o a c h e s must be f o u n d . F u r t h e r m o r e , r e c e n t government t a s k f o r c e r e p o r t s recommend t h a t " p r o f e s s i o n a l a s s o c i a t i o n s e x p l o r e t h e means whereby c o n t i n u - i n g e d u c a t i o n c o u l d be 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 has added a 5 new sense of urgency to the task (21) (19). PURPOSE This survey of the l i t e r a t u r e i s an attempt to determine the nature and scope of c o n t i n u i n g education i n four of the h e a l t h p r o f e s s i o n s : medicine, d e n t i s t r y , n u r s i n g , and pharmacy, covering the p e r i o d from 1960 to 1970. Such a review should help to c l a r i f y some of the 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 serve as a medium f o r the exchange of ideas and procedures r e l a t e d to the design and conduct of programs of c o n t i n u i n g 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 assumption on which t h i s study i s based i s that the pub l i s h e d 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 trends. CLARIFICATION OF TERMS "Continuing education" has been v a r i o u s l y defined i n the h e a l t h s c i e n c e s . Some d e f i n i t i o n s are very broad, encompassing a l l formal education 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), w h i l e others are very r e s t r i c t i v e and l i m i t the term to short r e f r e s h e r - t y p e n o n - c r e d i t courses designed 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) (9). Another way of d e f i n i n g c o n t i n u i n g education i s to make i t synonymous w i t h a d u l t education and a d u l t l e a r n i n g (2) (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 , which c o n t r i b u t e to an i n d i v i d u a l ' s f i e l d of p r a c t i c e . While no one would d i s p u t e the d e s i r a b i l i t y of t h i s l a t t e r d e f i n i t i o n , as noted by Cameron (2), "the pr o p o r t i o n s of the task are formidable indeed." The term c o n t i n u i n g education,as 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 clinical 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 ( 2 5 ) . 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 is that basic to program development. 7 Due t o t h e p a u c i t y of l i t e r a t u r e o f a r e s e a r c h n a t u r e , t h e d a t a p r e s e n t e d were d e r i v e d f r o m a v a r i e t y o f d e s c r i p t i v e s o u r c e s as w e l l as summaries o f s u r v e y s . S p e c i f i c r e f e r e n c e t o t h e n a t u r e o f t h e l i t e r a t u r e as i t imposes l i m i t a t i o n s i s documented as t h e need a r i s e s . 8 REFERENCES 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 , Avenues f o r C o n t i n u e d 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 Columbus C i r c l e , 1967. Cameron, 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 Thoughts on S p o n s o r s h i p , " 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 , 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 Through E d u c a t i o n ; A R e p o r t S u b m i t t e d t o t h e E x e c u t i v e C o u n c i l o f t h e A s s o c i a t i o n o f A m e r i c a n M e d i c a l C o l l e g e s , E v a n s t o n , 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 E x a m i n a t i o n o f t h e S u p p o r t i n g L i t e r a t u r e , B o s t o n , C e n t e r f o r t h e Study 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 Commission f o r H i g h e r E d u c a t i o n , 1969. DeCrow, R., "The Scope o f C o n t i n u i n g E d u c a t i o n , " C o n t i n u i n g 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., " E d u c a t i o n i s C o n t i n u o u s , " N u r s i n g O u t l o o k , 9:243-5, ( A p r i l , 1 9 6 1 ) . H a l l e n b e c k , W.E., "The F u n c t i o n and 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 t h e U n i t e d S t a t e s , W a s h i n g t o n , D.C, 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 , 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, A m e r i c a n C o u n c i l on E d u c a t i o n , 1961. Hornback, 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 / A u g u s t , 1 9 7 1 ) . H o u l e , C O . , "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 o f N o r t h A m e r i c a , 54:5-17, ( J a n u a r y , 1 9 7 0 ) . H o z i d , J . , " R o l e o f C o n t i n u i n g E d u c a t i o n i n D e n t a l O b s o l e s c e n c e , " J o u r n a l o f t h e A m e r i c a n D e n t a l A s s o c i a t i o n , 78:1299-1303, ( J u n e , 1 9 6 9 ) . Magraw, 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. S a u n d e r s , 1966. 9 14. M i l l e r , G.E., "What i s t h e Need?", A m e r i c a n J o u r n a l o f C a r d i o l o g y , 17:889-890, ( J u n e , 1 9 6 6 ) . 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 Consumer," J o u r n a l of 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 , 20:498-501, ( O c t o b e r , 1 9 6 9 ) . 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., " C o n t i n u i n g E d u c a t i o n : A C h a l l e n g e t o t h e P r o f e s s i o n , " J o u r n a l o f A m e r i c a n C o l l e g e o f D e n t i s t r y , 28:3-26, (M a r c h , 1 9 6 0 ) . 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 and 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 t h e H e a l i n g A r t s , Ottawa: Queen's P r i n t e r , 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 Task 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 t h e H e a l t h P r o f e s s i o n s , C h i c a g o : C e n t e r f o r t h e Study o f 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 Commission, W a s h i n g t o n D.C., U.S. P r i n t i n g O f f i c e , 1967, Volume .1. 22. Somers, A., H e a l t h Care 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 o f 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 Competence," J o u r n a l o f the 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 , 189:27-30, ( J u l y , 1 9 6 4 ) . 24. Task F o r c e R e p o r t s on t h e C o s t o f H e a l t h S e r v i c e s i n Canada, O t t a w a : Queen's P r i n t e r , 1970. 25. V e r n e r , C , " D e f i n i t i o n o f 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 Emerging 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 of 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 , 96:1040-1044, ( A p r i l 8, 1 9 6 7 ) . 27. W i l l i a m s , D., "The Shape o f T h i n g s t o Come," B r i t i s h C o l u m b i a M e d i c a l J o u r n a l , 10:12 ( J a n u a r y , 1 9 6 8 ) . PART TWO CONTINUING EDUCATION IN MEDICINE 10 11 CHAPTER I I THE PROFESSION AND CONTINUING EDUCATION I n k e e p i n g w i t h t h e r a p i d l y c h a n g i n g n a t u r e o f s c i e n c e and s o c i e t y , m e d i c i n e has undergone, and c o n t i n u e s t o undergo many changes, a l l o f w h i c h must be r e f l e c t e d i n e d u c a t i o n a t a l l l e v e l s . I n b o t h Canada and t h e U n i t e d S t a t e s t h e number o f a c t i v e p h y s i c i a n s has been i n c r e a s i n g o v e r t h e p a s t few d e c a d e s , b u t t h i s i s o f f s e t by t h e f a c t t h a t t h e number o f p a t i e n t s s e e k i n g m e d i c a l c a r e has 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) ( 2 4 3 ) . M o r e o v e r , d e s p i t e t h e i m m i g r a t i o n o f f o r e i g n d o c t o r s t o m a i n t a i n what i s c o n s i d e r e d t o be an 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 and u t i l i z a t i o n o f p h y s i c i a n s has c r e a t e d a d i s p a r i t y between demand and s u p p l y ( 1 7 1 ) . PHYSICIAN COMPOSITION AND DISTRIBUTION An a n a l y s i s o f m e d i c a l manpower r e v e a l s t h a t t h e number o f p h y s i c i a n s employed i n t e a c h i n g , r e s e a r c h , a d m i n i s t r a t i o n , and o t h e r a c t i v i t i e s u n r e l a t e d t o d i r e c t p a t i e n t c a r e , has been i n c r e a s i n g i n r e c e n t decades w h i l e t h e number i n p r i v a t e p r a c t i c e i s d e c l i n i n g ( 1 7 1 ) . Changes i n t h e p a t t e r n o f p r o v i d i n g m e d i c a l c a r e have a l s o o c c u r r e d w i t h - i n p r i v a t e p r a c t i c e . I n t h e U n i t e d S t a t e s , t h e number of g e n e r a l p r a c t i t i o n e r s * d e c l i n e d f r o m r o u g h l y 50 p e r c e n t o f t h e t o t a l number o f p h y s i c i a n s i n 1959, As used 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 and/or 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 f i e l d . 12 t o a p p r o x i m a t e l y 31 p e r c e n t i n 1967. C u r r e n t i n f o r m a t i o n on p h y s i c i a n man- power i n Canada r e v e a l s a s i m i l a r t r e n d . Whereas i n 1965 t h e p e r c e n t a g e of p h y s i c i a n s i n g e n e r a l p r a c t i c e was 67 p e r c e n t , i n 1968 t h e f i g u r e had dropped t o a p p r o x i m a t e l y 54 p e r c e n t (243) . S i n c e some of t h e s e r v i c e s f o r m e r l y p r o v i d e d by g e n e r a l p r a c t i t i o n e r s a r e b e i n g r e d i s t r i b u t e d among t h e s p e c i a l t i e s , and o t h e r h e a l t h w o r k e r s (195) (134) ( 9 2 ) , t h e i m p l i c a t i o n s o f t h i s c h a n g i n g p a t t e r n a r e n o t c l e a r . N e v e r t h e - l e s s , most, r e p o r t s s t r e s s t h e 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 t h e m e d i c a l p r o f e s s i o n o v e r t h e d e c l i n i n g numbers o f p h y s i c i a n s i n g e n e r a l p r a c t i c e , and many a u t h o r s (257) (96) (195) r e i t e r a t e t h e recommendation o f t h e M i l l i s r e p o r t ( 1 6 0 ) , t h a t a new 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 has g r a d u a t e t r a i n i n g i n f a m i l y m e d i c i n e . Of e q u a l c o n c e r n a r e the w i d e r e g i o n a l d i f f e r e n c e s i n t h e s u p p l y o f p h y s i c i a n s i n r e l a t i o n t o p o p u l a t i o n . D o c t o r s t e n d t o c o n c e n t r a t e i n t h e l a r g e r u r b a n a r e a s and i t i s e s t i m a t e d t h a t o v e r one h a l f o f a l l d o c t o r s a r e p r e s e n t l y p r a c t i s i n g i n c o m m u n i t i e s w i t h p o p u l a t i o n s i n e x c e s s o f 100,000 ( 2 5 7 ) . T h i s d i s p r o p o r t i o n a t e d i s t r i b u t i o n i s a l s o f ound a t t h e s t a t e and p r o v i n c i a l l e v e l s , v a r y i n g d i r e c t l y w i t h t h e p e r c a p i t a income and t h e p r o - p o r t i o n o f t h e p o p u l a t i o n i n u r b a n c o m m u n i t i e s . Thus, w h i l e t h e p h y s i c i a n / p o p u l a t i o n r a t i o i n Canada i n 1967 was 1:984, B r i t i s h C o l u m b i a had t h e most f a v o u r a b l e r a t i o o f 1:824, f o l l o w e d by O n t a r i o w i t h 1:849, and Newfoundland w i t h t h e l e a s t f a v o u r a b l e r a t i o o f 1:1549 ( 7 6 ) . Work P a t t e r n s : A number o f r e c e n t s u r v e y s ( 1 2 7 ) ( 2 3 2 ) ( 2 4 2 ) ( 2 5 7 ) d i s c l o s e t h a t p h y s i c i a n s a v e r a g e a 56 t o 63 hour work week, o f w h i c h r o u g h l y 80 p e r c e n t i s s p e n t i n d i r e c t p a t i e n t c a r e . The r e m a i n i n g 20 p e r c e n t o r l e s s o f t h e p h y s i c i a n ' s t i m e 13 i s s p e n t i n o f f i c e a d m i n i s t r a t i o n , c o n t i n u i n g e d u c a t i o n , m e d i c a l s o c i e t y and h o s p i t a l m e e t i n g s , r e s e a r c h and/or t e a c h i n g . C o n t r a r y t o t h e p o p u l a r b e l i e f t h a t o f f i c e p r a c t i c e i s d e c r e a s i n g , s t u d i e s r e v e a l t h a t p h y s i c i a n s a v e r a g e more t h a n t w i c e as 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 r o u g h o f f i c e v i s i 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) ( 1 6 ) . W h i l e g e n e r a l i z a t i o n s c a n n o t be 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 , most a u t h o r s a g r e e w i t h Anne Somers (232) t h a t "One l i m i t i n t h e d o c t o r ' s p r o d u c t i v i t y we have a l m o s t s u r e l y r e a c h e d . . . t h e number o f h o u r s t h a t he can be e x p e c t e d t o work." C h a n g i n g P a t t e r n s o f P r a c t i c e : I d e a l l y , group p r a c t i c e w h i c h b r i n g s t o g e t h e r g e n e r a l p r a c t i t i o n e r s and s p e c i a l i s t s who can s h a r e t h e i r e x p e r t i s e , f a c i l i t i e s , and t h e s e r v i c e s o f s u p p o r t i n g p e r s o n n e l , i s a l o g i c a l development t o o f f s e t t h e f r a g m e n t a t i o n „ r ~ ~ - . - . « ~ {z^.„„ „ _ , 3 . — . . - . „ 1 i - — f -\ c r\\ c — i - - - — - - - ~ ~ W J _ \,aX.\^ i . C O U J . L X U g JL J - Wi l l x i l U J L C a O C U o p C L I O X X ^ d U X U L L J • J U L U d l L C l U g C U l C l l L i ) s h o u l d a l s o f a c i l i t a t e t h e s h a r i n g o f on c a l l t i m e , t h u s r e l i e v i n g i n some measure t h e l e n g t h y work week o f p h y s i c i a n s . D e s p i t e t h e s e o f t q u o t e d 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 s l o w i n b o t h Canada and t h e U n i t e d S t a t e s (232) ( 1 9 5 ) . M o r e o v e r , t h e r e i s no c o n c l u s i v e 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 i mprove t h e e f f i c i e n c y o r e f f e c t i v e n e s s o f m e d i c a l c a r e ( 1 7 1 ) . On t h e o t h e r hand, t h e maj o r development i n t h e o 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 t r e n d toward h o s p i t a l based s e r v i c e s ( 2 3 2 ) . W i t h o u t e l a b o r a t i n g on t h e n a t u r e o f t h i s t r e n d , i t i s w o r t h n o t i n g t h a t t h e r e has been an i n c r e a s i n g number o f a r t i c l e s and r e p o r t s r e f l e c t i n g t h e g r o w i n g 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 t h e m e d i c a l c a r e s y s t e m . There a r e many comments about 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 t h e s o a r i n g c o s t s o f h o s p i t a l c a r e (243) (196) (183) ( 2 3 2 ) . F u r t h e r m o r e , i t has been s a i d t h a t t h e h o s p i t a l s y s t e m i s more p r o d u c e r t h a n consumer o r i e n t e d , and t h a t i t has been s o busy " k e e p i n g i n s t e p w i t h m e d i c a l a d v a n c e s , t h a t i t has l o s t s t e p w i t h t h e m e d i c a l needs o f t h e community" (252) (232) . The c h a r g e i s h e a r d i n c r e a s i n g l y t h a t w h i l e m e d i c a l s c i e n c e now has t h e knowledge and t e c h n o l o g y t o promote e f f e c t i v e " h e a l t h m e d i c i n e " , t h e b u l k o f m e d i c a l p r a c t i c e i s d i s e a s e o r c u r e o r i e n t e d (243) ( 1 9 5 ) . As i n d i c a t e d by t h e Task F o r c e on H e a l t h C o s t s i n Canada (243) "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 t r e a t - ment component, w h i l e p u b l i c h e a l t h and t h e p r e v e n t i v e a s p e c t s c o n s t i t u t e l e s s t h a n 5 p e r c e n t . " The R e p o r t 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 t h e pircf sm i i i co'T.cTTsts tdrms, i t sts.tss * T h i s i s n o t t h e f a u l t o f t h e 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 o v e r w o r k e d 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 t h e f a u l t r a t h e r , o f a h e a l t h s y s t e m i n w h i c h m e d i c a l s c h o o l s have f a i l e d t o emphasize p r e v e n - t i v e h e a l t h . . . a n d i n w h i c h t h e rewards i n income 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 work 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 . F u r t h e r m o r e , 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 , community 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 emphasizes t h a t t h e i s s u e s and p r o b l e m s o f t h e m e d i c a l c a r e s y s t e m a r e e n o r m o u s l y complex and w i l l n o t soon be r e s o l v e d . A t t h e same t i m e , as n o t e d by P a t r i c k S t o r e y (237) i n t h e U t a h r e p o r t : "any a t t e m p t t o i mprove m e d i c a l p r a c t i c e t h r o u g h 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 a c c o u n t t h e e x i s t i n g s y s t e m , and r e l a t e e f f e c t i v e e d u c a t i o n t o t h a t s y s t e m . " 15 NEED FOR CONTINUING EDUCATION Three d i s c r e t e phases o f 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 t h e f i e l d o f m e d i c i n e : u n d e r g r a d u a t e e d u c a t i o n l e a d i n g t o t h e M.D. d e g r e e ; g r a d u a t e e d u c a t i o n c o v e r i n g t h e i n t e r n e s h i p , r e s i d e n c y , o r o t h e r f u l l t i m e s t u d y l e a d i n g t o advanced academic d e g r e e s o r m e d i c a l s p e c i a l t i e s ; and c o n t i n u i n g e d u c a t i o n , c o m p r i s i n g t h o s e a c t i v i t i e s engaged i n by p r a c t i s i n g p h y s i c i a n s " b o t h t o r e f r e s h t h e i n d i v i d u a l i n v a r i o u s a s p e c t s o f h i s b a s i c m e d i c a l e d u c a t i o n , and t o i n f o r m him o f new developments i n h i s own and r e l a t e d . f i e l d s o f m e d i c a l 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 any f o r m a l advanced s t a n d i n g i n t h e p r o f e s s i o n " ( 5 1 ) . T h i s t h i r d p h a s e , f r e q u e n t l y r e f e r r e d t o as t h e " l a s t u n d e v e l o p e d f r o n t i e r o f m e d i c a l e d u c a t i o n , " c o n s t i t u t e s t h e c o n c e r n o f t h i s r e v i e w . • The p r o b l e m o f k e e p i n g 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 m e d i c i n e where new d e v e l o p m e n t s a r e , p e r h a p s , o c c u r r i n g more rap i i i l y t h a n i n any o t h e r f i e l d . 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 busy p r a c t i c e and by t h e o m n i p r e s e n t t h r e a t o f o b s o l e s c e n c e . A l t h o u g h o r g a n i z e d m e d i c i n e has i n v e s t e d money, manpower, and t i m e , i n a t t e m p t i n g 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 i n v e s t m e n t a r e now b e i n g q u e s t i o n e d . Manning (145) and o t h e r s (86) (194) (275) (222) e s t i m a t e t h a t o n l y 10 t o 25 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 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 so a v a i l a b l e t o them. To what e x t e n t t h e q u a l i t y and t e c h n i q u e s 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 a r e r e s p o n s i b l e f o r t h i s seeming d i s i n t e r e s t i s u n c l e a r , n o r i s i t known how many o f t h o s e 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 f r o m t h e programs o f f e r e d . A l t h o u g h much has been w r i t t e n about the n a t u r e o f t h e p r o b l e m t h e r e i s a l a c k o f s u f f i c i e n t r e l i a b l e d a t a t o u n d e r s t a n d t h e p r o b l e m . 16 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 i s n o t w i t h o u t i t s l a n d m a r k s . I n d e e d , most of 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 u r r e n t l y 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 have been r e c o g n i z e d and documented i n a number of s t u d i e s and 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 h a l f c e n t u r y . E a r l y Developments: I n h i s h i s t o r i c a l c h r o n o l o g y , Sheperd (227) r e p o r t s t h a t p r i o r t o 1930, 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 l a r g e l y d i r e c t e d t o w a r d c o r r e c t i n g d e f i c i e n c i e s i n b a s i c m e d i c a l e d u c a t i o n . I t was n o t u n t i l t h e t h i r t i e s , when t h e l a s t 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 s p e c i a l t y programs began t o d e v e l o p r a p i d l y , t h a t c o n t i n u i n g e d u c a t i o n came t o be v i e w e d as t h e n e c e s s a r y " t h i r d s t a g e i n t h e l i f e - l o n g e d u c a t i o n o f t h e p h y s i c i a n . " I n 1930 and 1931, t h r e e m e d i c a l s c h o o l s , t h e U n i v e r s i t y o f M i c h i g a n , A l b a n y C o l l e g e , and T u f t s U n i v e r s i t y , i n i t i a t e d p l a n n i n g f o r r e g i o n a 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 programs. Dr. B e n j a m i n H o r n i n g ' s d e s c r i p t i o n o f t h e e a r l y M i c h i g a n program d e f i n e s p r e c i s e l y t h e c o n c e p t o f r e g i o n a l i z a t i o n a d v o c a t e d t o d a y (108) ( 6 8 ) : 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 has 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 about 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 e x t e n d f r o m t h e m e d i c a l s c h o o l s out t h r o u g h s u c h h o s p i t a l s t o t h e 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 o f 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 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 f r o m 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 good m e d i c a l p r a c t i c e , and p r o v i s i o n s s h o u l d be made u l t i m a t e l y whereby e v e r y 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 be 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 t o t a k e c o n t i n u a t i o n c o u r s e s t o i n s u r e t h a t 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 t h e problems 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 a r e 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 need 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 program 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 and methods 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 ) . O t h e r s r e p e a t i n g t h e s e a d m o n i t i o n s and recommendations were J.H. Upham (250) i n 1937, and R a p p e l y e (227) i n 1940 who a l s o s t r e s s e d t h e need f o r a c r i t i c a l r e - e x a m i n a t i o n o f e x i s t i n g programs t o d e t e r m i n e w h e t h e r t h e y were m e e t i n g t h e needs o f p r a c t i s i n g p h y s i c i a n s . A s i g n i f i c a n t landmark i n t h e h i s t o r i c a l e v o l u t i o n 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 was a program e v a l u a t i o n r e p o r t e d by Youmans i n 1935 (256) Youmans made unnannounced v i s i t s t o 30 p h y s i c i a n s who had a t t e n d e d h i s c o u r s e s e v e r a l months e a r l i e r and by u s i n g a s e l f - d e v i s e d r a t i n g s c a l e f o r m e a s u r i n g t h e q u a l i t y o f m e d i c a l p r a c t i c e , he compared what he b e l i e v e d t o be each p a r t i c i p a n t ' s p r e - c o u r s e p e r f o r m a n c e a g a i n s t h i s p o s t - c o u r s e p e r f o r m a n c e . A l t h o u g h t h e s m a l l sample and c r u d e m e t h o d o l o g y l i m i t e d h i s f i n d i n g s , t h e s t u d y i s i m p o r t a n t b e c a u s e i t a p p e a r s t o be t h e f i r s t a t t e m p t a t 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 a p p r o a c h . Two o b s e r v a t i o n s by Youmans r e l a t i v e t o t h e t e a c h i n g - l e a r n i n g p r o c e s s were: " . . . t h e d e c i d e d s u p e r i o r i t y o f t h e p r a c t i c a l o v e r d i d a c t i c t e a c h i n g . . . I t was v e r y a p p a r e n t t h a t t h e work w h i c