"Education, Faculty of"@en . "Educational Studies (EDST), Department of"@en . "DSpace"@en . "UBCV"@en . "Nakamoto, June"@en . "2011-04-26T19:01:44Z"@en . "1972"@en . "Master of Arts - MA"@en . "University of British Columbia"@en . "This survey of the literature provides a comprehensive and comparative report on continuing education in the four senior health professions, medicine, dentistry, nursing, and pharmacy, covering the period from 1960 to 1970. Findings disclose that while continuing education is gaining momentum in the health field, each of the professions reviewed in this report admits that it has been far from successful in its implementation. The problems facing the professions, although in differing measure, were found to be: 1) the lack of resources\u00E2\u0080\u0094funds, qualified adult educators, and clinical facilities; 2) the need for more and better adult education research; and 3) the limitation of program goals within the context of the rapidly changing health care system. Recent public pressure to make continuing education a condition for practice, coupled with accelerating technological and scientific advances, indicate that continuing education can no longer be relegated to a secondary place in professional education. Due to the scarcity of substantive research, specific recommendations were not possible. However, it was suggested that: 1) more effective methods of defining learning needs be developed and tested; 2) more stress be placed on clinically oriented programs and those with built in evaluation schemes; and 3) regional centers be established to facilitate the development of ongoing, interrelated programs on both a uniprofessional and interprofessional basis. (Detailed descriptions of more innovative programs and evaluation practices are included.)"@en . "https://circle.library.ubc.ca/rest/handle/2429/33995?expand=metadata"@en . "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 \u00E2\u0080\u0094 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 \u00E2\u0080\u00A2 \u00E2\u0080\u00A2 \u00E2\u0080\u00A2 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 \u00E2\u0080\u009EEducational 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 \u00E2\u0080\u009E r ~ ~ - . - . \u00C2\u00AB ~ {z^.\u00E2\u0080\u009E\u00E2\u0080\u009E \u00E2\u0080\u009E _ , 3 . \u00E2\u0080\u0094 . . - . \u00E2\u0080\u009E 1 i - \u00E2\u0080\u0094 f -\ c r\\ c \u00E2\u0080\u0094 i - - - \u00E2\u0080\u0094 - - - ~ ~ 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 \u00E2\u0080\u00A2 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 . \u00E2\u0080\u00A2 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 \u00E2\u0080\u00A2 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 . \u00E2\u0080\u00A2 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 \u00E2\u0080\u00A2 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 \u00E2\u0080\u0094 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 \u00E2\u0080\u0094 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 \u00E2\u0080\u00A2 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. \u00E2\u0080\u00A2 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 ) \u00E2\u0080\u00A2 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 : \u00E2\u0080\u00A2 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 \u00E2\u0080\u009Eby 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 . \u00E2\u0080\u00A2 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 \u00E2\u0080\u0094 \" 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 s o n (211) c o n c l u d e s : \" S i z e o f t a r g e t a u d i e n c e must be weighed a g a i n s t c o s t , i n c l u d i n g t i m e and e f f o r t t o p r o d u c e and b r o a d c a s t t e l e v i s i o n programs... I f t h e t a r g e t a u d i e n c e i s s m a l l , t e l e v i s i o n , a mass medium, may be l e s s m o n i t a r i l y e f f i c i e n t and e d u c a t i o n a l l y p r o d u c t i v e t h a n o t h e r i n s t r u c t i o n a l methods\" ( 2 1 1 ) . The Oregon M e d i c a l A s s o c i a t i o n s p o n s o r e d i n 1966 a b r o a d c a s t t e l e v i s i o n s e r i e s p r o d u c e d by a committee o f s e v e n t e e n p h y s i c i a n members o f t h e a s s o c i a t i o n . By p l a c i n g t h i s r e s p o n s i b i l i t y on i t s a c t i v e membership, i t was hoped t h a t p r a c t i t i o n e r s would become more i n v o l v e d i n p l a n n i n g t h e i r own 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 s e r i e s e n t i t l e d \"The Oregon M e d i c a l R eview\" was b r o a d -c a s t w e e k l y f r o m J a n u a r y t o A p r i l and f o c u s s e d on c o n t e n t r e l e v a n t t o t h e r o l e o f t h e f i r s t c o n t a c t p h y s i c i a n . A s t u d y was made t h r o u g h m a i l q u e s t i o n n a i r e s and f o l l o w up t e l e p h o n e i n t e r v i e w s , u s i n g a r e p r e s e n t a t i v e sample drawn f r o m t h e p o t e n t i a l v i e w i n g a u d i e n c e o f 1,651 p h y s i c i a n s . T h i s d i s c l o s e d t h a t w h i l e t h e f i r s t f i v e programs a t t r a c t e d r e l a t i v e l y l a r g e numbers o f v i e w e r s , t h i s i n t e r e s t was n o t m a i n t a i n e d . The maximum number o f p h y s i c i a n s v i e w i n g any one program was 10.4 p e r c e n t . From r e s p o n s e s t o t h e t e l e p h o n e i n t e r v i e w s i t a p p e a r e d t h a t t h e i n v o l v e m e n t o f t h e e n t i r e membership o f t h e A s s o c i a t i o n i n programming was a c h i e v e d i n t h e o r y o n l y , p e r h a p s \"because t h e t e l e v i s i o n c o m m i t t e e i n t h e i r c o n c e r n t o g e t t h e j o b done, p e r m i t t e d t h e development o f an o r g a n i z a t i o n a l s t r u c t u r e t h a t was j u s t as d i s t a n t f r o m t h e a v e r a g e member and i n v o l v e d j u s t as h i e r a r c h i c p a t t e r n s as t h e s p o n s o r s h i p o f o t h e r 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 . \" M o r e o v e r , i t was f o u n d t h a t t h e program p l a n n e r s f r e q u e n t l y used i n d i v i d u a l s who were u n a b l e t o adapt t o t h e t e l e v i s i o n medium. Even more i m p o r t a n t , was t h e f a i l u r e t o i d e n t i f y s p e c i f i c i n s t r u c -t i o n a l o b j e c t i v e s f o r each program. I n c o n c l u s i o n , Meighan and T r e s e d e r (153) 83 n o t e d : \"The medium' p r o v i d e s a means whereby 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 may be d i s t r i b u t e d w i d e l y ; i t seems t o o f f e r some o u t s t a n d i n g l y a t t r a c t i v e f e a t u r e s . However, f u r t h e r s t u d y o f e d u c a t i o n a l e f f e c t i v e n e s s i s r e q u i r e d , t o show t h a t t h e s e o u t s t a n d i n g a t t r a c t i o n s a r e n o t i l l u s o r y . \" I n 1963, t h e New Y o r k Academy o f M e d i c i n e began p r e s e n t i n g on open c i r c u i t t e l e v i s i o n i t s w e e k l y C l i n i c a l S c i e n c e Seminars f o r p h y s i c i a n s . The p u r p o s e o f t h i s p r o j e c t was \" t o a s c e r t a i n t h e a c c e p t a b i l i t y and e f f e c t i v e n e s s o f t e l e v i s i o n as an a d d i t i o n a l medium f o r c o n t i n u a t i o n m e d i c a l e d u c a t i o n i n a m e t r o p o l i t a n a r e a \" . Through r e p e a t e d p o l l s , t h e s i z e , c o m p o s i t i o n , and o p i n i o n s o f p h y s i c a n s p a r t i c i p a t i n g i n t h e program were s t u d i e d . I n a d d i t i o n , t h e s t u d y sought t o d e t e r m i n e t h e i m p a c t o f t h e program on i t s a u d i e n c e by means o f an i n f o r m a t i o n t e s t w h i c h was a d m i n i s t e r e d t o 100 v i e w e r s and 100 n o n - v i e w e r s c o v e r i n g a p e r i o d o f f r o m f o u r t o e i g h t months a f t e r t h e p r e s e n t a t i o n o f s e l e c t e d programs i n t h e s e r i e s . W h i l e t h e f i n d i n g s o f t h i s s t u d y were somewhat c l o u d e d by t i m e v a r i a b l e s , t h e r e s u l t s i n d i c a t e d t h a t no s p e c i f i c l e a r n i n g c o u l d be d e m o n s t r a t e d (147) . McGuiness (148) i n d i c a t e d t h a t c u m u l a t i v e l y , p o l l s r e v e a l e d a n \" a u d i e n c e a v e r a g i n g o n l y 305 o r 4.8 p e r c e n t o f t h e p o t e n t i a l v i e w e r s t h a t was a t t r a c t e d r e g u l a r l y t o t h e s e r i e s . I t was f e l t t h a t c o n s i d e r i n g t h e expense and e f f o r t so s m a l l an a u d i e n c e d i d n o t j u s t i f y c o n t i n u i n g t h e program, so i t was t e r m i n a t e d i n 1968. Fahs and M i l l e r (94) d e s c r i b e d t h e e v a l u a t i o n o f a t e l e v i z e d s e r i e s b r o a d c a s t i n t h e s t a t e o f M i n n e s o t a betxvreen 1967-1968. I n t h e i r s t u d y , n i n e programs o f t h e s e r i e s were a n a l y z e d f r o m t h r e e p o i n t s o f v i e w : 1) t h e a c c u r a c y and r e c o g n i t i o n o f s c i e n t i f i c i n f o r m a t i o n ; 2) t h e s u c c e s s i n c o m m u n i c a t i o n ; and 3) t h e r e l e v a n c e o f t h e programs t o t h e c a r e o f p a t i e n t s . F o u r p a n e l s o f p h y s i c i a n s w i t h e x p e r t i z e i n t h e s e a r e a s were s e l e c t e d t o 84 make t h e e v a l u a t i o n . A c o m p a r i s o n was a l s o made o f t h e a c t u a l and p o t e n t i a l v i e w i n g a u d i e n c e \" w i t h i n f o r m a t i o n on why p h y s i c i a n s d i d n o t w a t c h and what i n s i g h t s came t o t h o s e who w a t c h e d . \" S i n c e o b j e c t i v e s f o r s p e c i f i c programs were n o t c l e a r l y d e f i n e d , t h e p a n e l i s t s were hampered i n t h e i r a t t e m p t s t o e v a l u a t e them. I n g e n e r a l , t h e s c i e n t i f i c c o n t e n t o f t h e s e r i e s was j u d g e d t o be a d e q u a t e , r e l i a b l e , and a c c u r a t e . W i t h r e s p e c t t o c o m m u n i c a t i o n and t e c h n i c a l p r o d u c t i o n , t h e comments of t h e p a n e l s were u n m i s t a k a b l y n e g a t i v e . As one p a n e l i s t p u t i t , \" t h e s e g e n t l e m e n c o m m u n i c a t i n g w i t h e ach o t h e r about t h