h d e a l t w i t h p a t i e n t s i n t h e wards and i n t h e o u t p a t i e n t d e p a r t m e n t s o r w i t h v a r i o u s t e c h n i c a l p r o c e d u r e s o f d i a g n o s i s and t r e a t m e n t , were 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 "The 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 n o t o n l y knowledge b u t 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 l i m i t a t i o n s imposed on t h e p r a c t i t i o n e r s by a busy p r a c t i c e . " Between 1937 and 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 and H o s p i t a l o f 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 c o n d u c t e d t h e f i r s t n a t i o n a l s u r v e y t o 18 d e t e r m i n e t h e n a t u r e o f e x i s t i n g p o s t g r a d u a t e programs. The r e p o r t o f t h i s s t u d y r e v e a l e d t h a t c i r c u i t t y p e c o u r s e s were b e i n g used i n t e n o f t h e s t a t e s v i s i t e d ( 1 9 1 ) . I t n o t e d t h a t : "Under t h i s a r r a n g e m e n t , one p h y s i c i a n o r a team o f p h y s i c i a n s would spend f r o m one t o two months i n a r e g i o n o f t h e c i r c u i t and t h e n move on t o a new a r e a " and t h a t " i n - r e s i d e n c e t y p e programs were e v i d e n t t h r o u g h o u t t h e c o u n t r y . . . O n e , two week o r l o n g e r p e r i o d s o f b e d s i d e i n s t r u c t i o n o f l i m i t e d g r o u p s w i t h p r o v i s i o n i n m e d i c a l s c h o o l s and i n h o s p i t a l s f o r b o a r d and/or l o d g i n g , and i n t i m a t e i n s t r u c t o r g r a d u a t e - s t u d e n t 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 t h e s e s h o r t t e r m r e s i d e n c i e s " . The most d i r e c t outcome o f t h i s r e p o r t was t h e d e c i s i o n o f 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 t o b e g i n p u b l i s h i n g a n a t i o n - w i d e l i s t i n g o f programs o f c o n t i n u i n g e d u c a t i o n a v a i l a b l e , " b o t h as a s e r v i c e t o p h y s i c i a n s i n s e l e c t i n g c o u r s e s t o a t t e n d , and as an a i d t o c o u r s e s p o n s o r s i n p l a n n i n g p r o g r a m s . " W h i l e p u b l i s h e d f i r s t on a q u a r t e r l y b a s i s , i t i s now p u b l i s h e d a n n u a l l y as t h e " A n n u a l Course L i s t i n g " . T h i s c o n s t i t u t e s one o f t h e m a j o r s o u r c e s of i n f o r m a t i o n c o n c e r n i n g t h e f i e l d 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 i n t h e U n i t e d S t a t e s ( 2 2 7 ) . Thus, t h e decade o f t h e t h i r t i e s saw t h e emergence o f a number o f v e r y modern i d e a s and s e v e r a l program i n n o v a t i o n s ; n e v e r t h e l e s s , a c c o r d i n g t o Sheperd ( 2 2 7 ) , e d u c a t i o n a l l y sound programs were t h e e x c e p t i o n r a t h e r t h a n t h e r u l e i n terms o f t h e n a t i o n as a w h o l e . A l t h o u g h a s e t b a c k i n t h e e v o l u t i o n 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 o c c u r r e d w i t h t h e o n s e t o f W o r l d War I I , t h i s i s t h o u g h t t o have had some l o n g range b e n e f i t s i n t h a t i t " f o r c e d t h e m e d i c a l s c h o o l s and h o s p i t a l s t o r e - e x a m i n e t h e i r programs w i t h r e s p e c t t o t h e i r q u a l i t y and q u a n t i t y , and s h i f t e d t h e m a j o r r e s p o n s i b i l i t y f o r 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 f r o m 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 t r a d i t i o n a l l y b e l o n g e d , t o t h e 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 " ( 1 6 8 ) . 19 One m a j o r s t u d y o f t h e e a r l y p o s t - w a r p e r i o d w h i c h r e f l e c t e d a g r o w i n g c o n c e r n f o r t h e r o l e o f t h e 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 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 s t u d y (45) w h i c h was a n a t i o n a l s u r v e y o f m e d i c a l s c h o o l programs i n c l u d i n g 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 . The recommendations o f t h i s r e p o r t r e l a t e d 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 were t h a t : 1) c o u r s e s s h o u l d be d e s i g n e d so t h a t s t u d e n t s c a n a c t i v e l y p a r t i c i p a t e and t h e i r p e r f o r m a n c e be e v a l u a t e d ; 2) c o u r s e s s h o u l d be i n c r e a s i n g l y l o c a t e d i n m e d i c a l s c h o o l s ; 3) m e d i c a l s c h o o l f a c u l t i e s s h o u l d be i n c r e a s e d t o meet 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 ; and 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 d e t e r m i n e d . P r o b a b l y t h e most c o m p r e h e n s i v e and s i g n i f i c a n t n a t i o n a l s t u d y on 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 t h a t u n d e r t a k e n f o r 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 between 1952-1955 by D. V o l l a n . T h i s s t u d y i n c l u d e d b o t h t h e p r o d u c e r s and 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 t h r o u g h o b s e r v a t i o n , a t t e n d a n c e a t c o u r s e s , i n t e r v i e w s w i t h more t h a n 400 p e r s o n s i n programs 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 s p o n s o r e d by o v e r 200 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 , and 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 of 5,000 r e s p o n s e s f r o m p r a c t i s i n g p h y s i c i a n s . The m a j o r c o n c l u s i o n s and recommendations o f t h i s s t u d y a r e summarized as f o l l o w s : 1. 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 L a c k s D i r e c t i o n : . . . I 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 i s t o d e v e l o p s o u n d l y i t i s e s s e n t i a l t o have t h e m a j o r p u r p o s e c l e a r l y . u n d e r s t o o d , t h e 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 r a n g e p l a n s t o o b t a i n t h e . 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. G e n e r a l P r a c t i t i o n e r s a r e N e g l e c t e d : ...The g r e a t e s t s i n g l e need i n t h i s f i e l d t o d a y i s f o r more and b e t t e r r e f r e s h e r c o u r s e s f o r g e n e r a l 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 g e n e r a l p r a c t i t i o n e r g r o u p s . 3. Q u a l i t y o f C o u r s e s i s n o t 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 undue emphasis on 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 t h a t o f t e n o b s t r u c t e d u c a t i o n a l i d e a l s . T h i s malady can o n l y be 20 c o r r e c t e d by an emphasis 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 e d u c a t i o n ; 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 fo 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 be 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 Not 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 an improvement i n t h e d i r e c t i o n and q u a l i t y of p o s t g r a d u a t e c o u r s e s so as 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 i n c l u d e : 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 away; b) f i n d i n g ways t o a t t r a c t t h e p h y s i c i a n ; f o r example, 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 of m e d i c i n e g e n e r a l l y consumes 60,hours o r more a week. 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 c a n g i v 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 . 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 : ...90% 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 most 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 more e q u i t a b l y d i s t r i b u t e d (256) . Emerging f r o m V o l l a n ' s s t u d y were 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 G u i d e R e g a r d i n g O b j e c t i v e s and B a s i c P r i n c i p l e 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 . 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 s e r v e s as t h e s t a t e m e n t o f s t a n d a r d s f o r t h e f i e l d 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 ( 6 5 ) . O t h e r 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 t h o s e by D a r l e y (70) , D r y e r (79) , and S t o r e y (237) , a l l o f w h i c h f o c u s s e d on a n a t i o n a l p l a n f o r 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 t h o u g h t h e recommendations of t h e s e r e p o r t s have n o t been i m p l e m e n t e d , t h e y c o l l e c t i v e l y o f f e r a sound framework f o r t h e e s t a b l i s h m e n t o f a " u n i v e r s i t y w i t h o u t w a l l s . " 21 CHAPTER I I I PARTICIPATION IN CONTINUING EDUCATION O r g a n i z e d 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 development b u t t h e tremendous 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 . As y e t t h e r e has been no d e f i n i t i v e s t u d y o f t h e e d u c a t i o n a l a c t i v i t i e s o f p h y s i c i a n s y e t t h e r e have been a number o f a t t e m p t s 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 and t h e d e g r e e o f p h y s i c i a n i n t e r e s t . Some s u r v e y s have a t t e m p t e d t o i n v o l v e p h y s i c i a n s i n d e f i n i n g t h e i r own f e l t l e a r n i n g n e e d s , and as w e l l , t o s o l i c i t 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 needs m i g h t b e s t be met. Most s t u d i e s d i s c l o s e t h a t p o s t g r a d u a t e c o u r s e s a r e r a t e d h i g h l y as a means o f g a i n i n g new m e d i c a l knowledge (83) (200) (256) (117) b u t , a t t h e same t i m e , 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. The o f t q u o t e d e s t i m a t e s o f t e n t o t w e n t y - f i v e p e r c e n t a t t e n d a n c e a r e a t v a r i a n c e w i t h r e c e n t s u r v e y s w h i c h s u g g e s t a more o p t i m i s t i c t h i r t y t o f i f t y p e r c e n t a t t e n d a n c e r a t e (263) (117) ( 3 7 ) . Recent r e p o r t s f r o m m e d i c a l s c h o o l s i n d i c a t e a s t e a d y i n c r e a s e i n e n r o l l m e n t f i g u r e s o v e r t h e p a s t s e v e r a l y e a r s ( 5 4 ) . W h i l e t h i s 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 p h y s i c i a n s a t t e n d i n g f o r m a l c o u r s e s , i t i s f e l t t h a t p h y s i c i a n p a r t i c i p a t i o n i s p r o b a b l y somewhat g r e a t e r t h a n has been g e n e r a l l y assumed (6) (37) ( 5 0 ) . 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 e x p r e s s c o n c e r n t h a t t h e r e r e m a i n 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 a v a i l t h e m s e l v e s o f o p p o r t u n i t i e s f o r p o s t g r a d u a t e work and w i l l n o t , u n l e s s a t t e n d a n c e i s made mandatory (6) ( 2 6 3 ) . On t h e o t h e r hand, p o l l s r e v e a l t h a t t h e m a j o r i t y o f p r a c t i t i o n e r s a r e o f 22 t h e o p i n i o n t h a t a t t e n d a n c e s h o u l d be a v o l u n t a r y m a t t e r and " t h e y a r e c o n c e r n e d by 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 c o n d i t i o n f o r p r a c t i c e " (254) ( 2 6 0 ) . F i e l d o f P r a c t i c e ; Most s t u d i e s i n d i c a t e t h a t s p e c i a l i s t s 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 (42) (185) (256) ( 1 7 7 ) , F u r t h e r , i t i s r e p o r t e d t h a t s p e c i a l i s t s 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 t y p i c a l work week i n some f o r m o f t e a c h i n g a nd/or r e s e a r c h , whereas g e n e r a l p r a c t i t i o n e r s a r e s a i d 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 (258) (127) ( 4 2 ) . V o l l a n (256) a t t r i b u t e d t h e s e d i f f e r e n c e s , i n p a r t , t o t h e l o n g e r p e r i o d o f 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, t h e N o r t h C a r o l i n a s t u d y (185) found no s i g n i f i c a n t r e l a t i o n s h i p between t h e l e n g t h o r t y p e o f i n t e r n e s h i p and su b s e q u e n t p o s t g r a d u a t e s t u d y h a b i t s . A r e c e n t C a l i f o r n i a s u r v e y (37) f o u n d t h a t when a d e t a i l e d a n a l y s i s 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 h i g h p e r c e n t a g e o f t h e d i s s a t i s f i e d n o n - p a r t i c i p a n t s were f o u n d i n s e l e c t s p e c i a l t i e s , n o t a b l y p s y c h i a t r y , a n e s t h e s i o l o g y , n e u r o s u r g e r y , 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 p r a c t i - t i o n e r s e x p r e s s e d 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 g r e a t e r i n t e r e s t i n p l a n n e d programs o f c o n t i n u i n g e d u c a t i o n . T h i s s t u d y r e v e a l e d t h a t s o m e " s p e c i a l i s t s , p a r t i c u l a r l y i n t e r n i s t s and s u r g e o n s ( o t h e r t h a n t h o s e i n g e n e r a l s u r g e r y ) a t t e n d e d c o u r s e s o f t e n . The I n d i a n a s u r v e y (117) d i s c l o s e d no s i g n i f i c a n t d i f f e r e n c e i n a t t e n d a n c e between g e n e r a l i s t s and s p e c i a l i s t s . P r a c t i c e A r r a n g e m e n t s : A l t h o u g h 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 e n c o u r a g e s 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 t h i s 23 assumption. At least two studies (37)(185) disclosed that while physicians in group practice were slightly better able to attend programs than were those in individual practice, the difference in participation was not s t a t i s t i - cally significant. In fact, one study found that while costs deterred relatively more physicians in solo practice from attending as many programs as they would l i k e , more respondents in group arrangements said they limited their attendance because of d i f f i c u l t i e s getting away from their practices. 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 attributes this seeming inconsistency to the traditional North American concept of "medical care as a personalized service provided by the private practitioner himself, and which therefore, cannot be easily delegated to others." On the other hand., a recent survey by the Canadian Medical Association (196) provides some interesting figures relative to group practice and continuing education. As shown in Table I, these data suggest that group practice promotes not only post graduate study, but even more important, i t provides a great variety of less formal but ongoing opportunities for learning continuously. TABLE I. QUALITY OF CARE PROCEDURE IN GROUPS (Canada, 1967) FEATURES OF GROUPS NO. PERCENT Total number of groups 246 100 Member selection 240 98 Supervision of new members 204 83 Cl i n i c a l Conferences 151 61 Frequent consultations 239 97 Postgraduate study 226 92 Reference library 160 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 Coleman (154) d i s c l o s e d t h a t t h e a d o p t i o n o f new d r u g s o c c u r r e d on t h e a v e r a g e .of two months s o o n e r where p h y s i c i a n s s h a r e d o f f i c e s , t h a n where d o c t o r s p r a c t i s e d a l o n g . B o t h C l u t e (46) and P e t e r s o n (185) f o u n d t h a t p h y s i c i a n s t h e m s e l v e s f r e q u e n t l y m e n t i o n e d group p r a c t i c e as a c o n v e n i e n t and i n e x p e n s i v e means o f c o n s u l t a t i o n . Thus, w h i l e group p r a c t i c e a r r a n g e m e n t s may n o t n e c e s s a r i l y be o r g a n i z e d to m a x i m i z e a t t e n d a n c e a t f o r m a l c o u r s e s , i t a p p e a r s t o p r o v i d e c o n d i t i o n s c o n d u c i v e t o c o n t i n u o u s l e a r n i n g . • L o c a t i o n o f 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 doubt e x p e r i e n c e more d i f f i c u l t y i n a r r a n g i n g to a t t e n d p r o g r a m s , an i n c r e a s e i n the s i z e o f t h e community does n o t n e c e s s a r i l y c o r r e l a t e w i t h i n c r e a s e d 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 . C o n v e r s e l y , s e v e r a l s t u d i e s (256) (37) (185) r e v e a l t h a t p h y s i c i a n s in Smaller c i t i e s and o u t l y i n g d i s t r i e L s a t t e n d courses more o f t e n t h a n do t h o s e i n l a r g e r m e t r o p o l i t a n a r e a s , and, when t h e y do a t t e n d , t h e y a r e more s a t i s f i e d t h a n t h e i r m e t r o p o l i t a n p e e r s ( 3 7 ) . R i s i n g e t a l (204) a t t r i b u t e d t h e 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 to g r e a t e r dependence on h o s p i t a l s t a f f m e e t i n g s as w e l l as t o t h e number o f p r o f e s s i o n a l c o n s u l t a t i o n s a v a i l a b l e , w h i l e 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 on c o u r s e a t t e n d a n c e f o r new i n f o r m a t i o n and p r o f e s s i o n a l c o n t a c t s . B o t h V o l l a n (256) and P e t e r s o n (185) made s i m i l a r o b s e r v a t i o n s . They a l s o f o u n d 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 t h e l a r g e s t c i t i e s a v e r a g e d t h e most h o u r s p e r y e a r i n c o n t i n u i n g e d u c a t i o n . 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 an i m p o r t a n t v a r i a b l e r e l a t e d t o 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 . B o t h V o l l a n (256) and P e t e r s o n (185) d i s c l o s e d an age r e l a t e d p a t t e r n o f p a r t i c i p a t i o n , c h a r a c t e r i z e d by a g r a d u a l i n c r e a s e 25 i n t h e p e r c e n t a g e o f p h y s i c i a n s a t t e n d i n g p o s t g r a d u a t e c o u r s e s as t h e number of y e a r s i n p r a c t i c e 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 decade and d e c l i n i n g t h e r e a f t e r . 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 younger 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 a t f o r m a l c o u r s e s (177) (37) ( 1 5 ) . A p p e l c o n c l u d e d t h a t t h i s t r e n d i s r e l a t e d t o t h e r e a l i z a t i o n by younger p h y s i c i a n s s t a r t i n g o u t i n p r a c t i c e t o d a y t h a t t h e y c a n n o t " c o a s t a l o n g f o r t h e f i r s t few y e a r s 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 t w e n t y y e a r s ago" ( 6 ) . O t h e r s s u g g e s t t h a t t h i s t r e n d may be due more t o d e f i c i e n c i e s i n b a s i c m e d i c a l e d u c a t i o n (37) ( 1 5 ) . OPINIONS-AND PREFERENCES Numerous s t u d i e s have sought some measure 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 a t t e m p t e d t o i d e n t i f y f a c t o r s i n the p r o v i s i o n s o f programs w h i c h may en c o u r a g e o r i n h i b i t p a r t i c i p a t i o n . These i n c l u d e s u c h m a t t e r s 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 p r o c e s s e s and c o n t e n t . Most o f t h e s e f a c t o r s l i e w i t h i n t h e domain o f t h o s e p r o v i d i n g p r o g r a m s , c o n s e q u e n t l y t h e f i n d i n g s from s u r v e y s c a n p r o v i d e c l u e s u s e f u l i n p l a n n i n g . D e t e r r e n t s t o A t t e n d a n c e : The m a j o r 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 th e i n a b i l i t y t o l e a v e a busy p r a c t i c e , r a t h e r t h a n g r o s s d i s 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 , o r l a c k 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) (34) (39) ( 1 1 7 ) . As m i g h t be e x p e c t e d , g e n e r a l p r a c t i t i o n e r s e x p e r i e n c e t h e g r e a t e s t d i f f i c u l t y i n g e t t i n g away f o r a d d i t i o n a l s t u d y (37) (200) ( 1 1 7 ) . 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 need f o r i t t h a n do s p e c i a l i s t s 26 who a r e more l i k e l y t o f e e l t h a t t h e y can g e t needed i n f o r m a t i o n t h r o u g h a l t e r n a t e r o u t e s . One s t u d y (37) 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 p e r c e n t o f t h o s e p h y s i c i a n s i n s u r g i c a l s p e c i a l t i e s and 60 p e r c e n t i n m e d i c a l s p e c i a l t i e s gave " g e t 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 t h e i r p r i m a r y r e a s o n f o r n o t 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 o f t h e g e n e r a l p r a c t i t i o n e r s l i s t e d t h e same r e a s o n . The p r i m a r y r e a s o n 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 t h i s group was " t i m e committed t o p a t i e n t s . " O t h e r d e t e r r e n t s t o a t t e n d a n c e m e n t i o n e d 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 - f a c t o r y s c h e d u l i n g o f p r o g r a m s ; c o s t s ; u n s u i t a b l e s u b j e c t m a t t e r (229) (197) (37) ( 1 1 7 ) ; l a c k o f awareness o f c o u r s e s a v a i l a b l e ( 3 9 ) ; and, t h a t t h e p h y s i c i a n f e l t h i m s e l f t o be a d e q u a t e l y i n f o r m e d and n o t i n need o f f u r t h e r s t u d y . Fees and S t i p e n d s : Most p h y s i c i a n s p r e f e r t o assume r e s p o n s i b i l i t y f o r t h e i r own c o n t i n u i n g _ j . . x-j J - j - c /ncr\\ /irv/.A /tens mi c u u t d L i u u ctnu a.i.c uus, a u v e i s e L U L U I L I U U J - C C O J \~> i ) ) \x.