e i r own h a b i t s o f p r a c t i c e j u s t d on't c o n v i n c e me t h a t I want t o e m u l a t e t h e i r s t y l e . \" A n o t h e r c o n c l u d e d , \"One program c o u l d have been p u t on a u d i o a l o n e w i t h no need f o r v i s i o n . The a p p e a r a n c e o f t h e p a n e l , u n l e s s i t s p e r s o n a l i t i e s a r e d y n a mic, i s l e s s t h a n w o r t h l e s s . \" Comments f r o m v i e w i n g p h y s i c i a n s s u g g e s t e d t h a t \"a c o n s i d e r a b l e amount o f program t e s t i n g o c c u r r e d , and where one program was u s e f u l t o t h e p h y s i c i a n i n h i s p r a c t i c e , he t r i e d o t h e r s . C o n v e r s e l y , when r e c e i v e d no b e n e f i t he q u i t w a t c h i n g . And the more programs t h e p h y s i c i a n saw, t h e c l e a r e r i t was t h a t he was g e t t i n g s o m e t h i n g o u t o f t h e s e r i e s . \" The m a j o r r e a s o n s g i v e n by p h y s i c i a n f o r n o t v i e w i n g were: n o t knowing o f t h e program's e x i s t e n c e , f o r g e t t i n g t o w a t c h , o r b e i n g too b u s y . Some a l s o i n d i c a t e d t h a t t h e y p r e f e r r e d t o w a t c h t h e t e n o ' c l o c k news. The a u t h o r s c o n c l u d e : No one d o u b t s t h a t c o n t i n u i n g m e d i c a l e d u c a t i o n t h r o u g h t e l e v i s i o n has p o t e n t i a l . However, few b e l i e v e t h a t i t s f u l l p o t e n t i a l i s p r e s e n t l y b e i n g u t i l i z e d , and v i r t u a l l y a l l a r e w i l l i n g t o e x p e r i m e n t t o some e x t e n t . T h i s e v a l u a t i o n r e a f f i r m s s u c h g e n e r a l i z a t i o n s and hopes t h a t c o n t i n u i n g e f f o r t be a p p l i e d t o b o t h new and o l d methods. A number o f m e d i c a l c e n t e r s i n Canada have r e p o r t e d some e x p e r i m e n t a t i o n i n t h e use o f b r o a d c a s t 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 (253) (119) ( 1 1 ) . The g e n e r a l i m p r e s s i o n g a i n e d from t h e l i t e r a t u r e i s t h a t most C a n a d i a n p r o d u c t i o n s have f o l l o w e d t h e t y p i c a l A m e r i c a n f o r m a t , namely, l e c t u r e s o r p a n e l p r e s e n t a t i o n s f o l l o w e d by a b r i e f q u e s t i o n and answer p e r i o d . As i n t h e U n i t e d S t a t e s , t h e pr o b l e m s o f t e c h n i c a l p r o d u c t i o n , c o s t s r e l a t i v e t o v i e w e r s h i p , and d i f f i c u l t i e s i n e v a l u a t i n g t h e w o r t h o f t e l e v i z e d p r o g r ams, have been i d e n t i f i e d as t h e ma j o r o b s t a c l e s i n t h e use and e x p a n s i o n o f t h e medium (119) ( 2 5 3 ) . Encoded o r Sc r a m b l e d B r o a d c a s t T e l e v i s i o n : W h i l e no s t u d i e s t o d a t e have r e v e a l e d s p e c i f i c r e a c t i o n s f r o m l a y v i e w e r s , t h e q u e s t i o n o f c o m p l e t e p r o f e s s i o n a l p r i v a c y i s s t i l l b e i n g d e b a t e d w i t h i n t h e m e d i c a l p r o f e s s i o n ( 2 6 3 ) , and t h i s has r e s u l t e d i n a n e t w o r k o f m e d i c a l s c h o o l s and a f f i l i a t i n g h o s p i t a l s i n C a l i f o r n i a u s i n g 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 (30) ( 1 6 5 ) . Under t h i s s y s t e m , t h e p i c t u r e a p p e a r s on t h e s t a n d a r d t e l e v i s i o n s c r e e n , b u t i n encoded f o r m t h u s p r e v e n t i n g p u b l i c v i e w i n g . D e c o d i n g o r u n s c r a m b l i n g i s a c c o m p l i s h e d by a m o d i f i e d r e c e i v e r . Because t h e s e d e c o d e r s a r e s t i l l r e l a t i v e l y e x p e n s i v e , i n t h e C a l i f o r n i a e x p e r i m e n t s t h e y have been p l a c e d o n l y i n t h e a f f i l i a t i n g h o s p i t a l s . T h i s i s b e l i e v e d t o have s e v e r a l a d v a n t a g e s : 1) i t makes the community h o s p i t a l t h e c e n t e r 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 , 2) i t makes f e a s i b l e an a c c u r a t e r e c o r d o f t h e number o f v i e w e r s o f each program, and 3) i t makes i t p o s s i b l e f o r t h e u n i v e r s i t i e s t o c h a r g e a t u i t i o n f e e f o r p a r t i c i p a t i o n i n t h e n e t w o r k , w h i c h i n t u r n makes p o s s i b l e s u p e r i o r p r o d u c t i o n t e c h n i q u e s ( 3 0 ) . The s u c c e s s o f an i n i t i a l p i l o t p r o j e c t l i n k i n g 15 community h o s p i t a l s w i t h t h e U n i v e r s i t y o f C a l i f o r n i a i n 1965, r e s u l t e d i n t h e e x p a n s i o n o f t h e number o f p a r t i c i p a t i n g h o s p i t a l s and t h e m e r g i n g o f s i x ma j o r m e d i c a l c e n t e r s 86 and t h e i r t e l e v i s i o n f a c i l i t i e s t o f o r m t h e M e d i c a l T e l e v i s i o n Network (MTN) f o r t h e p r o d u c t i o n and d i s t r i b u t i o n o f t e l e v i z e d programs. A t t h e end o f t h e second y e a r o f b r o a d c a s t i n g , B r a y t o n r e p o r t e d (29) 72 h o s p i t a l s p a