\jy j • m c i c i s , however, l e s s agreement w i t h r e s p e c t t o r e c e i v i n g f i n a n c i a l r e m u n e r a t i o n f o r c o u r s e a t t e n d a n c e . I n t h e C a l i f o r n i a s u r v e y ( 3 7 ) , 39 p e r c e n t o f r e s p o n d e n t s were 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 t h e r e s t were i n d i f f e r e n t . Surgeons were l e a s t i n f a v o u r o f f i n a n c i a l a s s i s t a n c 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 most i n f a v o u r . I n New J e r s e y ( 9 9 ) , w h i l e 40 p e r c e n t 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 , and 49 p e r c e n t d i d n o t r e s p o n d t o t h e q u e s t i o n . S c h e d u l i n g of Programs: P h y s i c i a n s a r e o v e r w h e l m i n g l y i n f a v o u r o f c o n c e n t r a t e d s h o r t c o u r s e s l a s t i n g one week o r l e s s (233) (99) (260) (266) (37) (256) ( 1 0 7 ) . Most ' i n d i c a t e t h a t e i t h e r week-end o r e v e n i n g programs would be r e l a t i v e l y e a s y t o a t t e n d , b u t 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) ( 1 6 9 ) . I n two 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 f i r s t c h o i c e , Wednesday o r a.Wednesday- Thursday c o m b i n a t i o n (233) ( 1 1 4 ) . W i t h few e x c e p t i o n s , t h e y p r e f e r c o u r s e s h e l d i n t h e i r l o c a l c o m munities (117) (266) (99) (20) b u t d i s t a n c e i s n o t as m a j o r a p r o b l e m 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 t o h i s p a t i e n t s " ( 1 8 5 ) . V o l l a n (17) found t h a t t w o - t h i r d s o f t h e p h y s i c i a n s were w i l l i n g t o t r a v e l 100 m i l e s o r more, as l o n g as t h e c o u r s e was a r e l a t i v e l y s h o r t one. O p i n i o n s d i f f e r w i t h r e g a r d s t o t h e p l a c e o f m e e t i n g . Many d o c t o r s 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 hence g i v e f i r s t p r e f e r e n c e t o a u n i v e r s i t y m e d i c a l c e n t e r (233) (192) ( 2 0 ) , a l o c a l h o t e l (192) ( 6 ) , o r r e s o r t a r e a s where t h e y 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 (192) (37) . O t h e r s w o u l d l i k e programs b r o u g h t t o t h e i r l o c a l h o s p i t a l (117) ( 2 0 0 ) . Long t e r m programs a r e n o t e n d o r s e d 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 e r e i s some i n d i c a t i o n 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 o f t h e p o t e n t i a l w o r t h o f l e n g t h i e r i n — h o s p i t a l t y p e t r a i n i n g programs (6) (192) ( 1 0 7 ) . I n one s t u d y ( 3 7 ) , t h r e e t o s i x month c l i n i c a l t r a i n e e s h i p s , and one t o t h r e e week i n s e r v i c e programs were c o n s i d e r e d i m p o r t a n t by t h o s e who were f a m i l i a r w i t h them. S i m i l a r l y , i n a v e r y r e c e n t s u r v e y (169) o f p s y c h i a t r i s t s , 38 p e r c e n t o f t h e r e s p o n d e n t s f a v o u r e d an e x t e n d e d i n t e r m i t t e n t c o u r s e o f f e r e d o v e r a p e r i o d of from one t o n i n e months. S p o n s o r s : S p e c i a l t y 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 e d u c a t i o n (42) (117) (197) (99) . A c c o r d i n g t o t h e C a l i f o r n i a s u r v e y ( 3 7 ) , c o u r s e s s p o n s o r e d by s p e c i a l t y 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 , w i t h 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 . O t h e r a g e n c i e s r a n k e d c o n s i d e r a b l y below t h e s e w i t h l o c a l m e d i c a l s o c i e t i e s r a t e d l a s t . A p p r o x i m a t e l y 41 p e r c e n t t h e r e s p o n d e n t s i n d i c a t e d a l a c k o f f a m i l i a r i t y w i t h c o u r s e s c o - s p o n s o r e d by 28 m e d i c a l s c h o o l s and h o s p i t a l s , and 38 p e r c e n t were n o t . f a m i l i a r w i t h c o u r s e s s p o n s o r e d by h o s p i t a l s a l o n e . I n c o n t r a s t , a r e c e n t s u r v e y (200) c o - s p o n s o r e d by t h e 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 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 M e d i c a l Program ( h e r e i n a f t e r r e f e r r e d t o as t h e WICHE s t u d y ) d i s c l o s e d t h a t i n t h e m o u n t a i n s t a t e s , w i t h t h e e x c e p t i o n o f Nevada, programs s p o n s o r e d by l o c a l m e d i c a l s o c i e t i e s r a n k e d f i r s t ; h o s p i t a l programs s e c o n d ; s t a t e m e d i c a l s o c i e t i e s t h i r d ; and m e d i c a l s c h o o l s f o u r t h . O t h e r s t u d i e s a l s o r e v e a l (263) (42) t h a t programs s p o n s o r e d by m e d i c a l 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 a r e r a t e d h i g h e r t h a n t h o s e s p o n s o r e d by m e d i c a l s c h o o l s . W h i l e t h e s e d i f f e r e n c e s a r e no doubt due i n p a r t t o r e g i o n a l v a r i a t i o n i n t h e a v a i l a b i l i t y o f p r o g r a m s , W e n r i c h (263) s u g g e s t s t h a t i t may a l s o be r e l a t e d t o t h e "town-gown" c o n f l i c t . I n h i s s t u d y , many r e s p o n d e n t s were o f t h e o p i n i o n t h a t t h e p h y s i c i a n t e a c h i n g i n a m e d i c a l s c h o o l had " l o s t t o u c h w i t h c l i n i c a l r e a l i t y . " I n s t r u c t i o n a l P r o c e s s e s P h y s i c i a n s seem t o p r e f e r t h e more f a m i l i a r i n s t r u c t i o n a l p r o c e s s e s . L e c t u r e s , p a n e l s , s e m i n a r s , c l i n i c d e m o n s t r a t i o n s , e d u c a t i o n a l f i l m s , s y m p o s i a , and g r a n d r o u n d s , a r e g e n e r a l l y f a m i l i a r and a p p r o v e d by most (200) (99) (233) ( 1 1 4 ) . A l t h o u g h t h e t r a d i t i o n a l l e c t u r e has been c r i t i c i z e d as a d i d a c t i c , p a s s i v e t e c h n i q u e i n a number o f s t u d i e s , d o c t o r s r a t e i t f i r s t i n t h e i r l i s t o f p r e f e r r e d t e c h n i q u e s (169) (37) (177) (233) ( 2 3 9 ) . Some p h y s i c i a n s i n Ruhe's s u r v e y (61) i n d i c a t e d t h a t t h i s was bec a u s e "group d i s c u s s i o n s and q u e s t i o n p e r i o d s were o f t e n dominated by more v o c a l d o c t o r s who d i d n o t n e c e s s a r i l y r e f l e c t t h e i n t e r e s t s o f t h e g r o u p . " On t h e o t h e r hand, many p h y s i c i a n s i n d i c a t e t h a t t h e exchange o f i d e a s and i n f o r m a t i o n i n i n f o r m a l c o n v e r s a t i o n s w i t h p e e r s can be an i m p o r t a n t r e a s o n f o r a t t e n d i n g c o u r s e s (212) ( 2 6 3 ) . Two s t u d i e s s u g g e s t t h a t s u p e r v i s e d c l i n i c a l p r a c t i c e , w h i c h i s 29 r a r e l y u sed 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) ( 2 0 0 ) . P h y s i c i a n s a l s o e x p r e s s i n t e r e s t i n t h e newer u s e s o f t h e mass media s u c h 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 t e n d t o r a t e them l o w e r t h a n t h e p e r s o n a l c o n t a c t methods (37) (117) ( 2 6 3 ) . W h i l e t h i s r a t i n g may be due i n p a r t t o t h e f a c t t h a t t h e s e media a r e n o t a l w a y s a v a i l a b l e i n a l l r e g i o n s (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 media a r e used e x t e n s i v e l y 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 , r e s p o n s e s i n d i c a t e t h a t t h e y a r e p e r c e i v e d by p h y s i c i a n s as s u p p l e m e n t a r y when measured 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 ) . A c c o r d i n g t o a number 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 i n s t r u c t i o n i s c o r r e s p o n d e n c e s t u d y (192) (37) ( 2 0 ) . One s t u d y f o u n d t h a t programmed i n s t r u c t i o n was w e l l r e c e i v e d ( 2 6 3 ) . I n g e n e r a l , s p e c i a l i s t s i n d i c a t e a p r e f e r e n c e f o r r e a d i n g , t e a c h i n g ward r o u n d s , and o t h e r more c l i n i c a l l y a p p l i e d t e c h n i q u e s (42) ( 1 1 7 ) . However, t h e r e a r e c o n s i d e r a b l e d i f f e r e n c e s i n t h e p r e f e r e n c e s l i s t e d among t h o s e o f t h e d i f f e r e n t s p e c i a l t i e s . G e n e r a l 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 c o m p a t i b l e w i t h a busy p r a c t i c e . They r a t e t h e mass media and b e d s i d e c l i n i c a l c o u r s e s i n m e d i c a l s c h o o l s r e l a t i v e l y h i g h , as opposed t o r e a d i n g and l o n g t e r m c l i n i c a l t r a i n e e s h i p s ( 3 7 ) . 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 (200) (117) ( 3 7 ) . They a r e a l s o b e t t e r a c q u a i n t e d w i t h t h e d i f f e r e n t t e a c h i n g t e c h n i q u e s and a r e more d i s c r i m i n a t i v e i n e v a l u a t i n g t h e i r 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 s u r v e y , w h i l e younger p h y s i c i a n s t e n d e d t o r a t e s h o r t c o u r s e s h i g h e r t h a n o l d e r p h y s i c i a n s , t h e y were l e s s l i k e l y 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 s u b j e c t m a t t e r t h a n were t h e i r e l d e r s . W i t h t h e e x c e p t i o n o f a u d i o - d i g e s t w h i c h was r a n k e d f a i r l y h i g h , t h e y c o n s i d e r e d t h e mass media l e s s e f f e c t i v e t h a n d i d t h e i r o l d e r c o l l e a g u e s . 30 F e l t L e a r n i n g Needs: S u r v e y s d i s c l o s e 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 w h i c h i s i m m e d i a t e l y p r a c t i c a l and a p p l i c a b l e t o t h e i r p a r t i c u l a r p r a c t i c e s i t u a t i o n (212) (84) ( 3 7 ) . The most 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 i s t h a t p s y c h i a t r i s t t e a c h e r s do n o t u n d e r s t a n d t h e i r p r a c t i c a l p r o b l e m s (258) (34) ( 2 2 9 ) . 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 a t t e n d i n g p o s t g r a d u a t e c o u r s e s 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 and t r e a t p a r t i c u l a r p a t i e n t s , and t o i n c r e a s e t h e i r s k i l l s i n c o m m u n i c a t i o n (217) (245) (36) (229) ( 2 3 3 ) . I n s h o r t , p r a c t i t i o n e r s a r e more i n t e r e s t e d i n common m e d i c a l 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 u n u s u a l p r o c e d u r e s (37) ( 1 9 0 ) , b u t t h i s does n o t mean t h a t t h e y w o u l d i g n o r e new d e v e l o p m e nts ( 1 2 6 ) . I n one s t u d y , 54 p e r c e n t o f t h e r e s p o n d e n t s f e l t t h a t i n s u f f i c i e n t a t t e n t i o n was g i v e n t o r e c e n t i n n o v a t i o n s i n m e d i c a l t e c h n i q u e s . T h i s o p i n i o n was more p r e v a l e n t among g e n e r a l i s t s and t h o s e i n m e d i c a l s p e c i a l t i e s t h a n amongst s u r g e o n s ( 3 7 ) . P h y s i c i a n s a l s o want programs t o d e a l w i t h one o r two t o p i c s i n d e p t h , r a t h e r t h a n a b r o a d c o v e r a g e o f s e v e r a l s u b j e c t s (126) (192) ( 1 0 7 ) . S p e c i a l i s t s a r e o f 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 even 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 ( 3 7 ) . T h e r e i s some e v i d e n c e t h a t p r a c t i t i o n e r s w o u l d l i k e r e f r e s h e r c o u r s e s i n t h e b a s i c s c i e n c e s (107) ( 3 7 ) , b u t t h e r e i s no g e n e r a l agreement on t h i s . I n one s t u d y some 90 p e r c e n t o f t h e r e s p o n d e n t s f e l t t h a t b a s i c s c i e n c e s and c l i n i c a l r e s e a r c h programs s h o u l d c o n t i n u e t o be o f f e r e d , b u t t o a l e s s e r d e g r e e ( 1 0 7 ) . I n a n o t h e r s t u d y a p p r o x i m a t e l y 69 p e r c e n t o f t h e r e s p o n d e n t s were i n f a v o u r o f more s u c h c o u r s e s , w i t h s p e c i a l i s t s i n m e d i c i n e more f a v o u r - 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 i n t e r e s t e d ( 3 7 ) . 31 At least two studies suggest that physicians would also lik e more courses dealing with medico-social problems, notably in the areas of "physician- patient relationships," and medico-legal problems (67) (37). According to the California report (37) , the subject matter most frequently requested by physicians relates to the diagnosis and treatment of disease. Moreover, physicians' interest pertaining to medical conditions i s to a considerable extent specific to their area of specialization and place of practice (42) (229) (20). Thus, i n the Utah study (42) i t was found that while endocrinopathies rated highest among a l l groups, and cardiac arrythmias second, these were ranked very low by surgeons. Similarly, i n one area where the socio-economic level of the population was higher, a l l physicians displayed a greater interest in psychiatric subjects than did those from less prosperous areas. When individual practices were examined, great variations occurred .in the physicians' perceptions of their learning needs. The Utah (42) and the WICHE (200) studies indicated there was l i t t l e correlation between a physician's expressed learning needs and those conditions most frequently encountered in medical practice. Of a l l groups, generalists were found to be the most r e a l i s t i c in relating educational needs to practice problems. At the same time, i t was observed that a great deal of the practitioner's time was spent in treating minor ailments which could have been delegated to medical assistants. 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 , d r u g sample l i t e r a t u r e , m e d i c a l j o u r n a l s , 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 p r o f e s s i o n a l m e e t i n g s , r a t h e r t h a n t h r o u g h f o r m a l c o u r s e s . 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 been l i t t l e change. A l t h o u g h t h e d e t a i l man i s g e n e r a l l y p e r c e i v e d as l e s s v a l u a b l e (117) (263) ( 2 6 5 ) , m e d i c a l j o u r n a l s , u n s o l i c i t e d l i t e r a t u r e , 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 p r o f e s s i o n a l m e e t i n g s , a r e u t i l i z e d e x t e n s i v e l y by most p h y s i c i a n s (200) (263) ( 1 1 7 ) . A t t h e same t i m e , w h i l e p h y s i c i a n s may use t h e s e i n f o r m a t i o n s o u r c e s , t h e y do n o t n e c e s s a r i l y f i n d them t o o u s e f u l (15) (185) ( 1 0 9 ) . I n t h e N o r t h C a r o l i n a s t u d y ( 1 8 5 ) , t h e most common c r i t i c i s m e x p r e s s e d by g e n e r a l p r a c t i t i o n e r s was t h a t m e d i c a l j o u r n a l s were t o o t h e o r e t i - c a l and t h e c o n t e n t n o t t o o r e l e v a n t t o m e d i c a l p r a c t i c e . A more r e c e n t s u r v e y by Dohner and Hamburg (109) s u g g e s t s t h a t d e s p i t e t h e p a s s a g e o f t i m e , t h o p i n i o n s o f g e r i p T - ^ l i s t s have n o t changed, w i t h o v e r 50 p e r c e n t o f t h e r e s p o n d s n r a t i n g c u r r e n t m e d i c a l l i t e r a t u r e as o f l i t t l e u s e as a s o u r c e o f i n f o r m a t i o n i n t h e f i e l d o f u r o l o g y . N o n e t h e l e s s , P e t e r s o n and h i s c o l l e a g u e s (185) were a b l e t o show a p o s i t i v e c o r r e l a t i o n between t h e q u a l i t y o f a p h y s i c i a n ' s p r a c t i c e and h i s i n t e r e s t i n s e e k i n g new knowledge t h r o u g h t h e p u r c h a s e o f m e d i c a l j o u r n a l s . S i m i l a r l y , W e n r i c h ' s p i l o t s t u d y (263) i d e n t i f y i n g t h e c h a r a c t e r i s t i c s o f " g a t e k e e p e r s " o r 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 one s m a l l community 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 more on w r i t t e n s o u r c e s , i n f o r m a l c o n s u l t a t i o n s , and d i s c u s s i o n w i t h r e l a t e d h e a l t h p r o f e s - s i o n a l s i n t h e h o s p i t a l t h a n d i d t h o s e p h y s i c i a n s who sought t h e i r a d v i c e . A l t h o u g h r e s e a r c h on t h e use of i n f o r m a l s o u r c e s of c o n t i n u i n g l e a r n i n g i s b o t h l i m i t e d and l i m i t i n g (150) ( 2 7 5 ) , P e t e r s o n e_t a i l c o n c l u d e , as have many o t h e r s s u b s e q u e n t l y , " t h a t b a s i c m e d i c a l e d u c a t i o n has been o n l y p a r t i a l l y s u c c e s s f u l i n i n c u l c a t i n g i n f u t u r e p r a c t i t i o n e r s b o t h t h e 33 a b i l i t y and the d e s i r e to seek out through 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 of medic ine throughout t h e i r p r o f e s s i o n a l l i v e s " (185) . 34 CHAPTER IV . ORGANIZATION AND ADMINISTRATION The 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 e d u c a t i o n has grown s t e a d i l y i n r e c e n t y e a r s . T h i s g r o w t h i n i n t e r e s t and p a r t i c i p a t i o n i s r e f l e c t e d i n t h e i n c r e a s e d number o f c o u r s e s r e p o r t e d as w e l l as 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 t h e s p o n s o r s h i p o f e d u c a t i o n a l a c t i v i t i e s f o r m e d i c a l p r a c t i t i o n e r s . A l o n g w i t h t h e growth i n o p p o r t u n i t i e s and p a r t i c i p a t i o n has come i d e n t i f i a b l e t r e n d s 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 o f p a t t e r n s o f o r g a n i z a t i o n a r e e n c o u n t e r e d i n c o n t i n u i n g ed^^^tde in fnT T n p r i x c i n e . These p a t t e r n s a r e d e t e r m i n e d t c some e x t e n t by t h e s p o n s o r s h i p o f t h e program. Numbers o f C o u r s e s and S p o n s o r s : The number o f c o u r s e s 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 o v e r t h e p a s t 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 5 p e r c e n t p e r y e a r f r o m 1961 t o 1970. In'1970-1971 t h e r e was an even g r e a t e r i n c r e m e n t o f 15 p e r c e n t o v e r t h e p r e c e d i n g y e a r and t h i s was. accompanied by an e q u a l l y s h a r p i n c r e a s e i n t h e t o t a l number o f i n s t i t u t i o n s p r e s e n t i n g c o u r s e s . I n 1968-1969, 372 i n s t i t u t i o n s s p o n s o r e d o r c o - s p o n s o r e d c o u r s e s and t h i s i n c r e a s e d t o 611 i n s t i t u t i o n s i n 1970-1971 (54) . These r e p r e s e n t e d 77 m e d i c a l s c h o o l s , 291 n o n - s c h o o l o r community h o s p i t a l s , 50 c i t y , c o u n t y , and s t a t e m e d i c a l s o c i e t i e s , 66 s p e c i a l t y m e d i c a l s o c i e t i e s and academies o f g e n e r 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 , and 94 " o t h e r s , " i n c l u d i n g TABLE II CONTINUING MEDICAL EDUCATION COURSES LISTED 1961-1962 TO 1970-1971 Total Number of Number of Courses Sponsored Courses Sponsored Year Courses Reported Primary Sponsors by Medical Schools by Hospitals Number Percent Number Percent 1961-62 1,105 206 — 1962-63 1,146 208 626 55% 104 9% 1963-64 1,2.64* 267* 760* 60% 163 13% 1964-65 1,569 251 857 55% 265 16% 1965-66 1,641 252 863 53% 351 21% 1966-67 1,608 262 910 57% 338 21% .1967-68 1,830 263 1,000 54% 224 12% 1968-69 1,922 • 300 1,024 53% 370 19% 1969-70 2,016 323 886 44% 441 22% 1970-71 2,319 303 813 35% 374 16% *Includes courses offered by five Canadian schools not reported in other years. SOURCE: J.A.M.A., 214:1526 (November 1970). 36 s c h o o l s o f p u b l i c h e a l t h , p o s t g r a d u a t e m e d i c a l s c h o o l s , p r i v a t e c l i n i c s , f o u n d a t i o n s , o r l o c a l and n a t i o n a l government a g e n c i e s ( 6 1 ) . The m a j o r p r o d u c e r s of c o u r s e s have been t h e m e d i c a l s c h o o l s and community h o s p i t a l s . As n o t e d i n T a b l e I I , m e d i c a l s c h o o l s a l o n e p r o d u c e d o v e r one h a l f o f a l l c o u r s e s o f f e r e d f r o m 1961 t o 1969. A l t h o u g h t h i s d e c r e a s e d t o 44 p e r c e n t i n 1969-70 and t o 35 p e r c e n t i n 1970-71, m e d i c a l s c h o o l programs a r e s t i l l t h e most 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 o f f e r e d p e r s c h o o l i s 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 o f f e r e d by o t h e r s p o n s o r i n g a g e n c i e s . M e d i c a l s c h o o l s a r e r e p o r t e d t o a v e r a g e a p p r o x i m a t e l y t w e l v e t o t h i r t e e n 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 h o s p i t a l s w h i c h a v e r a g e r o u g h l y two c o u r s e s p e r h o s p i t a l p e r y e a r ( 6 1 ) . C o u r s e C o n t e n t and E l i g i b i l i t y : F o r t h e p a s t s e v e n y e a r s t h e g r e a t e s t number o f c o u r s e s have been o f f e r e d 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 g e n e r a l m e d i c i n e , i n t h a t o r d e r (52) (54) (59) ( 6 1 ) . O t h e r major f i e l d s w i t h a s u b s t a n t i a l number i n c l u d e s u r g e r y , p a t h o l o g y , o p t h a l m o l o g y , p e d i a t r i c s , o b s t e t r i c s , and g y n a e c o l o g y ( 5 9 ) . D e s p i t e t h i s s p e c i a l t y o r i e n t a t i o n , o v e r one h a l f o f t h e c o u r s e s l i s t e d 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 g e n e r a l i s t and s p e c i a l i s t . Because o f t h e v a r y i n g b a c k g r o u n d s and d i f f e r i n g l e a r n i n g needs o f t h e two g r o u p s , one m i g h t q u e s t i o n t h e wisdom o f t h i s , however, Ruhe (220) n o t e s t h a t t h e e x p e r i e n c e o f m e d i c a l s c h o o l s d i s c o u n t s t h i s c o n c e r n as 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 f o r a g e n e r a l a u d i e n c e . An e x c e p t i o n t o t h i s i s p s y c h i a t r y where t h e r e i s a t e n d e n c y t o p r o v i d e d i f f e r e n t l e v e l s o f i n s t r u c t i o n s u i t e d t o the needs o f n o n - p s y c h i a t r i s t s (88) ( 2 3 1 ) . A t t h e U n i v e r s i t y o f S o u t h e r n C a l i f o r n i a , p r a c t i t i o n e r s a r e o f f e r e d t h r e e c o u r s e f o r m a t s : a b a s i c , an i n t e r m e d i a t e , and an advanced c o u r s e ( 8 8 ) . 37 W h i l e i t i s i m p o s s i b l e t o d e t e r m i n e t h e e x t e n t t o w h i c h programs a r e d e s i g n e d f o r i n t e r p r o f e s s i o n a l e d u c a t i o n , t h e g e n e r a l i m p r e s s i o n i s t h a t t h e number i s s m a l l ( 1 9 8 ) . One program w h i c h a p p e a r s s u i t a b l e t o an i n t e r d i s c i p l i n - a r y a p p r o a c h i s t h e "Care o f t h e P r e m a t u r e I n f a n t " w h i c h o r i g i n a t e d a t C o r n e l l M e d i c a l C e n t e r i n 1949 ( 1 9 ) . T h i s program 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 and n u r s e s and t h e program model has been used 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 S t a t e s (115) ( 1 9 ) . 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 and R e h a b i l i t a t i o n o f t h e S t r o k e P a t i e n t . " I n most o f t h e s e , p h y s i c i a n s , n u r s e s 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 t h e team n u c l e u s w i t h i n v o l v e m e n t o f o c c u p a t i o n a l t h e r a p i s t s , r e h a b i l i t a t i o n 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 t h e s e a r e a v a i l a b l e and r e q u i r e d ( 2 5 2 ) . O t h e r f i e l d s o f s t u d y r e p o r t i n g o c c a s i o n a l i n t e r p r o f e s s i o n a l e f f o r t s a r e p s y c h i a t r y ( 2 0 ) . and p u b l i c h e a l t h ( 1 8 2 ) . P a t t e r n s o f Course O r g a n i z a t i o n I n t h e a n n u a l l i s t i n g o f c o u r s e s 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 a r e s i x m a j o r p a t t e r n s o f c o u r s e o r g a n i z a t i o n : 1. C o n t i n u o u s c o u r s e s a r e t h o s e c o n d u c t e d o v e r a c o n s e c u t i v e number o f h o u r s , d a y s , 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 . 2. I n t e r m i t t e n t c o u r s e s e x t e n d o v e r a p e r i o d o f t i m e 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 t i m e . 3. C i r c u i t c o u r s e s a r e p r e s e n t e d i n r u r a l a r e a s by t r a v e l l i n g f a c u l t y . 4. T r a i n e e s h i p s a r e c l i n i c a l l y o r i e n t e d i n - h o s p i t a l r e s i d e n c y t y p e programs r a n g i n g i n l e n g t h f r o m f i v e days t o one y e a r . 5. Home Study i n v o l v e s c o r r e s p o n d e n c e s t u d y , programmed i n s t r u c t i o n , t a p e 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 t h a t e n a b l e t h e p h y s i c i a n 38 t o s t u d y i n h i s own t i m e . 6. TV-Radio c o u r s e s a r e s i m i l a r t o c o n t i n u o u s c o u r s e s b u t o f f e r e d t h r o u g h r a d i o o r t e l e v i s i o n t o p h y s i c i a n s a t home. Of t h e s e s i x t y p e s , c o n t i n u o u s c o u r s e s a p p e a r t o be t h e most common p a t t e r n as w e l l as t h e most p o p u l a r . I n t h e f o u r y e a r s r e p o r t e d i n T a b l e I I I t h e s e a c c o u n t e d f o r some 62.14 p e r c e n t o f a l l c o u r s e s i n 1964-65 w i t h a h i g h o f 66.79 p e r c e n t r e a c h e d i n 1966-67. D u r i n g 1969-70 (59) t h e 1261 c o n t i n u o u s c o u r s e s a c c o u n t e d f o r 65.54 p e r c e n t o f a l l c o u r s e s o f f e r e d w i t h 83.74 p e r c e n t l a s t i n g one week o r l e s s . I n t e r m i t t e n t 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 showing a d e c l i n e t o 26.86 p e r c e n t i n 1966-67 and a r e c o v e r y t o 30.95 p e r c e n t i n 1969-70. I n t h a t .year t h e s e c o u r s e s 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 and appear t o have 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 use o f i n t e r m i t t e n t s c h e d u l i n g where i t i s f e l t t h a t i n s t r u c t i o n e x t e n d e d o v e r a l o n g e r p e r i o d o f t i m e i s e s s e n t i a l i n c h a n g i n g 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 c o n c e p t s . C u r r e n t l y , o v e r 70 p e r c e n t of. a l l p s y c h i a t r i c c o u r s e s a r e o f f e r e d i n t e r m i t t e n t l y , and o f t h e s e , a few e x t e n d t h r o u g h o u t t h e whole academic y e a r (59) . T h i s i n p a r t may a c c o u n t f o r t h e p o o r o v e r - a l l a t t e n d a n c e (217) (245) ( 2 2 9 ) , s i n c e as p r e v i o u s l y n o t e d , busy p r a c t i t i o n e r s f i n d i t i n c o n v e n i e n t t o t r a v e l l o n g d i s t a n c e s f o r a few h o u r s o f i n s t r u c t i o n . P o s t g r a d u a t e T r a i n e e s h i p s a r e o f f e r e d by many h o s p i t a l s w i t h o u t f o r m a l p u b l i c i t y , hence t h e number r e c o r d e d i n t h e A n n u a l Course 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 b e i n g o f f e r e d ( 5 9 ) . Of t h e 77 l i s t e d f o r 1969-1970 ( 5 9 ) , a l l were o f f e r e d on a f u l l t i m e b a s i s r a n g i n g i n TABLE I I I PERCENTAGE DISTRIBUTION OF CONTINUING EDUCATION COURSES BY TYPE OF COURSE 1964-65 TO 1969-70 Type o f c o u r s e Y e a r 1964 -65 ! 1966--67 1968 -69 1969 -70 Number P e r c e n t Number P e r c e n t Number ! P e r c e n t Number ! P e r c e n t C o n t i n u o u s 975 62.14 1074 66.79 1264 65.76 1261 1 1 62.54 I n t e r m i t t e n t 493 31.42 432 26.86 555 28.87 624 ' 30.95 C i r c u i t 17 1.08 4 .24 15 .78 14 .69 T r a i n e e s h i p s 55 3.50 65 4.04 54 2.80 77 3.81 Home Study 9 .57 16 .99 19 .98 14 .69 TV-Radio 13 .82 14 .87 12 .62 12 .59 Not S t i p u l a t e d 1 - 3 .18 3 .15 8 .39 1569 100.00 1608 100.00 1922 100.00 2016 100.00 SOURCE': J o u r n a l o f 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 , 190:645, 198:232, 206:2051, 210:1523 40 l e n g t h f r o m f i v e d ays t o one y e a r . W h i l e 16 s p o n s o r s p r o v i d e d s p e c i f i c c o u r s e d a t e s , t h e r e m a i n i n g 61 s p o n s o r s l e f t t h e s c h e d u l i n g t o "be a r r a n g e d " i m p l y i n g t h a t e n r o l l m e n t was n e g o t i a b l e a n y t i m e t h r o u g h o u t t h e academic y e a r . I n a l l b u t t h r e e c a s e s , p l a n n e d i n s t r u c t i o n was used i n a d d i t i o n t o c l i n i c a l e x p e r i e n c e . Of t h e 68 s p o n s o r s s p e c i f y i n g , o n l y 10 l i m i t e d e n r o l l m e n t t o e i t h e r s p e c i a l i s t o r g e n e r a l i s t . The r e m a i n d e r were open t o b o t h g r o u p s . Fees v a r i e d g r e a t l y f r o m no f e e , t o $2,350 f o r one e i g h t month e x p e r i e n c e i n p e d i a t r i c s . Over 80 p e r c e n t o f t h e s p o n s o r s were m e d i c a l s c h o o l s , w i t h t h e U n i v e r s i t i e s o f Kansas and M a r y l a n d o f f e r i n g t h e g r e a t e s t number and v a r i e t y o f programs. • I n b o t h Canada and t h e U n i t e d S t a t e s , p h y s i c i a n i n t e r e s t i n t h i s t y p e o f program i s s a i d t o be i n c r e a s i n g , and a number o f m e d i c a l s c h o o l s r e p o r t p l a n s t o expand t h e i r p r e s e n t o f f e r i n g s (8) (35) ( 1 0 ) . M a j o r d e t e r r e n t s t o d a t e have been: t h e l a c k o f u n i v e r s i t y f a c i l i t i e s ; t h e c h r o n i c s h o r t a g e o f p h y s i c i a n s ; and t h e l o s s o f p h y s i c i a n income ( 1 8 9 ) . A program o f p h y s i c i a n and 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 t h e s u c c e s s f u l T u f t s r e g i o n a l program has been s u g g e s t e d as one p o s s i b l e s o l u t i o n t o t h e s e p r o b l e m s (47) (44) (61) ( 2 3 ) . 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 p r o p o s a l c a l l i n g f o r t h e e s t a b l i s h m e n t o f a N a t i o n a l G r a d u a t e M e d i c a l C e n t e r u s i n g one o r more o f t h e V e t e r a n ' s A d m i n i s t r a t i o n H o s p i t a l s . I n t h i s p l a n , p r a c t i s i n g p h y s i c i a n s 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 f o r one t o t w e l v e month p e r i o d s . A permanent s t a f f o f p r o v e n t e a c h e r s w o u l d be a s s i g n e d t o t h e C e n t e r and, 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 i n v i t e d as v i s i t i n g c l i n i c i a n s ( 7 4 ) . A t t h e o p e r a t i o n a l l e v e l , a p l a n w h i c h has been implemented w i t h r e l a t i v e s u c c e s s a t D a l h o u s i e U n i v e r s i t y i n H a l i f a x (67) , S t a u n t o n C l i n i c i n P i t t s b u r g h ( 1 8 6 ) , and more r e c e n t l y , by t h e W a s h i n g t o n / A l a s k a R e g i o n a l M e d i c a l 41 Program ( 7 1 ) , 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 b a s i s b u t e x t e n d i n g o v e r a f a i r l y l o n g p e r i o d o f t i m e . 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 M e d i c a l Program has o r g a n i z e d a p o s t g r a d u a t e p r e c e p t o r s h i p n e t w o r k 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 . C i r c u i t c o u r s e s have shown a s t e a d y d e c l i n e d u r i n g t h e f o u r y e a r s r e p o r t e d . P r o b a b l y t h e most s u c c e s s f u l c i r c u i t program i s t h a t o p e r a t e d by th e U n i v e r s i t y o f K a n s a s ' M e d i c a l C e n t e r . F o r t h e p a s t s e v e n y e a r s , t h i s program has o f f e r e d s i x s y m p o s i a i n each o f e i g h t c i r c u i t c e n t e r s d i s t r i b u t e d t h r o u g h o u t t h e 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 e d u c a t i o n t o a p p r o x i m a t e l y 500 t o 600 r u r a l p h y s i c i a n s a n n u a l l y (267) . A n o t h e r s u c c e s s f u l model i s t h a t o p e r a t e d i n M i c h i g a n . T o w s l e y (6) r e p o r t s t h a t i n t h e y e a r 1967-1968 programs were o f f e r e d t w i c e y e a r l y i n twenty a r e a s w i t h 1,033 p h y s i c i a n s a t t e n d i n g a t l e a s t one o f t h e two programs and 637 a t t e n d i n g b o t h . I n Canada, t h e s u c c e s s f u l p i o n e e r has been D a l h o u s i e U n i v e r s i t y w h i c h 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 34 c e n t e r s , e ach o f w h i c h r e c e i v e d f i v e o r s i x v i s i t s p e r y e a r f r o m t h e D a l h o u s i e f a c u l t y ( 1 5 ) . An e x t e n s i o n o f t h i s c i r c u i t c o n c e p t t o i n c l u d e t h e development o f community h o s p i t a l s ( n o n - t e a c h i n g 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 c e n t e r s , w i t h o n g o i n g i n f o r m a l and f o r m a l programs o f c o n t i n u i n g e d u c a t i o n , i s what i s r e c e i v i n g t h e g r e a t e s t emphasis i n t h e l i t e r a t u r e on 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 t o d a y (215) (246) (85) ( 1 0 4 ) . The i m p l e m e n t a t i o n o f P u b l i c Law 89-239, a u t h o r i z i n g f u n d s f o r c o n t i n u i n g e d u c a t i o n d e v e l o p e d c o - o p e r a t i v e l y by m e d i c a l s c h o o l s 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 R e g i o n a l M e d i c a l Programs ( h e r e i n a f t e r r e f e r r e d t o as RMPS) on h e a r t , s t r o k e , c a n c e r , and r e l a t e d d i s e a s e s , i s r e p o r t e d t o have been a m a j o r f a c t o r f a c i l i t a t i n g t h i s t r e n d i n t h e U n i t e d S t a t e s ( 2 5 2 ) . P r e s e n t l y , t h e r e a r e 55 RMPS 42 d i s t r i b u t e d t h r o u g h o u t t h e n a t i o n , and some o f them p r o v i d e s u b s t a n t i a l e v i d e n c e o f t h e wisdom o f d e v e l o p i n g c o n t i n u i n g e d u c a t i o n as an i n t e g r a l p a r t o f h e a l t h s e r v i c e s . R a d i o , t e l e v i s i o n , and home s t u d y a r e few i n number and have shown o n l y s l i g h t v a r i a t i o n o v e r t h e y e a r s r e p o r t e d i n T a b l e I I I . A n o t h e r t y p e o f e x t r a m u r a l program w h i c h d e s e r v e s b r i e f m e n t i o n i s t h e p o s t g r a d u a t e c r u i s e . As n o t e d e a r l i e r , p h y s i c i a n s i n d i c a t e a p r e f e r e n c e f o r a program w h i c h 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 . F o r a number o f y e a r s A l b a n y C o l l e g e ( 2 7 7 ) , t h e U n i v e r s i t y o f F l o r i d a ( 2 6 7 ) , and t h e Academies o f G e n e r a l P r a c t i c e (125) have s p o n s o r e d s u c h c r u i s e p r o g r a m s , b u t t h e h i g h c o s t and t h e t i m e f a c t o r a r e s a i d t o l i m i t t h e i r use ( 2 5 6 ) . SPONSORSHIP: ROLES AND RESPONSIBILITIES W h i l e 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 e d u c a t i o n l i e s i n t h e d i v e r s i t y o f a g e n c i e s a c t i v e i n t h e f i e l d , a t t h e same t i m e t h e need f o r c o - o r d i n a t i o n and c o - o p e r a t i v e p l a n n i n g has become a c c e n t u a t e d by t h e g r e a t p r o l i f e r a t i o n o f programs. I n 1955 V o l l a n (256) c o n c l u d e d : There 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 and 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 be engaged 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 one way o r a n o t h e r . T h i s d i v e r s i t y o f s p o n s o r s h i p 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 on t h e p a r t o f t h e p h y s i c i a n who has t o choose 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 . A l t h o u g h c o m p e t i t i o n i n i t s e l f i s n o t h a r m f u l , i n t h i s c a s e 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 , and 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 has i n c r e a s e d t w o - f o l d , and s t u d i e s b o t h 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 r e i t e r a t e t h e c o n - c l u s i o n o f t h e V o l l a n r e p o r t (230) (219) (64). ( 1 1 4 ) . I n 1952, t h e M a s s a c h u s e t t s 43 M e d i c a l 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 and m a l d i s t r i b u t i o n o f c o u r s e s by e s t a b l i s h i n g t h e P o s t g r a d u a t e M e d i c a l I n s t i t u t e , w h i c h s e r v e s as a c e n t r a l c l e a r i n g h o u s e and s i n g l e s o u r c e o f i n f o r m a t i o n p e r t i n e n t t o 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 n M a s s a c h u s e t t s and t h e o t h e r New E n g l a n d s t a t e s ( 2 6 4 ) . 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 s i m i l a r s t a t e w i d e i n f o r m a t i o n s e r v i c e i n 1964. P r e s e n t l y , d a t a p r o j e c t e d t h r e e t o f i v e y e a r s on a l l C a l i f o r n i a and H a w a i i e d u c a t i o n a l a c t i v i t i e s a r e a v a i l a b l e t o program s p o n s o r s . 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 c o u r s e s , t h e 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 an a n n u a l summary o f c o n t i n u i n g e d u c a t i o n f o r t h e S t a t e o f C a l i f o r n i a ( 6 4 ) . W i t h 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 c o - s p o n s o r s h i p p l a n s whereby m e d i c a l s c h o o l s , m e d i c a l s o c i e t i e s , and p u b l i c h e a l t h d e p a r t - 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 e n t i r e s t a t e (207) (252) o r r e g i o n (178) (252) (6) , the, p r o b l e m o f c o - o r d i n a t i o n r e m a i n s u n s o l v e d . R e l a t e d t o t h i s p r o b l e m and c o n t r i b u t i n g t o i t , 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 . The h i s t o r y 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 i s r e p l e t e w i t h i l l u s t r a t i o n s i n w h i c h t h e m a j o r r e s p o n s i b i l i t y f o r c o n t i n u i n g e d u c a t i o n li a s s h i f t e d b a c k and f o r t h between m e d i c a l s o c i e t i e s and m e d i c a l s c h o o l s (45) ( 2 5 6 ) , and more r e c e n t l y , community h o s p i t a l s and RMPS have become i n v o l v e d i n t h e dilemma ( 6 ) . M e d i c a l S c h o o l s : As n o t e d e a r l i e r , m e d i c a l s c h o o l s have been r e s p o n s i b l e f o r o v e r one h a l f o f t h e c o u r s e s o f f e r e d t o p r a c t i c i n g p h y s i c i a n s o v e r t h e p a s t decade. W h i l e t h e number o f s c h o o l s o f f e r i n g s u c h programs has v a r i e d , t h e o v e r a l l t r e n d has been toward i n c r e a s e d p a r t i c i p a t i o n (61) (59) (54) . R e s e a r c h d a t a s u g g e s t t h a t t h i s i n v o l v e m e n t 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 i n d i c a t e t h a t t h e m e d i c a l s c h o o l s have made a m a j o r commitment t o t h e f i e l d 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 . Norwood's s u r v e y i n 1952.(174) o f e i g h t e e n m e d i c a l s c h o o l s r e v e a l e d t h a t w h i l e most o f them r e g a r d e d s t a t e and l o c a l m e d i c a l s o c i e t i e s 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 f o r e d u c a t i o n a l a c t i v i t i e s a d m i n i s t e r e d by t h e m e d i c a l s c h o o l s , t h e i r own i n t e r e s t 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 was o n l y warm. The m a j o r i t y o f e d u c a t o r s and 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 t o f a v o u r t h e u n d e r g r a d u a t e and g r a d u a t e p r o g r a m s , and t o r e g a r d c o n t i n u i n g e d u c a t i o n as an " e x t r a c h o r e . " I n 1963, Ruhe's s t u d y (220) o f e i g h t - s i x A m e r i c a n and t w e l v e C a n a d i a n m e d i c a l s c h o o l s , d i s c l o s e d 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 programs r a t e d "good" by t h e c r i t e r i a o u t l i n e d by 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 . The m a j o r i t y o f program o f f e r i n g s c o n s i s t e d o f i s o l a t e d c o u r s e s u n r e l a t e d t o one a n o t h e r and f r e q u e n t l y l a c k i n g i n s p e c i f i c o b j e c t i v e s . Of t h e A m e r i c a n s c h o o l s , o n l y t h i r t y - s e v e n r a t e 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 as a m a j o r r e s p o n s i b i l i t y , w h i l e o n l y f o u r o f t h e C a n a d i a n s c h o o l s d i d s o . K r y s t a l ' s more r e c e n t s u r v e y (135) o f 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 e d u c a t i o n f o r p s y c h i a t r i s t s f o u n d t h a t w h i l e f o r t y - t w o r e s p o n d i n g m e d i c a l s c h o o l s f e l t t h a t c o n t i n u i n g e d u c a t i o n was t h e r e s p o n s i b i l i t y o f u n i v e r s i t i e s , o n l y n i n e t e e n d e p a r t m e n t s o f p s y c h i a t r y were a c t u a l l y o f f e r i n g c o u r s e s . F i v e were e m p h a t i c i n s t a t i n g t h a t t h i s was t h e r e s p o n s i b i l i t y o f t h e p r o f e s s i o n a l s o c i e t i e s . 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 s c h o o l s c o n t i n u e t o f a l l s h o r t i n f u l f i l l i n g t h e i r l e a d e r s h i p r o l e i n c o n t i n u i n g e d u c a t i o n . E a c h admonishes t h e 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 f o r n o t r e c o g n i z i n g t h e i r r e s p o n - s i b i l i t i e s i n t h e f i e l d (208) (137) (240) (6) (230) (246) . From s u c h w r i t i n g one g e t s t h e i m p r e s s i o n t h a t t h e m e d i c a l s c h o o l s have e x e r t e d v e r y l i t t l e 45 e f f o r t i n d e e d . But t h i s i s m i s l e a d i n g as many m e d i c a l s c h o o l s have been s t e a d i l y i m p r o v i n g t h e i r programs and e s t a b l i s h i n g more e f f e c t i v e a d m i n i - s t r a t i v e a r r a n g e m e n t s f o r programs o f c o n t i n u i n g e d u c a t i o n . I n t h e U n i t e d S t a t e s t h i s t r e n d has been f o s t e r e d by P u b l i c Law 89-239 b u t even w i t h o u t F e d e r a l a i d t h i s i n c r e a s i n g i n v o l v e m e n t o f m e d i c a l s c h o o l s w o u l d c o n t i n u e . I n Canada, a number o f u n i v e r s i t i e s r e p o r t an i n c r e a s i n g t r e n d toward c o - o p e r a t i v e l y s p o n s o r e d p r o grams, more o f t e n i n v o l v i n g m e d i c a l s c h o o l s and h o s p i t a l s o r m e d i c a l s o c i e t i e s (14) ( 8 ) . A l s o r e p o r t e d a r e p l a n s t o implement programs s p o n s o r e d j o i n t l y by m e d i c a l s c h o o l s (11) ( 1 0 ) . S t i l l t o be r e s o l v e d , however, i s t h e q u e s t i o n o f n a t i o n a l c o - o r d i n a t i o n , and p e r h a p s even more i m p o r t a n t , t h e q u e s t i o n o f how much r e s p o n - s i b i l i t y m e d i c a l s c h o o l s s h o u l d and/or can 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 o f p r a c t i s i n g p h y s i c i a n s . P r o b a b l y Hudson (120) summarized b e s t t h e p r e s e n t p o s i t i o n and f u t u r e r o l e o f t h e m e d i c a l s c h o o l s : Many f a c u l t i e s have 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 and 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 committments, t h e r e i s an 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 more 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 models e x i s t b u t an example h e r e and t h e r e i s n o t a dequate 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 must have 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 can be used f o r t h e b e n e f i t o f t h e i r p a t i e n t s . I n f u t u r e , I b e l i e v e 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 assume a m a j o r s h a r e o f r e s p o n s i b i l i t y i n t h e f i e l d 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 . A m a j o r s h a r e i s n o t t h e whole o f 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 by 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 and 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 be an exchange o f f a c t and knowledge f o r wisdom and e x p e r i e n c e . Community 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 and u t i l i z e 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 p r a c t i c e , a g r e a t d e a l o f a t t e n t i o n 46 i s now b e i n g d i r e c t e d toward t h e i r development as t h e m a j o r f o c i 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 (236) (269) (216) . I t has been emphasized t h a t i f t h e r e g u l a r h o s p i t a l s t a f f c o n f e r e n c e s , committee r e v i e w s , c o n s u l t a t i o n s , and o t h e r r o u t i n e day t o day a c t i v i t i e s were e f f e c t i v e l y o r g a n i z e d , t h e s e c o u l d s e r v e as t h e media t h r o u g h w h i c h c o n t i n u i n g e d u c a t i o n c o u l d become a b u i l t - i n component o f m e d i c a l p r a c t i c e ( 1 8 8 ) . Even more i m p o r t a n t l y , t h e r e i s a g r o w i n g consensus t h a t t h e h o s p i t a l s e t t i n g i s t h e one p l a c e where t h e q u a l i t y o f m e d i c a l , c a r e c o u l d be a s s e s s e d i f an o n g o i n g program o f c u r r e n t c a s e m e d i c a l a u d i t were e n f o r c e d (85) (225) ( 1 3 9 ) • On t h e o t h e r hand, p h y s i c i a n s i n p r a c t i c e may now s h a r e t h e s e v i e w s . Werch's s t u d y (264) o f f i v e community h o s p i t a l s r e v e a l e d t h a t w h i l e a l l f i v e u t i l i z e d r e g u l a r c h a r t r e v i e w s , t h e p r i m e o b j e c t i v e was t o meet t h e minimum s t a n d a r d s o f h o s p i t a l a c c r e d i t a t i o n . I n many i n s t a n c e s , t h e r e was a g e n e r a l "hands o f f " p o l i c y , and even g r o s s e r r o r s were o v e r l o o k e d and n o t c r i t i c i z e d c o n s t r u c t i v e l y . T h i s s t u d y 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 o f t e n u s e d s i m p l y as 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 o r s e r v i c e , and r a r e l y was t h e r e an exchange of m e d i c a l v i e w p o i n t s . S i m i l a r l y , Fox and R o b e r t s o n ' s r e v i e w (103) o f e i g h t y - s i x C o n s u l t a n t ' s L e t t e r s f o u n d t h a t o n l y 3 0 p e r c e r t o f 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 i n f o r m a t i o n o r r e i n f o r c e d e x i s t i n g i n f o r m a t i o n w h i c h m i g h t have been o f e d u c a t i o n a l v a l u e t o t h e r e f e r r i n g p h y s i c i a n s . M o r e o v e r , i n n o t one c a s e was a r e f e r e n c e c i t e d . W e n r i c h ' s s t u d y (263) i n one community h o s p i t a l d i s c l o s e d t h a t s i n c e h o s p i t a l b y - l a w s r e q u i r e d a c t i v e p h y s i c i a n s t o p a r t i c i p a t e on r e v i e w 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 c o n f e r e n c e s c o m p u l s o r y , "whatever t h e i r e d u c a t i o n a l v a l u e , t h e y were v i e w e d by p h y s i c i a n s as 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 , d e s i g n e d t o p o l i c e t h e p r a c t i c e o f m e d i c i n e . " 47 W i n r i c h q u o t e s Dr. N. S t e a r n as s a y i n g , " e d u c a t i o n a l a c t i v i t i e s a t t h e l o c a l l e v e l can be s u c c e s s f u l o n l y i f i n d i v i d u a l p h y s i c i a n s see t h e m s e l v e s n o t o n l y as p h y s i c i a n s b u t a l s o as t e a c h e r s , and a r e w i l l i n g t o assume some r e s p o n s i b i l i t y f o r p r e p a r a t i o n , p a r t i c i p a t i o n , and p r e s e n t a t i o n . " The phenomenal growth o f s e p a r a t e h o s p i t a l d e p a r t m e n t s o f m e d i c a l e d u c a t i o n i n r e c e n t y e a r s i s v i e w e d by many a u t h o r s as a s i g n i f i c a n t d e v e l o p - ment w h i c h w i l l f a c i l i t a t e t h i s t r e n d ( 1 0 4 ) . As a r e l a t i v e l y new e d u c a t i o n a l a c t i v i t y , t h e r o l e and f u n c t i o n o f t h e s e a d m i n i s t r a t i v e u n i t s a r e n o t c l e a r l y d e f i n e d and 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 d i r e c t o r s d e v o t e o n l y a few 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 e d u c a t i o n (188) ( 2 5 ) . M o r e o v e r , 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 and more demanding r o l e i s v a r i a b l e , w i t h some even r e s i s t i n g a t t e m p t s by m e d i c a l s c h o o l s t o a s s i s t t h e h o s p i t a l s i n d e v e l o p i n g t h e i r own o n g o i n g programs 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 (14) ( 1 8 8 ) . The 1967 P l a n n i n g 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 t h e 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 (188) recommended: 1. That community h o s p i t a l m e d i c a l s t a f f s be e ncouraged t o o r g a n i z e a committee t o s t u d y t h e p roblems o f c o n t i n u i n g e d u c a t i o n . 