r t i c i p a t i n g i n MTN w i t h an a d d i t i o n a l 18 h o s p i t a l s p a r t i c i p a t i n g i n a v i d e o t a p e d i s t r i b u t i o n s y s t e m whereby h o s p i t a l s r e c e i v e d t h e programs on one i n c h v i d e o t a p e w h i c h c o u l d t h e n be p l a y e d b a c k on r e l a t i v e l y i n e x p e n s i v e v i d e o r e c o r d e r s . Through a c o n t r a c t w i t h t h e U n i t e d S t a t e s P u b l i c H e a l t h S e r v i c e , t h e MTN i s c u r r e n t l y o p e r a t i n g w i t h a p r o f e s s i o n a l s t a f f and f a c i l i t i e s . C o n s e q u e n t l y , t h e q u a l i t y o f t h e programs has been g r e a t l y i m p r o v e d and t h e t u i t i o n c h a r g e d h o s p i t a l s has been l o w e r e d s u b s t a n t i a l l y . A t t e n d a n c e d a t a shows t h a t MTN b r o a d c a s t s a r e r e a c h i n g some 750 p h y s i c i a n v i e w e r s each week and t h a t a p p r o x i m a t e l y 28,000 h o u r s o f i n s t r u c t i o n a r e p r o v i d e d i n t h e 38 programs o f f e r e d y e a r l y . S i n c e most of t h e programs have g e n e r a l i s t s as t h e i r t a r g e t a u d i e n c e , i t i s n o t s u r p r i s i n g t h a t t h e g r e a t e s t number o f v i e w e r s have been g e n e r a l p r a c t i t i o n e r s and i n t e r n i s t s , w i t h s p e c i a l i s t s i n t h e n a r r o w e r s p e c i a l t i e s b e i n g t h e l e a s t m o t i v a t e d t o p a r t i c i p a t e . I n 1968 B r a y t o n (30) r e p o r t e d t h a t : . The MTN v i d e o t a p e r e d u p l i c a t i o n and d i s t r i b u t i o n s y s t e m has been r e - o r g a n i z e d t o combine t h e S o u t h e r n C a l i f o r n i a t e l e v i s i o n r e s o u r c e s w i t h t h o s e o f a s i m i l a r encoded n e t w o r k i n San F r a n c i s c o f o r N o r t h e r n C a l i f o r n i a . . . T h e r e s u l t i n g v i d e o t a p e d i s t r i b u t i o n s y s t e m , now c a l l e d t h e C a l i f o r n i a M e d i c a l T e l e v i s i o n Network w i l l r e d u p l i c a t e and p o o l t h e o u t s t a n d i n g programs b r o a d c a s t f o r m e d i c a l and p a r a m e d i c a l e d u c a t i o n i n e ach a r e a and r e g u l a r l y d i s t r i b u t e t h e s e t o p a r t i c i p a t i n g h o s p i t a l s . . . I n t h i s way, t h e combined m e d i c a l f a c u l t i e s i n t h e most p o p u l o u s s t a t e w i l l f o r m t h e academic base f o r c o n t i n u i n g m e d i c a l and p a r a m e d i c a l e d u c a t i o n u s i n g t h e newest t e l e v i s i o n m o d a l i t y . D e s p i t e s u c h o p t i m i s m r e g a r d i n g t h e f u t u r e o f encoded b r o a d c a s t t e l e v i s i o n , i n a r e c e n t r e p o r t of a t f e v a l u a t i o n o f f o u r programs s p o n s o r e d by t h e N o r t h e r n C a l i f o r n i a Network, Mock (165) c o n c l u d e d : W h i l e most o f t h e assessment t e c h n i q u e s i n t h i s s t u d y e n c o u n t e r e d s e r i o u s sample d e p l e t i o n , g i v e n t h i s l i m i t a t i o n . . . v i r t u a l l y no m e a s u r a b l e changes i n e i t h e r b e h a v i o u r o r i n f o r m a t i o n l e v e l were found w h i c h c o u l d be d i r e c t l y a t t r i b u t e d t o t h e programs... I t was n o t e d t h a t two 87 h o s p i t a l s changed t h e i r i n f e c t i o n c o n t r o l p r o c e d u r e s , b u t does t h i s make t h e s e r i e s w o r t h w h i l e ? The answer t o t h i s q u e s t i o n w o u l d r e q u i r e an o b j e c t i v e c o m p a r i s o n between p o s t g r a d u a t e m e d i c a l t e l e v i s i o n and o t h e r t e a c h i n g m edia. The s t u d i e s w h i c h w i l l p r o v i d e an answer t o t h i s q u e s t i o n r e m a i n t o be done. More p o i n t e d l y , L a u l e r (55) c o n c l u d e s : \"The e x p l o i t a t i o n o f a g i v e n medium w i t h o u t l e v e r a g i n g i t s a d v a n t a g e s i n j u x t a p o s i t i o n t o o t h e r media doomed t h e t e l e v i s i o n medium t o f a i l u r e . . . T h e m a j o r l i m i t a t i o n o f t h e p r o d u c t i o n o f t e l e v i s i o n o r movie m a t e r i a l r e s i d e s i n t h e s o f t w a r e a s p e c t . \" Slow Scan T e l e v i s i o n : An e x p e r i m e n t a l p r o j e c t c u r r e n t l y p l a n n e d 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 w i l l use s l o w s c a n t e l e v i s i o n c a r r i e d by a t e l e p h o n e and r a d i o l i n k f rom t h e c l a s s r o o m a t t h e M e d i c a l Communications C e n t e r t o f o u r s m a l l community h o s p i t a l s w i t h r e c e p t i o n f a c i l i t i e s . As d e s c r i b e d by Meyer ( 1 5 6 ) : U s i n g t h i s medium s t i l l s n a p s h o t s a r e t r a n s m i t t e d o v e r o r d i n a r y t e l e p h o n e w i r e s t h u s o b v i a t i n g t h e need f o r e x p e n s i v e c o - a x i a l o r m i crowave r s l a y s y s t e m s . S p e c i a l r e c e i v e r s s t o r e t h e p i c t u r e s and r e l e a s e them a p p r o x i m a t e l y e i g h t m i n u t e s l a t e