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. That t h e CMA s h o u l d communicate w i t h h o s p i t a l s t o i n f o r m them o f e d u c a t i o n a l a s s i s t a n c e t h a t i s a v a i l a b l e . F o r 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. That t h e CMA encourage community h o s p i t a l m e d i c a l s t a f f s and m e d i c a l s c h o o l s t o e n t e r i n t o e x p e r i m e n t a l p r o j e c t s d e s i g n e d 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 t h e C o u n c i l on E d u c a t i o n o f 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 (59) (61) s u g g e s t t h a t some p r o g r e s s has been made i n t h e s e d i r e c t i o n s . As p r e v i o u s l y m e n t i o n e d , RMPS have i n many i n s t a n c e s s e r v e d as a s t i m u l u s i n e n c o u r a g i n g community h o s p i t a l s t o assume a more s i g n i f i c a n t 48 r o l e , and i n t u r n t o se e k a s s i s t a n c e f r o m the m e d i c a l s c h o o l s . Some RMPS a r e t h e m s e l v e s now b e i n g c h a r g e d w i t h d e v e l o p i n g " p a r a l l e l o f f e r i n g s n o t n e c e s s a r i l y comp.lementary t o t h o s e o f u n i v e r s i t i e s and component s o c i e t i e s " (6) . M e d i c a l and S p e c i a l t y S o c i e t i e s : H i s t o r i c a l l y , l o c a l and s t a t e m e d i c a l s o c i e t i e s were t h e p i o n e e r s o f p o s t g r a d u a t e c o u r s e s f o r p h y s i c i a n s ( 1 9 1 ) . A l t h o u g h s t i l l a c t i v e i n t h e 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 . A c c o r d i n g t o t h e C o u n c i l ' s A n n u a l R e p o r t s (54) (59) (61) g e n e r a l m e d i c a l s o c i e t i e s a r e p r e s e n t l y a v e r a g i n g one p e r c e n t o r l e s s o f t h e t o t a l r e p o r t e d p o s t g r a d u a t e h o u r s o f i n s t r u c t i o n . A t t h e same t i m e , n a t i o n a l , s t a t e , and l o c a l m e e t i n g s w i t h an e d u c a t i o n a l component a r e r e p o r t e d on t h e i n c r e a s e (163) , b u t t h e g e n e r a l c o n s e n s u s i s t h a t most m e d i c 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 i t i s r e p o r t e d t h a t t h e b u s i n e s s and s o c i a l f u n c t i o n s f r e q u e n t l y t a k e p r e - cedence ovex e d u c a t i o n a l a c t i v i t i e s (263) ( 2 5 6 ) . A l t h o u g h many m e d i c a l s o c i e t i e s a r e p r e s e n t l y r e - a s s e s s i n g and a t t e m p t - i n g t o improve t h e i r c u r r e n t p r o g rams, o t h e r s a r e q u e s t i o n i n g t h e i r r o l e as p r o d u c e r s o f c o n t i n u i n g e d u c a t i o n ( 6 ) . A t a r e c e n t d i s c u s s i o n , Evans (268) advanced t h i s v i e w : L e a d e r s h i p 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 f r o m 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 good o r b a d , s i m p l y t h a t i t i s h a p p e n i n g . L o c a l g r o u p s t h a t a r e h i g h l y o r g a n i z e d a r e perh a p s 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 have many component b o d i e s c o n c e r n i n g t h e m s e l v e s w i t h e d u c a t i o n , t h u s h a v i n g c o n f u s i n g 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 o f 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 a p p r o a c h , i n c l u d i n g m e d i c a l c o l l e g e s . An a p p l i c a t i o n o f t h i s k i n d o f r o l e i s i l l u s t r a t e d by t h e a c t i v i t i e s o f t h e 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 . I n a d d i t i o n t o c o - o r d i n a t i n g c o u r s e 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 (187) , t h e 49 A s s o c i a t i o n i s c o n d u c t i n g R e g i o n a l M e d i c a l I n s t i t u t e s i n c o o p e r a t i o n w i t h s e v e r a l o f t h e s t a t e ' s m e d i c a l s c h o o l s ( 6 ) . To f u r t h e r a s s i s t t h e m e d i c a l s t a f f s x o f community h o s p i t a l s i n d e v e l o p i n g e f f e c t i v e c o n t i n u i n g e d u c a t i o n p r o g rams, t h e 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 t o 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 G u i d e ( 3 8 ) , and i s o p e r a t i n g a p i l o t p r o j e c t t o examine t h e p o t e n t i a l r o l e o f t h e community h o s p i t a l ( 3 8 ) . I n c o n t r a s t t o g e n e r a l m e d i c a l s o c i e t i e s , s p e c i a l t y s o c i e t i e s a r e w e l l e s t a b l i s h e d as p u r v e y o r s o f c o n t i n u i n g e d u c a t i o n . F o r t h e p a s t s e v e r a l y e a r s t h e y have a v e r a g e d f r o m e l e v e n t o t w e n t y p e r c e n t o f t h e t o t a l r e p o r t e d h o u r s o f i n s t r u c t i o n (52) ( 6 1 ) . W h i l e t h e i r o f f e r i n g s a r e few i n number i n c o m p a r i s o n 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 c o u r s e s a l m o s t e q u a l s t h e a t t e n d a n c e r e p o r t e d a t 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 ( 5 4 ) , s p e c i a l t y m e d i c a l s o c i e t i e s and Academies o f G e n e r a l P r a c t i c e o f f e r e d c o l l e c t i v e l y 467 c o u r s e s w h i c h were a t t e n d e d by 29,590 p h y s i c i a n s a t an a v e r a g e o f 63.36 p e r c o u r s e . I n c o n t r a s t , m e d i c a l s c h o o l s o f f e r e d 1,128 c o u r s e s w i t h an a t t e n d a n c e o f 34,106, a t an a v e r a g e o f 30.26 p e r c o u r s e . D e s p i t e t h i s s e e m i n g l y s u c c e s s f u l p e r f o r m a n c e , s p e c i a l t y m e d i c a l s o c i e t i e s a r e p r e s e n t l y r e c e i v i n g t h e same c r i t i c i s m t h a t i s d i r e c t e d a t m e d i c a l s c h o o l and g e n e r a l m e d i c a l s o c i e t y p rograms. I n s h o r t , i t i s s a i d t h a t t h e i r programs a r e e p i s o d i c , and t h a t t h e r e l e v a n c e o f "one s e t o f p r e s e n t a t i o n s t o o t h e r s , e i t h e r w i t h i n t h e m e e t i n g s t h e m s e l v e s o r r e l a t i v e t o o t h e r m e e t i n g s , o f t e n i s s t r i k i n g l y l a c k i n g " ( 2 3 0 ) . M i l l e r (159) adds s t i l l a n o t h e r d i m e n s i o n t o t h e p r o b l e m when he w r i t e s : The i n c r e d i b l e s u c c e s s o f modern 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 m e d i c i n e i s c h a n g i n g t h e b a s i c n a t u r e o f 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 o f 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 "Recent A d v a n c e s . . . " 50 i n d e a l i n g w i t h t h e s e p r o b l e m s 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 f r o m t h e p u r e l y b i o l o g i c d i s c i p l i n e s ; 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 by 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 programs o f f e r e d t o them. I t w i l l r e q u i r e t h e 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 t h e c o n t e m p o r a r y s o c i a l f a b r i c i n t o t h e 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 has 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 p r o b l e m s . . . PROGRAM PLANNING AND ADMINISTRATION The 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 and a d m i n i s t r a t i o n i s l i m i t e d t o t h e m e d i c a l s c h o o l s , c o n s e q u e n t l y , t h i s s e c t i o n i s c o n f i n e d t o arr a n g e m e n t s w i t h i n s c h o o l s o f m e d i c i n e . A d m i n i s t r a t i v e A r r a n g e m e n t s : I n a l l a r t i c l e s 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 recommendation i s made t h a t t h e r e s h o u l d be a c l e a r l y d e f i n e d d epartment o r d i v i s i o n w i t h a f u l l t i m e 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 program (207) ( 3 8 ) . T h i s i d e a l has been a c h i e v e d i n b u t a few m e d i c a l s c h o o l s t o d a y . I n 1963, Ruhe (220) fo u n d t h a t w h i l e 54 A m e r i c a n , and 6 C a n a d i a n s c h o o l s r e p o r t e d h a v i n g a d e p a r t m e n t , s e c t i o n , d i v i s i o n , o r s t a n d i n g committee f o r t h e p l a n n i n g and i m p l e m e n t 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 , o n l y 5 A m e r i c a n , and 1 C a n a d i a n 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 d e p a r t m e n t i d e n t i f i e d i n t h e D i r e c t o r y o f t h e A s s o c i a t i o n o f A m e r i c a n M e d i c a l C o l l e g e s . M o r e o v e r , w h i l e 57 A m e r i c a n and 7 C a n a d i a n s c h o o l s r e p o r t e d a p a r t - t i m e p e r s o n r e s p o n s i b l e f o r c o n t i n u i n g e d u c a t i o n , i n . o n l y 3 A m e r i c a n and i n no C a n a d i a n s c h o o l was t h e r e a f u l l - t i m e d i r e c t o r o r head. As l a t e as 1967, S u l l i v a n (241) n o t e d t h a t o f t h e 65 m e d i c a l s c h o o l s o f f e r i n g c o u r s e s i n t h e A n n u a l L i s t i n g , 20 p e r c e n t had a l i s t e d d epartment o r d i v i s i o n 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 . 51 R e p o r t i n g 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 S t a t e s , 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 ma j o r p r o b l e m s f a c i n g t h e a c c r e d i t a t i o n c o m m i t t e e . I t has been found t h a t i n many i n s t i t u t i o n s programs a r e d e v e l o p i n g w i t h i n s c h o o l s o r h o s p i t a l s w i t h l i t t l e c o - o p e r a t i o n among d e p a r t m e n t s . 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 some i n s t i t u t i o n s t h e r e s p o n s i b i l i t y f o r t h e development o f e d u c a t i o n a l programs i s l e f t t o i n d i v i d u a l s o r groups r a t h e r t h a n p l a n n e d on a d e p a r t m e n t a l b a s i s . As a r e s u l t , e d u c a t i o n a l o f f e r i n g s a r e s a i d t o r a n g e f r o m e x c e l l e n t t o p o o r . I n Canada, a 1968 s u r v e y (241) o f m e d i c a l s c h o o l s d i s c l o s e d t h a t w h i l e t w e l v e o f t h e f o u r t e e n r e s p o n d i n g s c h o o l s had an e s t a b l i s h e d d e p a r t m e n t , d i v i s i o n , 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 , o n l y one had a f u l l - t i m e p e r s o n i n c h a r g e . The r e m a i n i n g s c h o o l s r e p o r t e d p e r s o n s assuming t h i s r e s p o n s i b i l i t y on a p a r t - t i m e b a s i s , r a n g i n g f r o m one q u a r t e r t o t h r e e q u a r t e r t i m e . On t h e o t h e r hand, a l l f o u r t e e n r e s p o n d i n g u n i v e r s i t i e s i n d i c a t e d t h a t t h e p o s t g r a d u a t e d i v i s i o n o r s e c t i o n assumed m a j o r r e s p o n s i b i l i t y f o r t h e s e l e c t i o n and a r r a n g i n g o f c o u r s e c o n t e n t under t h e d i r e c t i o n o f an a p p o i n t e d c h a i r m a n . I n s t r u c t o r s : C o u r s e s s p o n s o r e d by m e d i c a l s c h o o l s a r e t a u g h t l a r g e l y by members o f t h e r e g u l a r f a c u l t y o r by g u e s t l e c t u r e r s from o t h e r m e d i c a l c e n t e r s . Non-academic p h y s i c i a n s o r n o n - m e d i c a l p e r s o n n e l a r e u t i l i z e d f a r l e s s f r e q u e n t l y (45)) (220) (241) . A v i e w g a i n i n g s t r e n g t h i s t h a t p r a c t i s i n g p h y s i c i a n s s h o u l d be encouraged t o p a r t i c i p a t e i n t e a c h i n g , t h e r e b y i n v o l v i n g them i n t h e i r own c o n t i n u i n g e d u c a t i o n and a t t h e same ti m e a l l e v i a t i n g some o f t h e e x c e s s i v e demands made on t h e m e d i c a l s c h o o l f a c u l t y . The 52 e v o l v i n g r o l e o f t h e t e a c h e r as c o n s u l t a n t i n r e g i o n a l programs (208) p r o b a b l y i l l u s t r a t e s b e s t the s u c c e s s f u l i m p l e m e n t a t i o n o f t h i s a p p r o a c h . The p i l o t p r o j e c t r e p o r t e d by t h e T u f t s New E n g l a n d M e d i c a l C e n t e r (210) u t i l i z e s r e s i d e n t s as t e a c h i n g c o n s u l t a n t s i n s e v e r a l o f t h e s m a l l community h o s p i t a l s i n Maine w h i c h i s a n o t h e r i n n o v a t i v e and p r o m i s i n g program model. D e s p i t e t h e t r e n d toward g r e a t e r u t i l i z a t i o n o f c l i n i c i a n s as t e a c h e r s , w i t h t h e e x c e p t i o n o f p s y c h i a t r y t e a c h e r t r a i n i n g programs a r e s t i l l s p a r s e . I n p s y c h i a t r y , s h o r t t r a i n i n g c o u r s e s f o r program d i r e c t o r s and t e a c h e r s have been u n d e r t a k e n by a v a r i e t y o f groups i n c l u d i n g : WICHE; t h e 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 I n s t i t u t e o f M e n t a l H e a l t h ' s C o n t i n u i n g 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 ; and o t h e r s . I n a r e c e n t e d i t o r i a l S t r a t o s (238) r e p o r t s t h a t t h e P s y c h i a t r y and M e d i c a l P r a c t i c e Committee and t h e P h y s i c i a n E d u c a t i o n P r o j e c t o f t h e 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 p l a n t o expand c o n s u l t a t i o n s e r v i c e s and i n t e n s i v e t e a c h e r t r a i n i n g s e s s i o n s f o r t h o s e i n v o l v e d i n t e a c h i n g p s y c h i a t r y t o n o n - s p y c h i a t r i s t s . From t h e g e n e r a l f i e l d , a r e c e n t p r o p o s a l by McMaster U n i v e r s i t y p l a n s t o p r o v i d e a v i s i t i n g t e a c h e r program i n w h i c h b o t h p r a c t i - t i o n e r s and c o n s u l t a n t f r o m t h e r e g i o n w i l l work i n t h e McMaster c l i n i c a l t e a c h i n g u n i t s t o u p d a t e t h e i r c l i n i c a l s k i l l s ( 1 1 ) . A l t h o u g h t h e r e i s a g r o w i n g i n t e r e s t i n t h e need t o improve t h e q u a l i t y o f i n s t r u c t i o n i n t h e u n d e r g r a d u a t e m e d i c a l t r a i n i n g program, t h i s has n o t ex t e n d e d g e n e r a l l y i n t o c o n t i n u i n g e d u c a t i o n . The g e n e r a l f e e l i n g t h a t p r o f i c i e n c y i n m e d i c i n e i s t h e 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 p e r s i s t s w i t h o u t r e g a r d t o t e a c h i n g a b i l i t y o r t o t h e amount o f l e a r n i n g a c h i e v e d by p a r t i c i p a n t s . Some moves a r e underway t o improve t h e q u a l i t y o f i n s t r u c t i o n by p r o v i d i n g c l i n i c i a n s w i t h t r a i n i n g f o r t h e i n s t r u c t i o n a l r o l e . 53 F i n a n c e s : • F i n a n c i a l s u p p o r t f o r c o n t i n u i n g e d u c a t i o n v a r i e s w i d e l y f r o m s c h o o l t o s c h o o l ( 2 2 0 ) . I n g e n e r a l , t h e m a j o r s o u r c e s o f revenue a r e t u i t i o n f e e s , some government h e a l t h g r a n t s , and d o n a t i o n s (8) (274) (135) ( 1 4 ) . The p e r c e n t a g e o f t h e m e d i c a l s c h o o l budget d e v o t e d t o c o n t i n u i n g e d u c a t i o n i s a l m o s t n e g l i g i b l e . N e v e r t h e l e s s , s i n c e most s c h o o l s do p r o v i d e f a c i l i t i e s as w e l l as f a c u l t y t i m e , t h e i r c o n t r i b u t i o n i s n o t i n s i g n i f i c a n t ( 4 5 ) . Some m e d i c a l s c h o o l s a t t a c h e d t o s t a t e u n i v e r s i t i e s r e c e i v e a d d i t i o n a l f u n d s f r o m t h e l e g i s l a t u r e and s t a t e h e a l t h d e p a r t m e n t s . O t h e r s s u p p o r t t h e i r programs t h r o u g h 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 e d u c a t i o n a l programs f o r r e s i d e n t s t a f f ; some c o n t i n u i n g e d u c a t i o n programs a r e f i n a n c e d by f e e s c h a r g e d f o r i n d i v i d u a l programs o r c o n s u l t a t i o n s e r v i c e s t o o t h e r i n s t i t u t i o n s ( 9 ) ; s t i l l o t h e r programs a r e managing t o b r e a k even' o r t o o p e r a t e a t a modest p r o f i t a l m o s t s o l e l y on t u i t i o n and t h e c o n t r i b u t e d s e r v i c e s of t h e r e g u l a r f a c u l t y (45) (9) ( 5 5 ) . Most i n s t i t u t i o n s seek d o n a t i o n s and g r a n t s f o r s p e c i a l p r o j e c t s . P r o f e s s i o n a l a s s o c i a t i o n s , v o l u n t a r y h e a l t h a g e n c i e s , f e d e r a l t r a i n i n g g r a n t s , p h a r m a c e u t i c a l f i r m s , and p h i l a n t h r o p i c s o c i e t i e s i n c l u d i n g t h e K e l l o g g F o u n d a t i o n , a l l c o n t r i b u t e s i g n i f i c a n t l y t o 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 (8) (45) (12) (55) (207) . More r e c e n t l y , p a r t i c u l a r l y i n t h e U n i t e d S t a t e s , t h e f e d e r a l g o v e r n - ment has p r o v i d e d g r e a t e r f i n a n c i a l a s s i s t a n c 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 . C h i l d s n o t e d t h a t p r o j e c t s s u p p o r t e d by government have p r o v e n e f f e c t i v e i n a c c e l e r a t i n g 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 m e d i c a l e d u c a t i o n ( 4 4 ) . P u b l i c i t y and P r o m o t i o n : I n t h e U n i t e d S t a t e s , s p o n s o r i n g i n s t i t u t i o n s may p u b l i c i z e t h e i r 54 c o u r s e o f f e r i n g s t h r o u g h t h e " A n n u a l Course L i s t i n g " p u b l i s h e d each y e a r i n t h e e a r l y August i s s u e o f t h e J o u r n a l of 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 . I n a d d i t i o n , m e d i c a l j o u r n a l s i n b o t h Canada and t h e U n i t e d S t a t e s p u b l i c i z e s e l e c t e d c o u r s e o f f e r i n g s . O t h e r t r a d i t i o n a l methods o f a d v e r t i s i n g programs 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 p e r s o n a l announcements ( 2 4 1 ) . A number o f s t a t e m e d i c a l s o c i e t i e s (6) (64) r e p o r t t h e use o f a s p e c i a 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 b u l l e t i n . One s u c h , w h i c h i s m a i l e d t o p h y s i c i a n s and h o s p i t a l s i n t h e New E n g l a n d S t a t e s , announces a l l f o r m a l programs o f f e r e d i n New E n g l a n d i n c l u d i n g e s s e n t i a l i n f o r m a t i o n as t o t h e i r t i m e , p l a c e , and t u i t i o n ( 2 4 8 ) . I n Canada, t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a (8) p u b l i s h e s an a n n u a l l i s t i n g o f c o u r s e s o f f e r e d by t h e D i v i s i o n o f C o n t i n u i n g E d u c a t i o n i n t h e H e a l t h S c i e n c e s . T h i s i s m a i l e d t o a l l p h y s i c i a n s i n t h e p r o v i n c e t o a s s i s t p r a c t i t i o n e r s i n p l a n n i n g t h e i r p e r s o n a l programs o f c o n t i n u i n g e d u c a t i o n w e l l i n advance. Because t h e s e p u b l i c a t i o n s a r e o f t e n o v e r l o o k e d by p h y s i c i a n s , some c o u r s e s p o n s o r s a r e u s i n g r e i n f o r c e m e n t t h r o u g h p e r s o n a l v i s i t s t o p h y s i c i a n s (222) (269) and newspaper, t e l e v i s i o n , o r r a d i o announcements (11) ( 2 6 9 ) . Programming: I n s p i t e o f a l l t h e s e e f f o r t s t o promote 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 e p r o b l e m o f r e l e v a n c e i s t h o u g h t t o l i m i t t h e e f f e c t i v e n e s s o f most programs o f f e r e d (84) ( 1 7 3 ) . Those e x p r e s s i n g t h i s v i e w s u g g e s t t h a t programs i g n o r e t h e i n t e r e s t s and e x p r e s s e d needs o f p r a c t i s i n g p h y s i c i a n s . R e p o r t s f r o m m e d i c a l s c h o o l s s u g g e s t t h a t many use q u e s t i o n n a i r e s e x t e n s i v e l y t o t e s t t h e market f o r c o n t i n u i n g e d u c a t i o n (220) ( 2 4 1 ) . I n d e e d , as e a r l y as 1952, Norwood (174) f o u n d t h a t i t was a common p r a c t i c e f o r m e d i c a l s c h o o l s 55 t o send o u t r e q u e s t forms on w h i c h p h y s i c i a n s c o u l d n o t e t h e i r s u g g e s t i o n s f o r c o u r s e s . Many programs a r e n o t d e s i g n e d w i t h c l e a r l y d e f i n e d o b j e c t i v e s and, as M i l l e r i n d i c a t e s , i n t h e p r o c e s s o f i m p l e m e n t a t i o n p h y s i c i a n s ' "wants" may become c o n f u s e d w i t h o r s u b o r d i n a t e t o what the programmers "want o r t h i n k t h e p r a c t i t i o n e r s n eed." M o r e o v e r , " u n l e s s t h e t e a c h e r i s c a r e f u l t o d e t e r m i n e where h i s s t u d e n t s a r e i n t h e i r l e a r n i n g . . . a n d r e q u i r e s them t o e x h i b i t some u n d e r s t a n d i n g o f each s t e p b e f o r e p r o c e e d i n g on t o t h e n e x t , a program o f g r e a t e s t r e l e v a n c e may end as a c o l l e c t i o n o f nonsense s y l l a b l e s w i t h c a r e f u l l y c o n c e a l e d i r r i t a t i o n and d i s a p p o i n t m e n t on b o t h s i d e s " ( 1 5 9 ) . Sodeman (230) has s t r e s s e d t h a t t h e i d e a l program i s "an i n d i v i d u a l one b u i l t t o s u i t t h e s p e c i f i c r e q u i r e m e n t s o f each p h y s i c i a n , and p e r h a p s a few more l i k e h i m . " The o b v i o u s i m p l i c a t i o n o f t h i s p r i n c i p l e i s t h a t t h e programs most l i k e l y t o s u c c e e d a r e t h o s e w h i c h i n v o l v e t h e l e a r n e r i n t h e p l a n n i n g p r o c e s s . That p r e s e n t 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 a d m i n i - s t r a t i v e p a t t e r n s a r e u n a b l e t o meet t h i s r e q u i r e d i s i m p l i e d i n t h e many c r i t i q u e s on 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 (104) (225) (246) ( 2 1 9 ) . 