r . . . T h u s t h e p a r t i c i p a n t s i n t h e community h o s p i t a l s have t h e l i v e v o i c e s , t h e s l i d e s , and o t h e r v i s u a l s used d u r i n g t h e c o n f e r e n c e as w e l l as t h e s t i l l p i c t u r e s . A c c o r d i n g t o Meyer, o t h e r a t t r i b u t e s w h i c h make s l o w s c a n t e l e v i s i o n a t t r a c t i v e a r e : I t s a b i l i t y f o r random a c c e s s i n f o r m a t i o n r e t r i e v a l so t h a t 5,000 h o u r s o f i n s t r u c t i o n and 10,000 v i s u a l s can be s t o r e s , r e t r i e v e d , and shown i n remote p o i n t s . I n a d d i t i o n , i t h o l d s the a b i l i t y f o r h a r d copy p r i n t o u t a t remote l o c a t i o n s so t h a t . p r i n t e d i n f o r m a t i o n i n s e r t e d a t one end o f t h e s y s t e m can be f a i t h f u l l y r e p r o d u c e d a t t h e o t h e r w i t h o u t t e l e t y p e w r i t e r s , a s o r t o f l o n g d i s t a n c e X e r o x M a c h i n e . SUPPORTING DEVICES The s u p p o r t i n g d e v i c e s r e v i e w e d h e r e a r e t h o s e newer e d u c a t i o n a l t e c h n o l o g i e s w h i c h have found t h e i r g r e a t e s t use as q u i c k i n f o r m a t i o n s o u r c e s , o r as a means of s e l f i n s t r u c t i o n . 88 M o t i o n P i c t u r e s ; V i d e o t a p e s : P r o b a b l y t h e most s i g n i f i c a n t development i n t h e a r e a o f f i l m s has been t h e e s t a b l i s h m e n t o f a S i n g l e Concept F i l m S e r v i c e o f f e r e d by t h e U n i v e r s i t y o f W i s c o n s i n . Community h o s p i t a l s a r e p r o v i d e d w i t h a s m a l l p o r t a b l e p r o j e c t o r a l o n g w i t h s i n g l e c o n c e p t f i l m s on new m e d i c a l t e c h n i q u e s w h i c h a r e on l o a n f o r s i x weeks. Each f i l m r u n s f r o m s i x t o t e n m i n u t e s and c o n t a i n s o n l y e s s e n t i a l i n f o r m a t i o n . When th e u s e r p r e s s e s a l e v e r t h e p i c t u r e and sound s t a r t i m m e d i a t e l y . S i n c e t h e f i l m i s s e l f r e - w i n d i n g , he can v i e w t h e f i l m a second t i m e m e r e l y by p r e s s i n g t h e l e v e r a g a i n . Meyer (155) r e p o r t s t h a t a s e r i e s o f s i x f i l m s a r e i n c i r c u l a t i o n among 47 h o s p i t a l s i n W i s c o n s i n . A r e c e n t s u r v e y based on a p p r o x i m a t e l y 1,600 q u e s t i o n n a i r e 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 r e v e a l e d t h a t 93 p e r c e n t o f r e s p o n d e n t s f e l t t h a t t h e f i l m s p r o v i d e d u s e f u l m e d i c a l i n f o r m a t i o n . A c c o r d i n g t o W e n r i c h (263) p h a r m a c e u t i c a l companies have a l s o p r o d u c e d a number o f f i l m s and TV k i n e s c o p e s w h i c h a r e l o a n e d t o h o s p i t a l and m e d i c a l g r o u p s . The U p j o h n Company has p r o d u c e d a s e r i e s c a l l e d Grand Rounds on 16 mm f i l m w h i c h i s a v a i l a b l e t h r o u g h i t s r e g i o n a l o f f i c e s . S i m i l a r l y , The Roche M e d i c a l L a b o r a t o r y p r o d u c e s v i d e o t a p e s f o r i t s - \"network 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 \" w h i c h i n c l u d e s h o s p i t a l s a c r o s s t h e c o u n t r y . Audio-Tape R e c o r d i n g s and D i s c S e r v i c e s : P r o b a b l y t h e o l d e s t and most e s t a b l i s h e d t a p e r e c o r d i n g s u b s c r i p t i o n s e r v i c e i n o p e r a t i o n i s A u d i o D i g e s t , a n o n - p r o f i t s u b s i d i a r y 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 . O a k l e y (175) r e p o r t s t h a t some 30,000 t a p e s a r e s e n t each month t o s u b s c r i b e r s i n t h e U n i t e d S t a t e s , Canada, and o v e r s e a s . These t a p e s , r a n g i n g f r o m one h a l f t o one hour i n l e n g t h , r e p r e s e n t e d i t e d p o r t i o n s o f l e c t u r e s , p a n e l s , d i s c u s s i o n s , and s y m p o s i a p u b l i s h e d i n t h e c u r r e n t l i t e r a t u r e . The a r e a s o f m e d i c i n e c o v e r e d by t h i s s e r v i c e i n c l u d e g e n e r a l p r a c t i c e , i n t e r n a l 89 medicine, surgery, obstetrics and gynecology, pediatrics, anesthesiology, and opthalmology. Important meetings are also taped and sent to subscribers. Wenrich (263) reports that Excerpta Medica has begun producing \"Voices of Medicine\" which provides weekly tape recordings of abstracted literature and feature presentations on selected subjects. The American College of Cardiology, in collaboration with the Radio Corporation of America, has begun a monthly tape service called Access Library Service focussing on subjects which have the greatest relevance to the practice of cardiology (146). While the aim of these services is to provide a way that busy practi-tioners can acquire information by listening in their homes or while driving to work, reports by Aitken (4) and others (263) (37) suggest that only a certain proportion of physicians are attracted to this process. A study reported by Aitken (4) found that of the 655 tapes requested and sent out in 1961, 29 users who took ten or more tapes each year used 513 of the total. Another finding of interest was that 60 percent of the tapes requested went to general practi-tioners in the country or small towns. In 1962, the Canadian College set up a disc service using twelve-inch long-playing discs in which the members of the service retained their own recordings. This method has proven extremely popular, and by 1963 a number of listening groups had formed. According to Harris (111) Smith and Hoist Incorporated in California have developed a series of illustrated medical lectures using both film strips and tape recordings produced by Loma Linda University School of Medicine. These lectures range from anesthesiology, internal medicine, obstetrics, cancer, and cariovascular disease to urology. Abrahamson and his colleagues (4) at the University of Southern California report a recent evaluation of a special self-instructional device 90 c o m b i n i n g a s e v e n i n c h r e c o r d w i t h a f i l m s t r i p . I n t h i s s t u d y , 100 g e n e r a l p r a c t i t i o n e r s s e l e c t e d by s t r a t i f i e d random s a m p l i n g i n t h e 11 W e s t e r n s t a t e s s e r v e d as t h e e x p e r i m e n t a l group w h i l e a n o t h e r 100 s e r v e d as c o n t r o l s . F i f t e e n programs were c i r c u l a t e d t o t h e 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 s t u d y . A ssessment p r o c e d u r e s i n c l u d e d : 1) p o s t t e s t s o f i n f o r m a t i o n ; 2) p r e - a n d - p o s t p r o j e c t q u e s t i o n n a i r e s a s s e s s i n g \" c o m m u n i c a t i o n b e h a v i o u r \" and program a c c e p t a b i l i t y , and 3) i n t e r v i e w s o f a sample o f t h e p h y s i c i a n s t o v a l i d a t e q u e s t i o n n a i r e r e s p o n s e s and t o augment th e d a t a . A n a l y s i s o f t h e d a t a r e v e a l e d a s i g n i f i c a n t l e a r n i n g o f i n f o r m a t i o n on a l l p r o g r a m s ; h i g h a c c e p t a b i l i t y o f t h e a p p r o a c h , b u t no s i g n i f i c a n t change i n \" c o m m u n i c a t i o n b e h a v i o u r \" ( d e f i n e d i n t h i s s t u d y as \" t h e way i n w h i c h p h y s i c i a n s a t t e m p t t o o b t a i n c o n t i n u i n g e d u c a t i o n \" ) . I n k e e p i n g w i t h h i s b a s i c p h i l o s o p h y t h a t l e a r n i n g s h o u l d be b o t h f u n and c h a l l e n g i n g , Woolsey (277) i s d e v e l o p i n g a m e d i c a l j u k e b o x w h i c h w i l l o f f e r p h y s i c i a n s 160 s i x - m i n u t e 33 1/3 rpm r e c o r d s , t o t a l l i n g 16 h o u r s of i n s t r u c t i o n . To i l l u s t r a t e t h e spoken word, two d i a l - a c c e s s C a r o u s e l p r o j e c t o r s have been i n t e g r a t e d i n t o t h e j u k e b o x mechanism so t h a t two by two i n c h c o l o r t r a n s p a r e n c i e s a r e a u t o m a t i c a l l y s y n c h r o n i z e d and p r o j e c t e d . I f t h e d o c t o r has a q u e s t i o n w h i c h t h e j u k e b o x c a n ' t answer, a t a p e r e c o r d e r w i l l r e c o r d t h e q u e s t i o n w i t h t h e p h y s i c i a n ' s name and a d d r e s s , and i t w i l l t h e n be answered by r e t u r n m a i l . A n o t h e r i n t e r e s t i n g f e a t u r e w i l l be t h a t t h e u s e r w i l l be a s k e d t o e v a l u a t e t h e m a t e r i a l p r e s e n t e d a t t h e c o n c l u s i o n o f e ach r e c o r d , r a t i n g i t . . . v e r y h e l p f u l ; h e l p f u l ; s l i g h t l y h e l p f u l ; o r no h e l p , by p u n c h i n g an a p p r o p r i a t e b u t t o n on t h e machine. A l s o b e i n g c o n s i d e r e d i s t h e i n c l u s i o n o f an o p t i o n t h a t w o u l d r e q u i r e t h e p h y s i c i a n t o drop a q u a r t e r i n t h e s l o t i n o r d e r t o g e t h i s program. A t i t s c o n c l u s i o n , he w o u l d be a s k e d a r e l e v a n t q u e s t i o n and o f f e r e d f o u r m u l t i p l e c h o i c e a n s w e r s . By p u s h i n g t h e a p p r o p r i a t e b u t t o n he w o u l d i n d i c a t e h i s c h o i c e . I f h i s answer i s c o r r e c t , h i s q u a r t e r i s r e t u r n e d . 91 Mediphone S e r v i c e s : I n 1966, t h e U n i v e r s i t y o f W i s c o n s i n p i o n e e r e d a n o n - c o m p u t e r i z e d D i a l A c c e s s s e r v i c e . The o b j e c t i v e s o f t h i s p r o j e c t were: 1) t o make a v a i l a b l e c u r r e n t a u t h o r i t a t i v e i n f o r m a t i o n t w e n t y f o u r h o u r s a day f o r use i n emergency s i t u a t i o n s , and 2) as a method o f u p d a t i n g m e d i c a l i n f o r m a t i o n . I n t e n d e d s t r i c t l y as a q u i c k s o u r c e of r e f e r e n c e e ach t a p e i s f i v e t o s i x m i n u t e s i n l e n g t h . When t h e p h y s i c i a n w i s h e s i n f o r m a t i o n r e l e v a n t t o any o f t h e 230 s u b j e c t s l i s t e d i n t h e d i r e c t o r y , he m e r e l y d i a l s t h e t o l l f r e e number d e s i g n a t e d , and r e q