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 a t t e m p t e d t o i n v o l v e t h e consumer i n p l a n n 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 n m e d i c i n e . MacLeod (144) 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 s e l f - a d m i n i s t e r e d c o u r s e on i n t e r n a l ' m e d i c i n e a t t h e Yale-New Haven M e d i c a l C e n t e r . A l t h o u g h i n i t i a t e d as an a n n u a l r e v i e w f o r i n t e r n i s t s p r e p a r i n g f o r b o a r d e x a m i n a t i o n s , t h i s program has e v o l v e d o v e r t h e y e a r s i n t o an o n g o i n g c o m p r e h e n s i v e r e v i e w o f t h e whole f i e l d . W h i l e t h e main c r i t e r i o n o f " s u c c e s s " has been measured l a r g e l y i n terms o f i n c r e a s e d e n r o l l m e n t ( f r o m 26 t o 60 p h y s i c i a n s o v e r f o u r y e a r s ) , i n t h e words of MacLeod: 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 a p p e a r s t o have been a f u n c t i o n o f t h e r e l e v a n c y o f 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 to t h e c h a n g i n g needs o f t h e g r o u p . The p r i n c i p l e s of 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 a d m i n i - s 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 , s e r v e d as t h e 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 t h e c o u r s e . These p r i n c i p l e s a r e i m p o r t a n t c o n s i d e r a t i o n s f o r o t h e r s d e s i r i n g t o s e t up s u c h a c o u r s e and m e r i t emphasis 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 o f i n s t i t u t i o n s p r o v i d i n g p o s t g r a d u a t e c o u r s e s . A n o t h e r e x p e r i m e n t a l p r o j e c t w h i c h p o i n t s o u t t h e need t o c o n s i d e r 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 a r r a n g e m e n t s f o r programming, i s t h a t r e p o r t e d by T o r r e n s (246) o f S t . L u k e ' s H o s p i t a l i n New Y o r k C i t y . I n t h i s p r o j e c t , a s p e c i a l l y c r e a t e d h o s p i t a l d epartment c a l l e d The Community P h y s i c i a n R e l a t i o n s O f f i c e was e s t a b l i s h e d i n o r d e r t o a s s i s t n o n - a f f i l i a t e d g e n e r a l p r a c t i t i o n e r s w i t h p a t i e n t r e f e r r a l p r o b l e m s and c o n c u r r e n t l y t o o f f e r c o n t i n u i n g e d u c a t i o n programs s p e c i f i c a l l y d e s i g n e d t o meet t h e day t o day p r o b l e m s e n c o u n t e r e d by p h y s i c i a n s i n t h e i r l o c a l p r a c t i c e . I n i t i a t e d t o o f f s e t t h e i n c r e a s i n g i s o l a t i o n o f g e n e r a l p r a c t i t i o n e r s f r o m t h e s p e c i a l i s t o r i e n t e d t e a c h i n g and r e s e a r c h h o s p i t a l s , t h i s program has r e s u l t e d i n i n c r e a s e d u t i l i z a t i o n o f t h e h o s p i t a l ' s r e f e r r a l s e r v i c e s as w e l l as t h e t e a c h i n g c o n f e r e n c e s and g rand rounds w h i c h p r e v i o u s l y t h e g e n e r a l p r a c t i - t i o n e r s had i g n o r e d as " o f l i t t l e u s e t o them i n t h e i r p r a c t i c e s . " T o r r e n s recommends t h a t " o t h e r t e a c h i n g h o s p i t a l s e s t a b l i s h a s i m i l a r o f f i c e o r d e partment t o s e r v e as a s i n g l e p l a c e t o w h i c h t h e community p h y s i c i a n knows he c a n t u r n f o r a s s i s t a n c e w i t h p r o b l e m s o f p a t i e n t s i n h i s p r a c t i c e , and from w h i c h he can o b t a i n i n f o r m a t i o n about p a t i e n t s he has r e f e r r e d t o t h e t e a c h i n g h o s p i t a l ^ f o r c a r e . " Webster (262) d e s c r i b e s a program i n N o r t h C a r o l i n a i n w h i c h a c i r c u i t 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 t o a l l p h y s i c i a n s i n f i v e c o u n t i e s and was a v a i l a b l e a t any t i m e p h y s i c i a n s w i s h e d t o c o n s u l t him about c a s e s . 57 D u r i n g t h e f i r s t 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 i n o p e r a t i o n , t h e number o f a d m i s s i o n s t o t h e s t a t e m e n t a l h o s p i t a l from t h i s f i v e c o u n t y a r e a d e c r e a s e d whereas a d m i s s i o n s f r o m o t h e r c o u n t i e s i n c r e a s e d . The program i s b e i n g expanded t h r o u g h o u t t h e s t a t e as an a d j u n c t t o community m e n t a l h e a l t h s e r v i c e s . The p r e c e p t o r s h i p p r o j e c t s p o n s o r e d by t h e W a s h i n g t o n / A l a s k a RMP i s s t i l l a n o t h e r example o f a program s p e c i f i c a l l y d e s i g n e d t o meet t h e l e a r n i n g needs of t h e i n d i v i d u a l p h y s i c i a n . The p h y s i c i a n r e q u e s t i n g a p r e c e p t o r s h i p i s a s k e d t o o u t l i n e what he w i s h e s t o l e a r n and t o i n d i c a t e w hether he w i s h e s a s t r u c t u r e d program o r one w i t h f r e e s t u d y and c o n f e r e n c e s . The p l a n n e r t h e n u s e s t h i s i n f o r m a t i o n t o d e s i g n a program o f s t u d i e s f o r t h e p h y s i c i a n . The e v a l u a t i o n o f t h e program i s b a s e d on t h e o b j e c t i v e s s t a t e d o r i g i n a l l y by t h e p h y s i c i a n on h i s a p p l i c a t i o n f o r m . To d a t e , 92 p e r c e n t o f t h e p h y s i c i a n s who have p a r t i c i p a t e d i n t h e program a r e r e p o r t e d t o have s a t i s f i e d a t l e a s t t h r e e - f o u r t h s o f t h e i r e d u c a t i o n a l o b j e c t i v e s . A l t h o u g h no s t a t i s t i c a l e v i d e n c e was o f f e r e d t o show impro v e d p a t i e n t c a r e as a r e s u l t o f t h e program, D a v i d s o n e_t a l _ (71) n o t e d t h a t " I n t h i s t y p e o f program, t h e p h y s i c i a n i s a b l e t o s a t i s f y h i s own e d u c a t i o n a l needs w h i c h makes h i s e x p e r i e n c e r e l e v a n t t o h i s p r a c t i c e . " Under t h e a u s p i c e s o f t h e Oregon RMP, Meighan and Burg (152) a r e i n v e s t i g a t i n g t h e e f f e c t i v e n e s s o f an e x p e r i m e n t a l p r o j e c t ' i n w h i c h h e a l t h p r o f e s s i o n a l s , i n two Oregon c o m m u n i t i e s a r e g i v e n an o p p o r t u n i t y t o d e v e l o p t h e i r own e d u c a t i o n a l programs on t h e c a r e o f t h e s t r o k e p a t i e n t . T h i s i s b a s e d on M i l l e r ' s " p r o c e s s " model w h i c h assumes t h a t b e f o r e a d u l t s l e a r n t h e y must r e c o g n i z e t h e i r need t o know, and t h a t t h i s i s b e s t a c c o m p l i s h e d by i n v o l v i n g them i n i d e n t i f y i n g p roblems and s e e k i n g s o l u t i o n s . T o 58 implement t h i s , " s t r o k e s t u d y groups"were f o r m e d , membership o f w h i c h was i n t e r d i s c i p l i n a r y r e p r e s e n t i n g a l l h e a l t h c a r e p r o f e s s i o n a l s a v a i l a b l e i n t h e c o m m u n i t i e s . T h e i r t a s k was t o " i d e n t i f y e x i s t i n g b a r r i e r s t o t h e d e l i v e r y o f o p t i m a l s t r o k e c a r e and t h e n t o d e s i g n e d u c a t i o n a l programs t o surmount them...The p r o j e c t s t a f f p a r t i c i p a t e d as f a c i l i t a t o r s e n a b l i n g t h e groups t o work t o g e t h e r i n i d e n t i f y i n g l o c a l e d u c a t i o n a l needs o r i n p l a n n i n g p r o g r a m s . . . " To d a t e , two g r o u p s have p l a n n e d community programs 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 a p p r o a c h e s . One o f t h e s e g r o u p s has s u b m i t t e d a p r o p o s a l f o r a g r a n t t o c o n t i n u e t h e program i n d e p e n d e n t l y when t h e e x p e r i m e n t a l p r o j e c t ends. Meighan and Burg q u e s t i o n "whether s u c h a group can f u n c t i o n w i t h o u t a d m i n i s t r a t i v e a s s i s t a n c e f r o m o u t s i d e t h e community..." CURRENT AND RECURRING ISSUES AND TRENDS D e s p i t e t h e many u n r e s o l v e d i s s u e s and o p e r a t i o n a l p r o b l e m s , 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 t h r i v i n g . C o n c u r r e n t l y , a number o f d e v e l o p - ments a r e o c c u r r i n g w h i c h can be e x p e c t e d t o i n f l u e n c e f u t u r e t r e n d s b u t t h e r e a r e s t i l l 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 . A c c r e d i t a t i o n : S i n c e t h e p u b l i c a t i o n o f t h e o r i g i n a l " G u i d e " i n 1957, 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 has been w o r k i n g on a v o l u n t a r y s y s t e m t o a c c r e d i t i n s t i t u t i o n s s p o n s o r 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 i i 1961, i t 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 a p p o i n t e d an a d v i s o r y c o m m i t t e e , and under i t s d i r e c t i o n a number o f s i t e s u r v e y s were c o n d u c t e d t o d e t e r m i n e t h e f e a s i b i l i t y o f s u c h a p l a n ( 2 1 9 ) . As a r e s u l t o f t h e s t u d y , an a c c e p t a b l e program o f a c c r e d i t a t i o n was p r o p o s e d and a p p r o v e d by t h e A s s o c i a t i o n ' s House o f 59 D e l e g a t e s . I n 1967, f o r m a l a c c r e d i t a t i o n was i n i t i a t e d ( 8 1 ) . By September 1970, 86 i n s t i t u t i o n s 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 e A n n u a l Course L i s t i n g . U l t i m a t e l y , o n l y a c c r e d i t e d c o u r s e s w i l l be i n c l u d e d i n t h i s A n n u a l L i s t . I n t h i s way i t i s hoped t h a t programs o f i n f e r i o r q u a l i t y w i l l e i t h e r be im 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 o r d i s c o n t i n u e d 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 them ( 6 1 ) . The " G u i d e " p r o v i d e s t h e c r i t e r i a used „by t h e s u r v e y teams r e s p o n s i b l e f o r a c c r e d i t i n g programs ( 6 5 ) . 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 has ad o p t e d t h i s " G u i d e " as t h e s t a t e m e n t o f b a s i c p r i n c i p l e s f o r i t s p r o p o s e d a c c r e d i - t a t i o n o f programs ( 1 8 7 ) . B r i e f l y s t a t e d , t h e s e c r i t e r i a (65) a r e : There s h o u l d be 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 s u p p o r t o f t h e p r o f e s s i o n a l s t a f f o f t h e 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 . The BUDGET s h o u l d be adequate t o t h e e d u c a t i o n a l program u n d e r t a k e n t o 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 t e n d s t o r e s t r i c t u n d u l y t h e q u a l i t y o f c o n t i n u i n g e d u c a t i o n programs. 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 and t h e i r a s s o c i a t e s 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 . • The CURRICULUM o f any 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 program 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 one 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 ba c k g r o u n d and advances i n one s u b j e c t i s emph a s i z e d . There s h o u l d be a v a i l a b l e F A C I L I T I E S t h a t e n courage p a r t i c i p a t i v e methods o f e d u c a t i o n . 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 o r p a n e l d i s c u s s i o n s i n w h i c h t h e p h y s i c i a n s a r e p r i m a r i l y p a s s i v e r e c i p i e n t s . 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 s t u d e n t i n v o l v e m e n t . 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 as p a r t o f each program. 1. 2. 3. 4. 5. 6. 7. 60 8. Each PHYSICIAN'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 and the 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 a d v e n t u r e . W h i l e i t i s t o o e a r l y t o p r e d i c t t h e l o n g term e f f e c t s o f t h i s a c c r e d i t a t i o n p r ogram, 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 r e g u l a t o r y mechanism 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 f o r t h e development of t h e f i e l d ( 6 1 ) . N a t i o n a l P l a n s : D a r l e y and C a i n (70) p r o p o s e d i n 1961 t h e e s t a b l i s h m e n t - o f a N a t i o n a l Academy w h i c h w o u l d c e n t r a l i z e t h e n a t i o n ' s e d u c a t i o n a l r e s o u r c e s f o r 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 e r e b y h e l p i n g t o c o - o r d i n a t e and f u r t h e r i t s development. Subsequent t o t h i s , t h e m a j o r 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 J o i n t S t u d y Committee t o c o n s i d e r t h e development o f s u c h an Academy. The c o m m i t t e e ' s r e p o r t , w r i t t e n by D r y e r (79) p r o p o s e d t h e c r e a t i o n o f an 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 w o u l d d e v e l o p 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 t h e needs o f t h e n a t i o n ' s p h y s i c i a n s . " 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 programs would be 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 , and p h y s i c i a n s would be a b l e t o choose 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 n d i v i d u a l n e e d s . Among i t s many f a r s i g h t e d recommendations, t h e r e p o r t emphasized t h a t . . . " a p a r t n e r - s h i p o f o u r m a j o r m e d i c a l r e s o u r c e s w i l l g i v e s t r e n g t h t o a l l w h i c h none p o s s e s s s e p a r a t e l y , and t h a t s u c h an e f f i c i e n t b a l a n c e can be o r g a n i z e d t o a r t i c u l a t e 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 , and l o c a l p l a n s . " F o l l o w i n g t h e p u b l i c a t i o n o f t h i s r e p o r t , 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 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 under t h e l e a d e r s h i p o f S t o r e y ( 2 3 7 ) , an 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 ' needs was begun i n a p i l o t p r o j e c t i n U t a h . I n 1966, t h i s p r o j e c t was d i s c o n t i n u e d because i t was f e l t t h a t l o c a l and 61 r e g i o n a l c o n d i t i o n s were n o t r e a d y f o r s u c h 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 and c r e a t i v e i d e a s i n h e r e n t i n t h e s e r e p o r t s a r e germane. The I n t e r u n i v e r s i t y Communications C o u n c i l founded by D a r l e y and a s m a l l group 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 1965 was a p r o d u c t o f h i s o r i g i n a l p l a n f o r t h e e s t a b l i s h m e n t o f a N a t i o n a l Academy ( 1 6 3 ) . S i m i l a r l y , Dimond's p r o p o s a l f o r t h e c r e a t i o n o f a N a t i o n a l G r a d u a t e M e d i c a l C e n t e r w o u l d have t h i s C e n t e r s e r v e as t h e base f o r D r y e r ' s " u n i v e r s i t y w i t h o u t w a l l s " ( 7 3 ) . The most r e c e n t p r o p o s a l was t h a t o u t l i n e d by Bloom (6) and c a l l e d t h e AMA P l a n . 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 way, t h e AMA would expand i t s p r e s e n t programs t o appro v e e x i s t i n g o f f e r i n g s and 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 s t a t e s o c i e t i e s . 3. What i s needed 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 as 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 needs and e v a l u a t i n g p e r f o r m a n c e , and as 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 c o n t i n u i n g e d u c a t i o n . 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 and 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 c o n t i n u i n g e d u c a t i o n . 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; each composed o f AMA, u n i v e r s i t y and RMP e l e m e n t s ( p l u s any o t h e r p e r t i n e n t r e p r e s e n t a t i o n ) . T h i s s e c t o r would g u i d e o p e r a t i o n s o f a t o t a l s y s t e m f r o m 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 f e e d b a c k . The e x i s t e n c e o f t h i s d e v i c e would 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 where 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 and m u l t i p l e o t h e r f o r c e s p r o c e e d u n i l a t e r a l l y 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 . I n c e n t i v e s f o r L e a r n i n g : 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 m e d i c i n e f o r e c a s t 62 t h a t t h e p r o b l e m o f 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 w i l l 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 r e l i c e n s u r e . I n t h e absence o f v a l i d c r i t e r i a f o r m e a s u r i n g " p r o f e s s i o n a l competence," t h e m e d i c a l p r o f e s s i o n r e m a i n s d i v i d e d on t h i s i s s u e . An ad hoc committee o f t h e AMA's Committee on E d u c a t i o n (195) p r o p o s e d r e c e n t l y t h a t r e g u l a 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 s h o u l d be t h e c o n d i t i o n f o r r e l i c e n s u r e , b u t t h e o n l y c o n c r e t e a c t i o n t h e AMA has t a k e n i n t h i s r e s p e c t i s t o o f f e r a ' R e c o g n i t i o n Award' t o p h y s i c i a n s p a r t i c i p a t i n g 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 . F o r t h o s e p h y s i c i a n s w i s h i n g t o q u a l i f y , " t h e r e q u i r e m e n t s a r e 150 c r e d i t h o u r s o f c o n t i n u i n g e d u c a t i o n i n a p e r i o d o f t h r e e y e a r s , 60 h o u r s o r more made up o f r e q u i r e d e d u c a t i o n a l a c t i v i t i e s and t h e r e m a i n i n g 90 h o u r s , i n e l e c t i v e s " ( 1 8 4 ) . A c c o r d i n g t o most a c c o u n t s , p h y s i c i a n s have r e s p o n d e d w e l l t o t h i s v o l u n t a r y a c c r e d i t i n g scheme and a t t h e c o m p l e t i o n o f i t s f i r s t y e a r , more t h a n 14,000 p h y s i c i a n s a r e r e p o r t e d t o have q u a l i f i e d f o r t h e award ( 6 1 ) . 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 i s i s s u i n g a s i m i l a r award o f a " C e r t i f i c a t e 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 " b u t has e x t e n d e d t h e scheme t o c o v e r a w i d e r r a n g e o f i n f o r m a l e d u c a t i o n a l a c t i v i t i e s . Upon r e c e i v i n g t h i s C e r t i f i c a t e , p h y s i c i a n s a u t o m a t i c a l l y q u a l i f y f o r t h e AMA P h y s i c i a n ' s Recog- n i t i o n Award ( 1 2 8 ) . S i n c e i t s i n c e p t i o n , t h e Academy o f G e n e r a l P r a c t i c e has r e q u i r e d 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 as a c o n d i t i o n f o r membership, and r e c e n t l y t h e Oregon S t a t e M e d i c a l S o c i e t y f o l l o w e d t h i s l e a d by making r e g u l a 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 c o n d i t i o n f o r member- s h i p ( 1 8 2 ) . There i s some c o n c e r n b e i n g e x p r e s s e d as t o how much e f f e c t t h i s l o s s o f s t a t e m e d i c a l s o c i e t y membership w o u l d have on t h e c h r o n i c a l l y n o n - p a r t i c i p a t i n g p h y s i c i a n . Many f e e l t h a t s u c h p h y s i c i a n s a r e b e t t e r "under t h e u m b r e l l a o f o r g a n i z e d m e d i c i n e t h a n o u t s i d e i t " ( 6 ) . 63 S t e i n r e p o r t s (236) t h a t " w h i l e t h e g e n e r a l s u b j e c t o f r e - e x a m i n a t i o n s and r e - c e r t i f i c a t i o n o f l i c e n s e d p h y s i c i a n s has been r e p e a t e d l y d i s c u s s e d by 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 rds and by t h e N a t i o n a l B o a r d o f M e d i c a l 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 been r e a c h e d . " The newly e s t a b l i s h e d A m e r i c a n Board o f F a m i l y P r a c t i c e has s t i p u l a t e d r e c e r t i f i c a t i o n e v e r y s i x y e a r s ( 5 5 ) , and r e c e n t l y , t h e A m e r i c a n Board o f I n t e r n a l M e d i c i n e announced i t s i n t e n t i o n t o implement a r e c e r t i f i c a t i o n p r o c e d u r e ( 1 1 8 ) . The 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 d e v i s e d a v o l u n t a r y e x a m i n a t i o n f o r 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 t e s t . I t i s hoped t h a t t h i s w i l l h e l p an i n d i v i d u a l i n t e r n i s t become more aware o f h i s d e f i c i e n c i e s so t h a t he w i l l s eek 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 knowledge. I n i t i a l l y , 5,000 o f t h e 150,000 ACP members t o o k t h e t e s t , and s i n c e t h a t t i m e , an a d d i t i o n a l 5,600 members and non-members have p a r t i c i p a t e d . A c c o r d i n g t o 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 have been e n t h u s i a s t i c . More r e c e n t l y , t h e 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 ( 4 0 ) , t h e A m e r i c a n C o l l e g e o f P e d i a t r i c s (69) , and 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) a r e r e p o r t e d d e v e l o p i n g s i m i l a r p r o g r a m s . Commenting on t h e v a r i e d a p p r o a c h e s c u r r e n t l y b e i n g t r i e d i n an e f f o r t t o e n s u r e p r o f e s s i o n a l competence, M i l l e r (159) w r i t e s : 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 competence has been a c h i e v e d , n o t t o s p e l l o u t t h e method o f a c h i e v i n g i t , o r 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 wholesome a c t i v i t i e s w i t h a c h i e v e m e n t o f t h e g o a l . The A m e r i c a n Academy of G e n e r a l P r a c t i c e has a l r e a d y done so and i s o f t e n commended f o r t h e courageous 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 programs o f p o s t - g r a d u a t e e d u c a t i o n a r e q u i r e m e n t f o r c o n t i n u e d membership. One can o n l y a p p l a u d t h e m o t i v e s t h a t l e d t o t h i s d e c i s i o n , b u t t h e 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 and t h e p r a c t i c e s accompanying i t . F o r t h e s p i r i t o f 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 , you can make him d r i n k . I n t h e same v e i n , a r e c e n t s t a t e m e n t i s s u e d by t h e Committee on M e d i c a l E d u c a t i o n o f t h e New Y o r k Academy o f M e d i c i n e (55) c o n c l u d e s : 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 number o f h o u r s i n some k i n d of 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 u n w a r r a n t e d m e r i t t o c o u r s e work. The committee a l s o s t r o n g l y opposes any mandatory 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 of one'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 n o t 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 t h e r e s u l t s o f most s u c h t e s t s and the 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 f o r t h e i r p a t i e n t s . . . A c c o r d i n g l y , t h i s c ommittee recommends: " t h e e s t a b l i s h m e n t o f programs b a s e d on management t y p e o r a u d i t t y p e p r o c e d u r e s whereby b o t h h o s p i t a l and community 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 e ach o t h e r ' s c h a r t s o r r e c o r d room c h a r t s g e n e r a l l y , t o i n d i c a t e f e a t u r e s o f p a r t i c u l a r d i s e a s e s w h i c h must be c o n s i d e r e d and a p p r o p r i a t e a p p r o a c h e s i n t h e i r management." Whatever t h e m e r i t s and/or l i m i t a t i o n s o f t h e s e v a r i e d a p p r o a c h e s , c l e a r l y t h e t r e n d i s " t o g i v e r e c o g n i t i o n 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 " ( 6 1 ) . 