u e s t s t h e t a p e . I n an a v e r a g e o f t w e n t y seconds a f t e r r e c e i p t o f t h e c a l l t h e t a p e r e q u e s t e d i s p l a y e d f o r him o v e r t h e t e l e p h o n e l i n e . A p r e l i m i n a r y s u r v e y i n 1968 r e v e a l e d t h a t : 1) s u c h a l i b r a r y had e q u a l a p p e a l t o g e n e r a l p r a c t i t i o n e r and s p e c i a l i s t i n b o t h u r b a n and r u r a l a r e a s ; 2) a s i g n i f i c a n t number o f p h y s i c i a n s u s e d t h e s e r v i c e as l o n g as p r o m o t i o n was r e i n f o r c e d f r e q u e n t l y w h i l e a s m a l l number o f p r a c t i t i o n e r s u s e d t h e l i b r a r y as an e s t a b -l i s h e d s o u r c e o f i n f o r m a t i o n r e t r i e v a l ; and 3) a s i g n i f i c a n t p e r c e n t o f l i b r a r y u t i l i z a t i o n was f o r c o n t i n u i n g e d u c a t i o n , t h a t i s , r e v i e w , o r u p d a t i n g knowledge o r g a i n i n g new m e d i c a l i n f o r m a t i o n . On t h e b a s i s of t h e s e f i n d i n g s , Meyer (157) c o n c l u d e s : \"Whether on t h e b a s i s o f p o p u l a r i t y o r e v a l u a t i o n d a t a i t a p p e a r s t h a t t h e r e i s a s u f f i c i e n t d e g r e e o f e n t h u s i a s m f o r t h i s means o f i n f o r m a t i o n r e t r i e v a l and t h a t t h e d i a l a c c e s s l i b r a r y c o n c e p t can be e x p e c t e d t o e x p e r i e n c e r a p i d g r o w t h . \" M i n n e s o t a and N o r t h D a k o t a a r e l i n k e d t o t h e W i s c o n s i n L i b r a r y u s i n g t h e i r own s e p a r a t e c o m m u n i c a t i o n s y s t e m s . I n Canada, t h e U n i v e r s i t y o f Saskatchewan has r e c e n t l y i n i t i a t e d a D i a l A c c e s s S e r v i c e . To d a t e , \"Three hundred and s i x f i v e - m i n u t e messages have been r e c e i v e d f r o m W i s c o n s i n and b o o k l e t s l i s t i n g t i t l e s have been d i s t r i -b u t e d t o a l l Saskatchewan p h y s i c i a n s . Twenty new s c r i p t s f o r messages have been c o m p l e t e d by Saskatchewan s p e c i a l i s t s and t w e n t y more a r e i n p r e p a r a t i o n . \" 92 U t i l i z a t i o n o f t h e s e r v i c e i s r e p o r t e d s a t i s f a c t o r y t o d a t e ( 1 3 ) . The M i s s o u r i RMP has s p o n s o r e d t h e development o f a D i a l A c c e s s L i b r a r y . I t d i f f e r s f r o m t h e W i s c o n s i n L i b r a r y i n t h a t t h e s y s t e m i s c o m p u t e r i z e d . A c c o r d i n g t o Sawyer ( 1 0 1 ) , \" t h i s makes t h e s e r v i c e c h e a p e r and more e f f i c i e n t , e l i m i n a t i n g t h e f a c t o r o f human e r r o r . \" A number o f m e d i c a l s p e c i a l i s t s a r e h e l p i n g t o t e s t t h e s y s t e m by e v a l u a t i n g t h e messages f r o m t h e e x p e r t s ' v i e w p o i n t and a d v i s i n g where c o r r e c t i o n s a r e r e q u i r e d ( 1 0 1 ) . Under t h e Alabama RMP t h e U n i v e r s i t y o f Alabama has r e c e n t l y become th e h e a d q u a r t e r s f o r a \"wide a r e a t e l e p h o n e s y s t e m \" p r o v i d i n g l i v e t e l e p h o n e c o n s u l t a t i o n s e r v i c e s f o r p h y s i c i a n s i n w i d e l y s c a t t e r e d r u r a l and s e m i - r u r a l c o m m u n i t i e s and t h e i r h o s p i t a l s . C a l l e d MIST, t h i s p r o j e c t i s r e p o r t e d t o have s e r v e d o v e r 900 c o n s u l t a t i o n r e q u e s t s f r o m a l l p a r t s o f t h e s t a t e o v e r a s h o r t s i x month p e r i o d . Brown and U h l (32) r e p o r t t h a t b o t h community p h y s i c i a n s and f a c u l t y have f o u n d t h e s y s t e m b o t h f e a s i b l e and u s e f u l . C o r r e s p o n d e n c e ; Programmed I n s t r u c t i o n : I n 1962 t h e j o u r n a l Spectrum p u b l i s h e d an a r t i c l e on programmed l e a r n i n g a l o n g w i t h a programmed sequence on how t o r e a d an e l e c t r o c a r d i o g r a m on myo-c a r d i a l i n f a r c t i o n . The i s s u e was c i r c u l a t e d t o 225,000 p h y s i c i a n s i n t h e U n i t e d S t a t e s , o f whom 50,000 r e p l i e d w i t h a \" b l a n k e t endorsement o f t h e program.\" As a r e s u l t , a l o n g e r program on a l l e r g y and h y p e r s e n s i t i v i t y was made a v a i l a b l e t o p h y s i c i a n s on r e q u e s t . B a l s o n (18) r e p o r t s t h a t t h i s program i s i n use i n 74 of t h e 91 A m e r i c a n m e d i c a l s c h o o l s . I n 1964 S p r e i g e l (234) r e p o r t e d a s u b j e c t i v e e v a l u a t i o n o f a c o u r s e on D i a b e t e s C o n t r o l t a u g h t by programmed i n s t r u c t i o n on a t e a c h i n g m a c hine. Of t h e 78 p h y s i c i a n s who c o m p l e t e d t h e c o u r s e , a l l f e l t i t was a m e a n i n g f u l program. I n c omparing t h i s d e v i c e w i t h o t h e r e d u c a t i o n a l t e c h n i q u e s , t h e 93 physicians strongly endorsed the teaching machine approach. On the basis of post program interviews and follow-up mail questionnaires, i t was