65 CHAPTER V INSTRUCTIONAL PROCESSES I n t h e l i t e r a t u r e d e s c r i b 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 n m e d i c i n e , t h e terms a p p l i e d t o i n s t r u c t i o n a l p r o c e s s e s a r e used i n d i s c r i m i - n a t e l y and w i t h o u t e i t h e r p r e c i s i o n o r c o n s i s t e n c y . S i n c e t h e d e s c r i p t i o n s o f t h e p r o c e s s e s a r e i n a d e q u a t e t o a l l o w t r a n s l a t i o n i n t o the- s t a n d a r d t e r m i n o l o g y o f a d u l t e d u c a t i o n i t w i l l be n e c e s s a r y t o summarize t h e l i t e r a t u r e as p r e s e n t e d r a t h e r t h a n a t t e m p t i n g t o s y n t h e s i z e i t . Among o t h e r t h i n g s , t h e r e p o r t s o f programs do n o t c l e a r l y d i f f e r e n t i a t e between t h e methods and t e c h n i q u e s employed ( 2 5 5 ) . N e v e r t h e l e s s , i t i s p o s s i b l e t o i d e n t i f y the m a j o r methods. The most used method i s t h a t o f t h e c o u r s e o r c l a s s w i t h t h r e e m a j o r v a r i a n t s o r p a t t e r n s o f t h i s method b e i n g t h e c o n t i n u o u s , i n t e r m i t t e n t , and c i r c u i t c o u r s e s d e s c r i b e d e a r l i e r . O t h e r , methods e n c o u n t e r e d i n c l u d e ward r o u n d s , c a s e s e m i n a r s , c l i n i c a l c o n f e r e n c e s , c l i n i c a l p r a c t i c e , and t h e d i s c u s s i o n g r o u p . The l i t e r a t u r e i n w h i c h t h e s e methods 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 t h e r e i s s c a n t e v i d e n c e o f a t t e m p t s t o a s s e s s t h e e f f e c t i v e n e s s o f t h e methods n o r t o compare one w i t h a n o t h e r . The t e c h n i q u e s o f i n s t r u c t i o n r e p o r t e d a r e e q u a l l y p o o r l y d e f i n e d and d e s c r i b 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 w i t h t h o s e i d e n t i f y i n g t e c h n i q u e s . F u r t h e r m o r e , i n s t r u c t i o n a l a i d s o r d e v i c e s a r e o f t e n t r e a t e d as i n s t r u c t i o n a l t e c h n i q u e s . The r e s u l t a n t c o n f u s i o n i n l a n g u a g e makes i t v i r t u a l l y i m p o s s i b l e t o a s s e s s t h e c o m p a r a t i v e e f f e c t i v e n e s s o f v a r i o u s program d e s i g n s w i t h any v a l i d i t y . I t i s c l e a r t h a t t h o s e 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 m e d i c i n e a r e n o t k n o w l e d g e a b l e a b out how l e a r n i n g o c c u r s i n a d u l t s , t h e c o n d i t i o n s e s s e n t i a l t o a c h i e v e l e a r n i n g , n o r s k i l l e d i n t h e d e s i g n and management o f i n s t r u c t i o n . PATTERNS OF INSTRUCTION W h i l e no one t e c h n i q u e can be t h o u g h t t o o u t w e i g h a l l o t h e r s i n i m p o r t a n c e , t h o s e w h i c h f a c i l i t a t e t h e a p p l i c a t i o n o f knowledge a r e g e n e r a l l y c o n s i d e r e d t o be s u p e r i o r t o t h o s e i n w h i c h t h e l e a r n e r i s a p a s s i v e r e c i p i e n t o f i n f o r m 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 one o f t h e g r e a t e s t p r o b l e m s has been t h e e x c e s s i v e use o f n o n - p a r t i c i p a t i v e , o r d i d a c t i c t e c h n i q u e s . I n 1940, R a p p e l y e s t a t e d , " t o o o f t e n p o s t g r a d u a t e m e d i c a l i n s t r u c t i o n has been g i v e n s o l e l y by d i d a c t i c l e c t u r e s . . . w h i l e d i d a c t i c l e c t u r e s a r e v a l u a b l e , d e m o n s t r a t i o n s , f i r s t h a n d e x p e r i e n c e under g u i d a n c e , and c o n f e r e n c e s a r e t h e most s u c c e s s f u l forms o f t e a c h i n g . Any w e l l c o n c e i v e d program s h o u l d s t r e s s t h e s e methods" ( 2 2 7 ) . T h i s r e c o m m e n d a t i o n , v a r i o u s l y e x p r e s s e d , was r e p e a t e d by Norwood ( 1 7 4 ) , V o l l a n ( 2 5 6 ) , D r y e r ( 7 9 ) , and i n t h e many r e p o r t s t h a t f o l l o w e d . I n 1957 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 G u i d e , a l o n g w i t h a l e n g t h y e x p l a n a t o r y s e c t i o n on 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 ( 6 5 ) . I n t h e meantime, c o u r s e s r e p o r t e d i n t h e A n n u a l L i s t i n g have c o n s i s t e n t l y p u b l i c i z e d t h e use o f a w i d e v a r i e t y o f p a r t i c i p a t i v e t e c h n i q u e s . Thus t h 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 Course L i s t i n g r e v e a l e d t h a t o f t h e 1,529 c o u r s e s l i s t e d , o n l y 2 2 p e r c e n t s p e c i f i e d t h e use o f s o l e l y d i d a c t i c ' f o r m a t s d e f i n e d i n t h i s s u r v e y as " t h e l e c t u r e , the l e c t u r e and b r i e f d i s c u s s i o n 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 a u d i o - v i s u a l a i d s " ( 5 7 ) . U s i n g t h e same r e s t r i c t i v e d e f i n i t i o n , o f t h e 2,016 c o u r s e s l i s t e d i n 1969-1970, 67 r o u g h l y 20 p e r c e n t i n d i c a t e d t h e use of o n l y n o n - p a r t i c i p a t i v e t e c h n i q u e s . A l l o t h e r s s p e c i f y i n g t h e l e c t u r e and s u c h t h i n g s as t h e s e m i n a r , l a b o r a t o r y work, o r c l i n i c a l c o n f e r e n c e s ( 5 9 ) . These f i g u r e s a l o n e a r e m i s l e a d i n g , s i n c e t h e m a j o r i t y o f c o u r s e s 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 r e b o t h s h o r t t e r m and f o r l a r g e g r o u p s . When e n r o l l m e n t r e a c h e s t h e h u n d r e d s , and t i m e i s l i m i t e d , i t becomes e x t r e m e l y d i f f i c u l t t o i n c o r p o r a t e a v a r i e t y of t e c h n i q u e s w h i c h would f a c i l i t a t e a c t i v e l e a r n e r p a r t i c i p a t i o n ( 5 7 ) . I t i s n o t s u r p r i s i n g t h e r e f o r e , t h a t i n a c t u a l p r a c t i c e , w h i l e t h e p u r e l y d i d a c t i c f o r m a t i s no l o n g e r r e p o r t e d ( 2 2 0 ) , t h e m a j o r i t y o f s p o n s o r s s t i l l make use o f t h e l e c t u r e , s y m p o s i a , p a n e l , and o t h e r d i d a c t i c t e c h n i q u e s (88) (129) (267) . The C o u n c i l ' s s u r v e y 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 l a r g e r p r o p o r t i o n o f c o u r s e s s p o n s o r e d by m e d i c a l and s p e c i a l t y s o c i e t i e s u sed s o l e l y d i d a c t i c t e c h n i q u e s (57) . More r e c e n t a c c o u n t s s u g g e s t t h a t t h e s i t u a t i o n r e m a i n s r e l a t i v e l y unchanged, b u t t h e s t r u c t u r e and q u a l i t y o f programs i s s a i d t o v a r y c o n s i d e r a b l y a c c o r d i n g t o t h e p a r t i c u l a r s o c i e t y i n v o l v e d (263) . Thus, t h e 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 t o f a c i l i t a t e 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 1968, s e v e n r e g i o n a l p o s t - g r a d u a t e i n s t i t u t e s were h e l d w i t h 885 p a r t i c i p a n t s b u t w i t h a f a c u l t y - s t u d e n t r a t i o o f 1:10. S i m i l a r l y 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 and 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 as s e m i n a r s o r c l i n i c s (230) ( 2 6 3 ) . Rhue r e p o r t e d t h a t i n 1963, 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 s c h o o l s i n d i c a t e d 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 p e r i o d ; 21 p e r c e n t l i v e c l i n i c s ; 20 p e r c e n t group c o n f e r e n c e s and s e m i n a r s ; 9 p e r c e n t l a b o r a t o r y work; and 7 p e r c e n t b e d s i d e r ounds (220) . A more r e c e n t u n p u b l i s h e d s u r v e y of C a n a d i a n 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 f i n d i n g s ( 2 4 1 ) . 68 I n b o t h Canada and t h e U n i t e d S t a t e s , t h e e x p a n s i o n o f r e g i o n a l programs s u g g e s t s t h a t g r e a t e r use w i l l be made o f s m a l l group s e m i n a r s , s u p e r v i z e d c l i n i c a l 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 t e c h n i q u e s i n t h e f u t u r e (235) ( 9 7 ) . Of 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 t h e g r e a t e s t number o f c o u r s e s w i t h e n r o l l m e n t l i m i t e d t o s m a l l groups ( a r b i t r a r i l y d e f i n e d as any l e a r n i n g group w i t h 25 p a r t i c i p a n t s o r l e s s ) and, as p r e v i o u s l y n o t e d , i t makes t h e g r e a t e s t use o f i n t e r m i t t e n t s c h e d u l i n g ( 5 9 ) . SMALL GROUPS The 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 c l i n i c a l c o n f e r e n c e , i s w i d e l y used 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 b u t , as 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 t h e f o r m a l l e c t u r e . S h e e l e y (226) r e p o r t s an e x p e r i m e n t i n w h i c h an i n s t i t u t i o n o f f e r e d t h e 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 by two d i f f e r e n t methods: a s e r i e s o f 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 . The l e c t u r e s e r i e s had o v e r 25 r e g i s t r a n t s w h i l e 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. S i n c e a c c e p t a n c e and 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 of t h e d i s c u s s i o n group method, i t may be u s e f u l t o i l l u s t r a t e i t s u s e . P s y c h i a t r i c Case S e m i n a r s : I n r e v i e w i n g t h e v a r y i n g r e s u l t s o f a p s y c h i a t r i c c o u r s e f o r non p s y c h i a t r i s t s h e l d i n t h r e e W a s h i n g t o n c o u n t i e s o v e r a t h r e e y e a r p e r i o d , S t u e n and h i s a s s o c i a t e s (239) c o n c l u d e d t h a t many p h y s i c i a n s a r e n o t c a p a b l e o f t a k i n g p a r t i n t h e f r e e g i v e and t a k e o f t h e p s y c h i a t r i c s e m i n a r w h i c h can be i n i t i a l l y a t r a u m a t i c e x p e r i e n c e . They recommended b e g i n n i n g w i t h a d i d a c t i c a p p r o a c h t h e n g r a d u a l l y s h i f t i n g t o t h e s t u d y o f c a s e m a t e r i a l s and 69 t h e use o f d i s c u s s i o n . I n B r o o k l y n , Brody and h i s c o l l e a g u e s (31) f ound t h a t by k e e p i n g t h e group under t e n , even t h e most " d i f f i d e n t p h y s i c i a n a c t i v e l y p a r t i c i p a t e d i n d i s c u s s i o n . " R e p o r t i n g on t h e p s y c h i a t r i c c a s e s e m i n a r used i n t h e f o u r s t a t e U t a h p r o j e c t , Mead (151) c o n c l u d e d t h a t t h e d e g r e e o f p h y s i c i a n p a r t i c i p a t i o n was d i r e c t l y r e l a t e d t o 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 , t h u s t h o s e p h y s i c i a n s who most needed h e l p w i t h t h e i r c a s e s were l e a s t l i k e l y t o r e c e i v e i t . He a l s o c o n c l u d e d t h a t c o n c e n t r a t i n g s o l e l y on c a s e s f r o m t h e p h y s i c i a n s ' p r a c t i c e r e s u l t e d i n i n s u f f i c i e n t p r e p a r a t i o n i n b a s i c m e t h o d o l o g y , so t h a t t h e U t a h p r o j e c t was m o d i f i e d t o i n c l u d e l e c t u r e s as w e l l as c a s e o r i e n t e d d i s c u s s i o n s . To c i r c u m v e n t t h e p r o b l e m o f a p h y s i c i a n ' s r e l u c t a n c e t o d i s c u s s c a s e p r o b l e m s i n t h e p s y c h i a t r i c group s e t t i n g , t h e program i n E l m h u r s t , New Y o r k i n c o r p o r a t e d 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 t o e ach s e m i n a r , as w e l l as 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 a p p o i n t m e n t ( 2 2 ) . Commenting on t h e c u r r e n t w i d e s p r e a d use o f t h e i r o r i g i n a l p s y c h i a t r i c c a s e s e m i n a r t e c h n i q u e , t h e B a l i n t s have emphasized t h a t "such v e n t u r e s , no m a t t e r how g r e a t l y m o d i f i e d , r e q u i r e much more t i m e t h a n t h e p o p u l a r week-end G.P. c o u r s e " ( 1 7 ) . C l i n i c a l C o n f e r e n c e s : One o f 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 c o n f e r e n c e s r e p o r t e d i s t h e c o n s e c u t i v e c a s e c o n f e r e n c e (CCC) d e v i s e d by t h e A m e r i c a n H e a r t A s s o c i a t i o n . I n t h i s , a p a n e l o f e x p e r t s a n a l y z e s the c h a r t s o f t e n p a t i e n t s c o n s e c u t i v e l y d i s c h a r g e d . The p h y s i c i a n s a r e r e q u i r e d t o a c c o u n t f o r t h e i r c o n d u c t o f e a c h c a s e as i t comes under r e v i e w . A l t h o u g h i t i s s t r e s s e d t h a t t h e p u r p o s e o f t h e CCC i s e d u c a t i o n a l , namely, t o p r o v i d e "an o p p o r t u n i t y f o r p h y s i c i a n s t o r e f l e c t b ack on t h e i r own p e r f o r m a n c e and t o g a i n i n s i g h t i n t o t h e management o f t h e c a s e w i t h t h e h e l p o f acknowledged e x p e r t s " ( 2 7 0 ) , most 70 w r i t e r s a g r e e (263) (254) (282) t h a t i t r e q u i r e s c o n s i d e r a b l e ego s t r e n g t h on t h e p a r 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 . A s t u d y by W i l l i a m s o n and M c G u i r e (270) w h i c h compared t h e r e l a t i v e e f f e c t i v e n e s s o f t h e CCC and t h e l e c t u r e i n i m p r o v i n g c l i n i c a l judgement, f o u n d "no o v e r a l l s i g n i f i c a n t d i f f e r e n c e as t e s t e d by s i m u l a t e d p a t i e n t p r o b l e m s s i x months a f t e r c o m p l e t i o n o f t h e i n s t r u c t i o n . " More s u c c e s s f u l programs u s i n g t h i s a p p r o a c h have s t r e s s e d the a nonymity o f i n d i v i d u a l p h y s i c i a n s and f o c u s s e d on group p r o b l e m s and group p r o b l e m s o l v i n g (97) (235) ( 1 6 2 ) . V aneslow (254) q u o t e s S l e e as s a y i n g t h a t 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 b ecause t h e y f a i l e d t o take, i n t o c o n s i d e r a t i o n t h e w o r r i e s of t h e m e d i c a l s t a f f r e g a r d i n g t h e p o s s i b l e consequences of a program o f t h i s t y p e . " F a r l e s s t h r e a t e n i n g and t h e r e f o r e w i d e l y used i n community h o s p i t a l programs i s t h e c l i n i c a l c o n f e r e n c e u s i n g t h e p h y s i c i a n s ' own c a s e m a t e r i a l as a b a s i s f o r g e n e r a l d i s c u s s i o n . T u p p e t t and Cudmore (67) r e p o r t e d a p r e l i m i n a r y s t u d y t h a t compared t h e r e s u l t s when one group engaged i n e x t r a p r e p a r a t i o n p r i o r t o a v i s i t i n g t e a c h e r program and t h e o t h e r d i d n o t . F o l l o w up i n t e r v i e w s w i t h p h y s i c i a n s r e v e a l e d t h a t t h e amount o f p r e p a r a t o r y work u n d e r t a k e n by the two groups d i d n o t d i f f e r s i g n i f i c a n t l y d e s p i t e t h e e x t r a encouragement g i v e n t o t h e e x p e r i m e n t a l g r o u p . A t McMaster U n i v e r s i t y a t i m e l o g i s k e p t t o d e t e r m i n e w h e t h e r t h e r e i s a p r o g r e s s i v e change i n t h e amount o f d i s c u s s i o n t i m e used by t h e v i s i t i n g f a c u l t y v e r s u s t h e l e a r n e r g r o u p . R e s u l t s t o d a t e have shown no s i g n i f i c a n t i n c r e a s e i n t h e t i m e u t i l i z e d by t h e p r a c t i s i n g p h y s i c i a n s p a r t i c i p a t i n g i n t h e program. D e m o n s t r a t i o n s ; S u p e r v i s e d C l i n i c a l P r a c t i c e : I n p s y c h i a t r y a number o f c o u r s e s a r e r e p o r t e d w h i c h combine t h e c a s e 71 c o n f e r e n c e a p p r o a c h w i t h p a t i e n t d e m o n s t r a t i o n s , r e t u r n d e m o n s t r a t i o n , and s u p e r v i z e d c l i n i c a l p r a c t i c e . I n t h e s e programs f e e d b a c k p r o v i d e d t h r o u g h t h e use o f t h e two-way m i r r o r and/or v i d e o t a p e s e r v e as t h e b a s i s f o r group d i s c u s s i o n s (26) (28) ( 2 7 4 ) . A l s o r e p o r t e d from t h i s f i e l d a r e s u c c e s s f u l u s e s o f psychodrama and r o l e p l a y i n g ( 2 6 ) . A t y p i c a l example i s t h a t d e s c r i b e d by L e v i n s o n (140) i n w h i c h t h e p h y s i c i a n p a r t i c i p a n t s r e - e n a c t p a t i e n t s i t u a t i o n s p r i o r t o and f o l l o w i n g t h e i r c l i n i c a l e x p e r i e n c e s . F l e i s h e r (98) r e p o r t s t h a t a t t h e U n i v e r s i t y of S o u t h e r n C a l i f o r n i a , 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 t h e r o l e o f p a t i e n t s . T h i s d e v i c e has been d e v e l o p e d f u r t h e r a t M i c h i g a n S t a t e C o l l e g e and t h e U n i v e r s i t y o f 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 r e l i a b l e d egree o f o b j e c t i v i t y on t h e p a r t o f t h e a c t o r s , t h e r e b y s u g g e s t i n g t h a t an a s s e s s m e n t o f s t u d e n t l e a r n i n g c o u l d be p o s s i b l e . I n c o n t r a s t t o t h e f o r e g o i n g , K e r n e t a l (130) a t Johns H o p k i n s U n i v e r s i t y have d e s c r i b e d an e x p e r i m e n t a l p r o j e c t i n community p s y c h i a t r y u s i n g what t h e y c a l l "The 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 p h y s i c i a n s e x p e r i e n c e t h e same u n s t r u c t u r e d f i e l d work as t h a t u s e d i n t r a i n i n g r e s i d e n t s . T h i s has been e v a l u a t e d by p h y s i c i a n s r e s p o n s e s t o q u e s t i o n n a i r e s w h i c h s u g g e s t t h a t t h i s t e c h n i q u e i s p l a c i n g r e s p o n s i b i l i t y on t h e p h y s i c i a n s f o r t h e i r own l e a r n i n g and, i n an ambiguous s i t u a t i o n r e q u i r i n g f r e q u e n t changes o f s t y l e and r o l e s , i s c a p a b l e o f f o s t e r i n g s e l f - l e a r n i n g and an a t t i t u d e f a v o u r a b l e t o i m p l e m e n t i n g change. A number o f programs r e p o r t e d a l s o p r o v i d e e v i d e n c e o f a movement f r o m t h e c l a s s r o o m t o t h e c l i n i c a l p r a c t i c e f i e l d . R i c h a r d s o n (202) d e s c r i b e d a v i s i t i n g t e a c h e r program c o n d u c t e d i n one s m a l l community h o s p i t a l i n P e n n s y l v a n i a i n w h i c h a c o n s u l t a n t a l l e r g i s t v i s i t e d t h e a l l e r g y c l i n i c e v e r y 72 two weeks. A t t h i s v i s i t , s p e c i a l i z e d t e c h n i q u e s were d e m o n s t r a t e d . The l o c a l p h y s i c i a n s p r a c t i c e d t h e t e c h n i q u e s under s u p e r v i s i o n and f o r m u l a t e d t h e r a p e u t i c p l a n s f o r s e l e c t e d p a t i e n t s . Between c l i n i c s e s s i o n s , t h e l o c a l s t a f f p h y s i c i a n s implement t h e p r o p o s e d t r e a t m e n t p l a n s . I t i s t h e aim o f t h i s program t o d e c r e a s e g r a d u a l l y t h e number o f c o n s u l t a n t v i s i t s and i n c r e a s e t h e t r a n s f e r o f r e s p o n s i b i l i t y t o l o c a l p h y s i c i a n s ( 2 0 2 ) . S i m i l a r l y , S t . J u s t i n e ' s C h i l d r e n ' s H o s p i t a l i n M o n t r e a l has r e p o r t e d 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 t o t h r e e p e d i a t r i c i a n s spend two days i n a community h o s p i t a l . I n t h e m o r n i n g t h e y meet w i t h f a m i l y p h y s i c i a n s and do ward r o u n d s , r e v i e w i n g a l l c a s e s . I n t h e a f t e r n o o n t h e y see o u t p a t i e n t s whom t h e f a m i l y p h y s i c i a n s p r e s e n t f o r e x a m i n a t i o n and c o n s u l t a t i o n . A c c o r d i n g t o R o s i e r ( 2 1 5 ) , t h i s e x p e r i m e n t i s p r o v i n g f r u i t f u l , "not o n l y 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 , b u t a l s o as a way o f p r o v i d i n g t h e p u b l i c w i t h t h e s e r v i c e s o f a q u a l i f i e d c o n s u l t a n t . " G o l d f i n g e r and Federman (106) have d e s c r i b e d a s u c c e s s f u l r e f r e s h e r program i n w h i c h t h r e e g e n e r a l p r a c t i t i o n e r s s e r v e d as housemen i n t h e emer- gency department o f a t e a c h i n g h o s p i t a l w h i l e r e c e i v i n g f o r m a l l e c t u r e s and s u p e r v i z e d c l i n i c a l i n s t r u c t i o n on t h e l a t e s t i n t e n s i v e c a r e t e c h n i q u e s . W h i l e t h i s p rogram i l l u s t r a t e s t h e t y p i c a l t r a i n e e s h i p i n most r e s p e c t s , what i s o f p a r t i c u l a r i n t e r e s t i s t h a t t h e emergency n a t u r e o f t h e ward r e s p o n s i b i - l i t i e s a u t o m a t i c a l l y d e f i n e d t h e p h y s i c i a n s ' r e a l l e a r n i n g n e eds. On t h e o t h e r hand, Brown (33) a t P a c i f i c M e d i c a l C e n t e r d e s c r i b e d an e x p e r i m e n t a l p r o j e c t d e s i g n e d t o 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 i n w h i c h i t was f ound t h a t t h e c o n v e n t i o n a l t r a i n e e s h i p program was i n a d e q u a t e f o r a group who were n o t o n l y 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 r e q u i r e d a s y s t e m a t i c r e v i e w c o u r s e u s i n g d i d a c t i c i n s t r u c t i o n . They recommend t h a t t h e c u r r i c u l u m f o r p h y s i c i a n s i n t h i s c l a s s s h o u l d c o n s i s t o f two p h a s e s : an 73 i n t e n s i v e r e v i e w c o u r s e on b a s i c a s p e c t s o f c l i n i c a l m e d i c i n e f o l l o w e d by a program o f s u p e r v i z e d p a t i e n t c o n t a c t w i t h a g r a d u a l a s s u m p t i o n o f r e s p o n s i - b i l i t y . The o n l y r e p o r t o f an o n g o i n g i n s e r v i c e t r a i n i n g program e n c o u n t e r e d i n 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 by Jampol ( 1 2 4 ) . Sponsored by 60 p h y s i c i a n s i n group p r a c t i c e , t h i s program u t i l i z e d s m a l l group b e d s i d e s e s s i o n s w i t h emphasis on c l i n i c a l d i a g n o s i s and t h e management o f t h e p a r t i c i p a n t ' s own p a t i e n t s . A f o l l o w up m e d i c a l a u d i t a f t e r two y e a r s i n d i c a t e d t h a t , i n g e n e r a l , "more a p p r o p r i a t e l a b o r a t o r y and X - r a y s t u d i e s were b e i n g o r d e r e d i n p r o b l e m c a s e s , w i t h l e s s t e n d e n c y t o i n i t i a t e t h e r a p y b e f o r e d i a g n o s t i c s t u d i e s . " C o n s u l t a n t s p e c i a l i s t s a l s o f e l t t h a t b e t t e r p a t i e n t a s s e s s m e n t s were b e i n g p e r f o r m e d p r i o r t o r e f e r r a l 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 u n d e r - s t a n d i n g o f t h e p r o b l e m s i n v o l v e d . U s i n g a s i m u l a t e d c o r o n a r y c a r e u n i t a t t h e P a c i f i c M e d i c a l C e n t e r , t h e 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 r e g u l a r l y s c h e d u l e d c l a s s e s on c o r o n a r y c a r e f o r m u l t i p r o f e s s i o n a l h e a l t h p e r s o n n e l . The equipment used f o r c l a s s r o o m i n s t r u c t i o n and w h i c h i s a v a i l a b l e f o r l o a n t o o t h e r c e n t e r s c o n d u c t i n g s i m i l a r programs i n c l u d e : t a p e s and m o n i t o r s f o r t e a c h i n g t h e a r r t h y m i a s ; A.V, p r e s e n t a t i o n s ( s l i d e s ; f i l m 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 t r e a t m e n t o f h e a r t d i s e a s e ; and computer programming on v a r i o u s c o r o n a r y c a r e t o p i c s . I n c o n j u n c t i o n w i t h t h e s e c l a s s e s , c o n s u l t a t i v e s e r v i c e s a r e p r o v i d e d and p o s t - g r a d u a t e p r e c e p t o r s h i p s a r e a r r a n g e d f o r p h y s i c i a n s ( 2 6 1 ) . 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 RMPS a r e r e p o r t e d d e v e l o p i n g s i m i l a r o r m o d i f i e d programs (252) . LARGE GROUPS I n s t r u c t i o n p r o v i d e d 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 w h i c h 74 w i l l enhance p a r t i c i p a n t i n t e r a c t i o n . D e s p i t e t h e w i d e s p r e a d use of l a r g e g r o u p s , t h e r e a r e few s t u d i e s of i t s use and e f f e c t i v e n e s s . The two d e s c r i p t i v e s t u d i e s s e l e c t e d f o r t h i s r e v i e w a r e p a r t i c u l a r l y i n f o r m a t i v e w i t h r e s p e c t t o t h e use o f t h e 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 e d u c a t i o n . H a r s h b a r g e r (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 workshop a t t e n d e d by some 80 i n d i v i d u a l s f r o m v a r i o u s h e a l t h p r o f e s s i o n s . He had p a r t i c i p a n t o b s e r v e r s g a t h e r d a t a on t h e p e r t i n e n t i s s u e s d i s c u s s e d i n t h e s m a l l b u z z g r o u p s and a c o m p a r i s o n was made o f the o b s e r v e r s ' summaries and t h e r e p o r t s f r o m e a c h b u z z group t o t h e t o t a l g r o u p . T h e i r f i n d i n g s r e v e a l e d t h a t w h i l e s t i m u l a t i n g and m e a n i n g f u l p r o b l e m s were r a i s e d i n t h e s m a l l group s e s s i o n s , t h e s e were n o t r e p o r t e d back t o t h e t o t a l g r o u p . I n s t e a d , " p r o f e s s i o n a l o v e r p o l i t e n e s s " c h a r a c t e r i z e d most of t h e r e p o r t s . T h i s s t u d y c o n c l u d e s : " I f workshops a r e t o be c r e a t i v e forums f o r new i d e a s , t h e t r a d i - t i o n a l r o l e s o f t h e v a r i o u s p r o f e s s i o n a l p a r t i c i p a n t s must be d i s r u p t e d . " The recommendations s t r e s s t h e 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 t h a t p r o v i d e d by p a r t i c i p a n t o b s e r v e r s who w o u l d e n s u r e t h a t t h e e s s e n t i a l c o n t r a s t i n g p r o f e s s i o n a l v i e w p o i n t s w o u l d be r e l a y e d t o t h e l a r g e r 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 c l a r i f i c a t i o n . S c h l e s i n g e r (221) r e p o r t e d a q u e s t i o n n a i r e e v a l u a t i o n o f a t h r e e day symposium on e p i l e p s y p r e s e n t e d t o a d i v e r s e group o f p h y s i c i a n s and o t h e r h e a l t h w o r k e r s . He f o u n d t h a t t h e h i g h e s t mean r a t i n g was g i v e n t o t h e d i d a c t i c f o r m a t and t h e l o w e s t t o exchanges between s p e a k e r s , p a n e l i s t s , and t h e a u d i e n c e . He a l s o f ound t h a t t h e r e was a d i s c r e p a n c y between t h e o b j e c t i v e s o f t h e p a r t i c i p a n t s and t h e c o n t e n t o f t h e program. F u r t h e r m o r 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 r e l a t i v e l y s a t i s f i e d w i t h t h e . p r o g r a m , 75 s p e c i a l i s t s e x p r e s s e d d i s s a t i s f a c t i o n w i t h t h e b r o a d c o v e r a g e o f s u b j e c t m a t t e r . 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 a h i g h d e g r e e o f i n t e r e s t i n a l l t o p i c s y e t , t h e a u t h o r n o t e d , " t h e s u b j e c t m a t t e r was g e a r e d t o p h y s i c i a n s and much o f i t was o n l y i n d i r e c t l y r e l e v a n t t o the n u r s e s ' i n t e r e s t s . " One may i n f e r t h a t t h e f i n d i n g s o f t h i s s t u d y m e r e l y r e i t e r a t e one of t h e b a s i c p r o b l e m s i n h e r e n t i n l a r g e 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 c a s t , and 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 r a d i o , t e l e v i s i o n , and t h e t e l e p h o n e a r e t h r e e o f t h e most u b i q u i t o u s c o m m u n i c a t i o n d e v i c e s i n N o r t h A m e r i c a . A l l t h r e e o f t h e s e have been u s e d 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 b u t i t i s o n l y r e c e n t l y t h a t t h e y have been used t o p r o v i d e s y s t e m a t i c i n s t r u c - t i o n . These media p r o v i d e a way o f e x t e n d i n g t h e range o f an i n s t r u c t o r t o many group s and o b v i a t e t h e n e c e s s a r y o f f o r m i n g a s p e c i f i c i n s t r u c t i o n a l group a t a s p e c i f i e d 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 p e r s o n . I n some r e s p e c t s , t h e s e media have been used more e x t e n s i v e l y 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 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 . T h i s i s due, no d o u b t , t o t h e f a c t t h a t t h e p o t e n t i a l p a r t i c i p a n t s a r e c l e a r l y i d e n t i f i e d and t h e m o t i v a t i o n t o l e a r n i s g e n e r a l l y h i g h . 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 n o t been s t u d i e d a d e q u a t e l y . R a d i o C o n f e r e n c e s : 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 by Woolsey a t A l b a n y C o l l e g e i n 1955 ( 2 7 9 ) . I n t h e t y p i c a l program, p h y s i c i a n s g a t h e r around a c o m b i n a t i o n t r a n s m i t t e r and r e c e i v e r s e t l o c a t e d i n t h e i r community h o s p i t a l s . F o l l o w i n g a b r i e f 76 l e c t u r e by m e d i c a l s c h o o l p e r s o n n e l , p h y s i c i a n s i n 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 t a k e t u r n s i n s u b m i t t i n g q u e s t i o n s and comments t o t h e l e c t u r e r s . F r e q u e n t l y , s l i d e s and o t h e r s u p p l e m e n t a r y m a t e r i a l s d i s t r i b u t e d i n advance to t h e h o s p i t a l s a r e used i n c o n j u n c t i o n w i t h t h e program. I n i t i a l l y begun on a l i m i t e d s c a l e , 21 h o s p i t a l s were l i n k e d w i t h t h e m e d i c a l c o l l e g e . I n t h e f o u r t h y e a r o f o p e r a t i o n , Woolsey r e p o r t e d f i v e New E n g l a n d M e d i c a l c o l l e g e s and t h e i r a f f i l i a t e d h o s p i t a l s p a r t i c i p a t i n g i n t h e n e t w o r k . P h y s i c i a n s i n a f f i l i a t e d h o s p i t a l s were p r o v i d e d w i t h an o p p o r t u n i t y t o l i s t e n t o and t o d i r e c t comments and q u e s t i o n s t o f a c u l t y e x p e r t s f r o m s i x d i f f e r e n t m e d i c a l c o l l e g e s . I n 1963, E b b e r t (80) e s t i m a t e d t h a t a p p r o x i - m a t e l y 1,298 p h y s i c i a n s i n 36 h o s p i t a l s were b e i n g r e a c h e d by t h e s e r a d i o c o n f e r e n c e s . 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 l i s t e n e d t o t h e programs was f e l t t o be c o n s i d e r a b l e . The c o s t t o e a c h p a r t i c i p a t i n g h o s p i t a l i n t h e A l b a n y Network i s $700 p e r y e a r p e r h o s p i t a l . T h i s f e e c o v e r s more t h a n one h u n d r e d programs and t h e s u p p l e m e n t a r y i n s t r u c t i o n a l m a t e r i a l s ( 2 7 7 ) . Woolsey a l s o d e s c r i b e s a new program f o r m a t b e i n g o f f e r e d c o - o p e r a t i v e l y w i t h s i x m e d i c a l s c h o o l s i n 15 p a r t i c i p a t i n g s t a t e s . T h i s program i s p r e s e n t e d as a m e d i c a l c a s e w h i c h t h e p h y s i c i a n s f i r s t a n a l y z e on a s p e c i 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 p r o c e d u r e s . A f t e r e a c h p a r t i c i - p a n t has d e c i d e d on h i s d i a g n o s i s and t r e a t m e n t , t h e i n s t r u c t o r a n a l y z e s t h e c a s e " a n d p r e s e n t s h i s a p p r o a c h t o t h e p r o b l e m . When t h e p r e s e n t a t i o n has been c o m p l e t e d , p h y s i c i a n s d i s c u s s t h e c a s e management v i a two-way r a d i o c o m m u n i c a t i o n . 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 s k i l f u l i n t h e i r d i a g n o s i s a f t e r e x p e r i e n c e w i t h t h i s a p p r o a c h t o c a s e management. F a r b e r (95) e s t i m a t e s t h a t p r e s e n t l y - more t h a n 800 p h y s i c i a n s w i t h i n a 500 m i l e r a d i u s a r e p a r t i c i p a t i n g i n t h e programs c o n d u c t e d by t h e U n i v e r s i t y 77 o f C a l i f o r n i a S c h o o l o f M e d i c i n e . More t h a n 1,510 c o p i e s o f s p e a k e r s ' l e c t u r e n o t e s and c a s e p r e s e n t a t i o n s a r e m a i l e d each week t o p a r t i c i p a t i n g h o s p i t a l s . Many h o s p i t a l s t a p e t h e programs so t h a t p h y s i c i a n s may h e a r any b r o a d c a s t a t t h e i r c o n v e n i e n c e . To d a t e , t h e f i n d i n g s o f t h e C a l i f o r n i a e x p e r i e n c e show t h a t t h e g r e a t e s t r e s p o n s e has been from g e n e r a l p r a c t i t i o n e r s . F a r b e r c o n c l u d e s : " t h e m e d i c a l r a d i o c o n f e r e n c e s have been a m a j o r s t e p f o r w a r d i n b r i n g i n g t h e most r e c e n t c o n c e p t s i n t o o u t l y i n g d i s t r i c t s w i t h a minimum o f e x p e n d i t u r e . " T h e r e have been few, i f any, m e a n i n g f u l e v a l u a t i o n s o f t h e e f f e c t i v e n e s s o f two-way r a d i o c o n f e r e n c e s . The o n l y o b j e c t i v e e v a l u a t i o n f o u n d was t h a t u n d e r t a k e n by R i c h a r d s o n (201) i n 1963. T h i s s t u d y a t t e m p t e d t o e v a l u a t e a r a d i o s e r i e s t h r o u g h t h e use o f b e f o r e and a f t e r t e s t s o f knowledge g a i n . U s i n g a sample o f 70 v o l u n t e e r p h y s i c i a n s who had p a r t i c i p a t e d i n t h e program, and a c o n t r o l group c o n s i s t i n g 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 was a b l e t o show a s t a t i s t i c a l l y 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 between t h e f i r s t and s e c o n d t e s t s f o r t h e e x p e r i m e n t a l g r o u p , and no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e f o r t h e c o n t r o l g r o u p . The medium o f r a d i o has s c a r c e l y been used i n Canada. The o n l y r e p o r t o f a v i a b l e program e n c o u n t e r e d was t h a t f r o m t h e U n i v e r s i t y o f A l b e r t a . I n 1968, a s e r i e s o f twenty-one r a d i o s e m i n a r s were o f f e r e d . These were f e l t t o be s u c c e s s f u l , so i t was p l a n n e d t o e x t e n d the b r o a d c a s t s ( 7 ) . As p a r t o f i t s p r o p o s e d M u l t i - M e d i a I n f o r m a t i o n R e t r i e v a l System, t h e U n i v e r s i t y o f Saskatchewan r e p o r t s p l a n s t o e s t a b l i s h a p r o v i n c e - w i d e r a d i o - t e l e p h o n e s e r i e s i n c o - o p e r a t i o n w i t h t h e C.B.C. ( 1 3 ) . M e d i c a l R a d i o Network: An e x p e r i m e n t i n t h e 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 ) . A M e d i c a l R a d i o Network has been e s t a b l i s h e d i n B o s t o n w h i c h b r o a d c a s t s m u s i c a l programs 78 i n t o t h e p a r t i c i p a t i n g p h y s i c i a n ' s o f f i c e t w e l v e h o u r s a day. The m u s i c i s i n t e r r u p t e d e v e r y hour by a f i f t e e n t o t h i r t y m i n u t e m e d i c a l program t o w h i c h th e d o c t o r may l i s t e n , w i t h t h r e e o p p o r t u n i t i e s each day t o l i s t e n t o each o f t h e f o u r programs o f f e r e d . T e l e l e c t u r e s : A p i l o t p r o j e c t t o p r o v i d e c o n t i n u i n g e d u c a t i o n t o p h y s i c i a n s v i a t e l e l e c t u r e s o r a m p l i f i e d t e l e p h o n e a t t h e U n i v e r s i t y o f W i s c o n s i n has been d e s c r i b e d by Meyer ( 1 5 6 ) . I n i t i a t e d i n 1965, s e v e n t y h o s p i t a l s a r e l i n k e d by p r i v a t e t e l e p h o n e l i n e s t o t h e U n i v e r s i t y ' s M e d i c a l Communication C e n t e r . The g e n e r a l program f o r m a t f o l l o w s t h a t used w i t h t h e two-way r a d i o c o n f e r e n c e s , i n c l u d i n g a b r i e f l e c t u r e w i t h s l i d e s f o l l o w e d by d i s c u s s i o n p e r i o d . P a r t i c i p a t i n g h o s p i t a l s t a k e t u r n s s u b m i t t i n g . q u e s t i o n s and comments. A c c o r d i n g t o Meyer, i n t h e 1967-1968 academic 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 w i t h " n e i t h e r f a c u l t y n o r s t u d e n t s moving away f r o m t h e i r communi- t i e s o r t h e i r h e a l t h c a r e r e s p o n s i b i l i t i e s . " F o r t n e y (101) r e p o r t s t h a t t h e M i s s o u r i RMP has 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 t h e u n i v e r s i t y ' s m e d i c a l c e n t e r . 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 c o n f e r e n c e s i n t h e f i e l d o f m a l i g n a n t d i s e a s e s o f c h i l d r e n v i a s t a t e w i d e t e l e l e c t u r e s . P l a n s a r e u n d e r - way t o make v i d e o t a p e s o f p a t i e n t s as w e l l as s p e c i a l d i a g n o s t i c and t h e r a - p e u t i c p r o c e d u r e s w h i c h w i l l 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 . S i m u l t a n e o u s v i e w i n g w i l l t h e n be p o s s i b l e d u r i n g t h e c o n f e r e n c e s (166) . I n c o n t r a s t , Lyons (143) r e p o r t s 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 New Y o r k RMP's e x p e r i m e n t w i t h t e l e p h o n e n e t w o r k s . Among t h e many t e c h n i c a l p r o b l e m s d i s c u s s e d , he n o t e s t h a t f a c u l t y u n f a m i l i a r w i t h 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 an unknown a u d i e n c e and t h a t p h y s i c i a n s a r e e q u a l l y r e l u c t a n t t o a s k q u e s t i o n s . He n o t e s f u r t h e r t h a t n u r s e s and m e d i c a l 79 t e c h n i c i a n s have made g r e a t e r u s e of t h e t e l e p h o n e n e t w o r k t h a n have p h y s i c i a n s . T e l e v i s i o n : D u r i n g 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 p r o b a b l y r e c e i v e d more a t t e n t i o n t h a n any o t h e r medium. R e f e r r i n g t o i t s use 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 , O h l i g e r (176) s t a t e s , "Mass media c o u r s e s f o r t h e m e d i c a l p r o f e s s i o n a r e b l o s s o m i n g a l l o v e r t h e map, but m a i n l y i n t h e U n i t e d S t a t e s , " and he q u o t e s 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 p r o v e n t o be immensely u s e f u l i n k e e p i n g d o c t o r s a b r e a s t o f advances i n m e d i c a l p r a c t i c e . . . " D e s p i t e a l l t h e p u b l i c i t y s u r r o u n d i n g i t s v a r i e d and w i d e s p r e a d u s e , 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 t h e use o f t e l e v i s i o n has s p r e a d r a t h e r s l o w l y ( 1 9 3 ) . M o r e o v e r , much o f what i s i n use i s s t i l l e x p e r i m e n t a l ( 1 1 1 ) . S i n c e H a r r i s (111) has so r e c e n t l y r e v i e w e d t h e p u b l i s h e d l i t e r a t u r e on c l o s e d c i r c u i t s y s t e m s , t h i s s u r v e y i s c o n c e r n e d l a r g e l y w i t h t h e use o f open c i r c u i t , s t a n d a r d r e c e i v e r , and s c r a m b l e d o r encoded b r o a d c a s t t e l e v i s i o n , a l o n g w i t h s t u d i e s of t h e i r e f f e c t i v e n e s s . I n 1954 Warner and Bowers (259) r e p o r t e d t h e f i r s t use o f open c i r c u i t t e l e v i s i o n 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 a t t h e U n i v e r s i t y o f U t a h . T h e i r program c o n s i s t e d o f a s e r i e s o f m e d i c a l c l i n i c s and was t e l e c a s t o v e r a c o m m e r c i a l s t a t i o n 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 t h a t i n c l u d e d 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 . I n o r d e r t o m i n i m i z e p u b l i c v i e w i n g , o f f a i r t i m e was used and p u b l i c i t y was r e s t r i c t e d t o d i r e c t m a i l t o t h e p h y s i c i a n s . To promote p a r t i c i p a t i o n , an u n l i s t e d t e l e p h o n e was i n s t a l l e d and p h y s i c i a n s were enc o u r a g e d t o p l a c e q u e s t i o n s by c o l l e c t c a l l s . The s u c c e s s o f t h e e x p e r i m e n t was a t t e s t e d by f a v o u r a b l e p h y s i c i a n r a t i n g s o f t h e program, 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 no a d v e r s e c r i t i - c i s m s from t h e l a y p u b l i c . T h i s r e s u l t e d i n t h e r e g u l a r use o f open c i r c u i t 80 t e l e v i s i o n f o r 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 by t h e U n i v e r s i t y o f U t a h . A f t e r t h a t e x p e r i m e n t , Wayne S t a t e U n i v e r s i t y , t h e U n i v e r s i t y o f T e x a s , t h e U n i v e r s i t y of Oklahoma, and o t h e r s began t e l e c a s t i n g s i m i l a r programs on an e x p e r i m e n t a l b a s i s f r e q u e n t l y u s i n g t a p e s made a t t h e U n i v e r s i t y o f U t a h ( 4 3 ) . Commenting on t h e t e a c h i n g t e c h n i q u e s used i n t h e s e e a r l y p r o g r a m s , C a s t l e (43) n o t e s : 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 from 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 answer 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 been i n f o r m a l d i s c u s s i o n between two t e a c h e r s w i t h l i b e r a l use 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 emphasize s a l i e n t f e a t u r e s o f t h e p r e s e n t a t i o n . A s l i g h t l y d i f f e r e n t a p p r o a c h a t t h e U n i v e r s i t y of F l o r i d a was r e p o r t e d i n 1963 by M i c h a e l ( 1 5 8 ) . T h i s program c o n s i s t e d o f a g r and rounds t y p e o f p r e s e n t a t i o n i n w h i c h t h r e e l o c a l p h y s i c i a n s s e r v e d as one h a l f o f a p a n e l i n one s t u d i o i n J a c k s o n v i l l e some s i x t y - f i v e m i l e s away, w i t h t h e o t h e r h a l f c o n s i s t i n g o f f a c u l t y members l o c a t e d i n t h e s t u d i o a t G a i n s v i l l e . A m i c r o - r e l a y s y s t e m p r o v i d e d a s e r i e s o f exchange q u e s t i o n s and answers f o l l o w i n g a c a s e p r e s e n t a t i o n i n t h e J a c k s o n v i l l e s t u d i o . T h i s a p p r o a c h was f e l t t o " b r i n g t h e u n i v e r s i t y t o t h e b e d s i d e t e a c h i n g " and i t was c o n c l u d e d t h a t t h i s t y p e o f c o n f e r e n c e was h i g h l y d e s i r a b l e . I n P i t t s b u r g h p a r t i c u l a r e f f o r t s have been made t o i n v o l v e l o c a l h o s p i t a l s . I n 1962 a s e r i e s o f r e g u l a r w e e k l y b r o a d c a s t s c o n s i s t i n g o f " l i v e " g r a n d rounds and c l o s i n g w i t h a b r i e f m e d i c a l n e w s c a s t was i n i t i a t e d i n 29 community h o s p i t a l s . I n 1965, Moses and W o l f e (167) r e p o r t e d an e x p a n s i o n o f t h i s program t o i n c l u d e 63 h o s p i t a l s e x t e n d i n g t h r o u g h o u t t h e t r i - s t a t e a r e a o f South Western 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 N o r t h e r n West V i r g i n i a . I n 1967, G l a d m i n (176) r e p o r t e d 70 h o s p i t a l s p a r t i c i p a t i n g i n t h i s n e t w o r k . 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 l a u n c h e d 81 i n 1964 t a k i n g as one o f i t s p r i n c i p a l o b j e c t i v e s , " t h e r e g i o n a l i z a t i o n o f m e d i c a l e d u c a t i o n by means o f t e l e v i s i o n , e x p e c t i n g i t t o become a p a r t o f a p r o p o s e d u n i v e r s i t y w i t h o u t w a l l s . " I n t h i s n e t w o r k were s t a t i o n s i n M a i n e , New H a m p s h i r e , M a s s a c h u s e t t s ( 2 0 9 ) , and more r e c e n t l y , Rhode I s l a n d and Vermont ( 1 7 6 ) . One n o t e w o r t h y element o f t h e s e r i e s was t h e " P h y s i c i a n s ' Notebook f o r t h e B o s t o n R e p o r t s . " I n t e n d e d 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 t o t h e 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 n o t ebook w i t h i n f o r m a t i v e m a t e r i a l s a n n o u n c i n g t h e s e r i e s , i t s p u r p o s e , and f o r m a t was m a i l e d t o a l l p o t e n t i a l v i e w e r s i n M a i n e . S u b s e q u e n t l y , s u p p l e m e n t a r y l i t e r a t u r e accompanying each l e c t u r e was s e n t t o p h y s i c i a n s t o add t o t h e n o t e b o o k w h i c h c o u l d t h e n s e r v e as a s o u r c e of r e f e r e n c e . Another i m p o r t a n t element o f t h i s p r o j e c t was t h e e f f e c t i v e n e s s s t u d i e s w h i c h " p r o v i d e d c o n t i n u o u s f e e d b a c k t o program p l a n n e r s so t h a t t h e y c o u l d m o d i f y f u t u r e p r o g r a m s . " A l t h o u g h a t t e m p t s a t an o b j e c t i v e e v a l u a t i o n o f t h e s e r i e s were hampered by l i m i t a t i o n s of t h e r e s e a r c h d e s i g n s , i t was f e l t " t h a t B o s t o n M e d i c a l R e p o r t s d i d p r o v i d e a r e v i e w o f m e d i c a l t o p i c s and f o r some v i e w e r s , 9 s i g n i f i c a n t l e a r n i n g d i d t a k e p l a c e . " M o r e o v e r , i t was f e l t t h a t " t h e s e r i e s l a u n c h e d a s t r o n g movement toward a g r e a t e r use o f mass c o m m u n i c a t i o n t e c h n i q u e s i n New E n g l a n d , " i n c l u d i n g t h e i n i t i a t i o n o f a s i m i l a r s e r i e s e n t i t l e d "New E n g l a n d D e n t a l R e p o r t s f o r C o n t i n u i n g D e n t a l E d u c a t i o n . " I n a d d i t i o n , i t p i o n e e r e d an e f f o r t a t r e g i o n a l c o - o p e r a t i o n and p r e s e n t l y a s p e c i a l package o f 42 programs 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 u f f a l o , P i t t s b u r g h , i s b e i n g o f f e r e d by t h e E a s t e r n E d u c a t i o n a l T-V Network t o i t s member s t a t i o n s . The t o t a l c o s t o f each program was a p p r o x i m a t e l y $4,000 o r about $4 p e r p o t e n t i a l v i e w e r and between $10 and $12 p e r a c t u a l v i e w e r i n M a i n e . I n c r e a s i n g r e g i o n a l d i s t r i b u t i o n d e c r e a s e s c o s t s and t h e e s t i m a t e s o f t h e 82 number o f v i e w e r s range f r o m 9 p e r c e n t t o 38 p e r c e n t p e r program o f t h e p o t e n t i a l p h y s i c i a n p a r t i c i p a n t s . R o b e r t