estimated that two thirds to three quarters of the physicians who completed the program have modified, or w i l l modify, their diagnostic and/or treatment practices with diabetes as a result of having participated i n the course. Programmed instruction li k e correspondence studies, appears to have found i t s greatest use as a supplementary device used in conjunction with other forms of instruction (54) (59) (61). Computer Assisted Instruction: Computer assisted instruction (CAI) in medical education is s t i l l in i t s infancy. Paxton (180) reports that a number of diversified medical cases have been computer programmed by the University of I l l i n o i s . A physician with an interesting case can question the computer in his own words and the imaginative r i V A r r m - m -? T-> r> /z> n M O n +-V\u00C2\u00BB/^ /\">m -r-\ i \u00C2\u00BB y TN -T /-Or- 1 r/>Ti v.-\u00C2\u00BB/-\ -v A r*> -An +-T-i/> 3^ /-\u00C2\u00BB\u00C2\u00BB-\u00C2\u00BB 4- e-\ -y- ^ r i i ^ f o + * r i n i o n f j> J- Vy ^ i- Uuuua.iijj U J . I . U J X ^ U V.1.XV- vviii^UwCi k. \ J -t- V- iv UUL iv*\u00E2\u0080\u0094_y WWJ-UkJ J.11 ti l t - u O L v - V J L i _ * i_> U-Cl.k-Vl-lHV--l-l.V-for which i t then provides the appropriate answer. Also under development are several computerized self-testing programs. Although these are s t i l l experi-mental, i t is planned that they w i l l be expanded to include continuing education hookups with some outlying hospitals. Ohio State University has some tutorial evaluation programs routinely available to medical students and by telephone lines to physicians in ten area hospitals. The equipment is less elaborate in that i t uses teletypewriter terminals instead of TV display screens. The teleprinter i s augmented by a slide projector with coloured slides. The computer instructs the user when to view a particular slide. The learner takes as long as he likes to examine i t then types the response called for by the program. The University of Oklahoma tested a variety of computerized teaching programs between 1965 and 1968. Harless et. a l (110) report the findings of 94 one s tudy i n v o l v i n g f o u r t e e n p r a c t i s i n g p h y s i c i a n s who at tended a one week course i n c l i n i c a l a n e s t e h e s i o l o g y i n which a one hour CAI l e s s o n was i n c l u d e d . Data showed t h a t the p h y s i c i a n s ' a t t i t u d e s toward C A I , e d u c a t i o n a l t e l e v i s i o n , and programmed i n s t r u c t i o n t e x t s were comparable b e f o r e exposure to C A I . A f t e r the CAI l e s s o n , a t t i t u d e s toward CAI were s i g n i f i c a n t l y more p o s i t i v e than were a t t i t u d e s towards e i t h e r e d u c a t i o n a l t e l e v i s i o n or programmed i n s t r u c t i o n . At the U n i v e r s i t y of Southern C a l i f o r n i a , Abrahamson and Denson (3) have produced a computer ized l e a r n i n g a i d c a l l e d Sim One, a r e a l i s t i c mannequin upon which p h y s i c i a n s may l e a r n how to c a r r y out e n d o t r a c h e a l i n t u b a t i o n . The computer i s programmed so tha t the mannequin r e a c t s p h y s i o l o g i c a l l y to v a r i o u s drugs or t reatments which may be a d m i n i s t e r e d . Continuous g r a p h i c d i s p l a y s show the changes i n b l o o d p r e s s u r e , p u l s e r a t e , e t c . , d e p i c t i n g the mannequin's responses to t r e a t m e n t . Wires from the s t r a t e g i c a l l y p l a c e d magnets and sensors r u n from Sim One through a l a r g e c a b l e to the computer and to the i n s t r u c t o r at a c o n t r o l c o n s o l e , so t h a t the i n s t r u c t o r i s kept posted on the p h y s i c i a n ' s p r o g r e s s i n l e a r n i n g . I n one s tudy of s k i l l a c q u i s i t i o n , the l e a r n i n g r a t e of t e n new a n e s t h e s i o l o g y r e s i d e n t s was compared, f i v e of whom took the c o n v e n t i o n a l i n s t r u c t i o n , and f i v e of whom l e a r n e d the technique u s i n g the mannequin. F i n d i n g s r e v e a l e d tha t those who used Sim One took an average of 30 at tempts over a p e r i o d of 45.6 days to ach ieve n i n e out of ten p r o f e s s i o n a l l y competent i n t u b a t i o n s as compared w i t h 60 at tempts i n 77 days f o r the c o n t r o l g r o u p . Abrahamson and Denson p l a n to develop re f inements of Sim One f o r t e a c h i n g o ther s p e c i f i c techniques to m e d i c a l and p a r a m e d i c a l w o r k e r s . Paxton (180) i n d i c a t e s t h a t the Sims \" can s h o r t e n the t ime r e q u i r e d to teach manual p r o c e -dures i n almost every phase of m e d i c i n e . \" 95 A l l e n and Ottem (5) r e p o r t t h r e e e x p e r i m e n t a l programs u t i l i z i n g a u d i o r e s p o n s e computer s e r v i c e s . One i s a d r u g c o m p a t a b i l i t y program i n w h i c h t h e i n p u t i s a p a i r o f d r u g codes and t h e o u t p u t one o f f o u r c o m p a t a b i l i t i e s : \" y e s \" , \"no\", \" c o n d i t i o n a l \" , or\"unknown.\" The second program i s a b u r n f o r m u l a program w h i c h c a l c u l a t e s t h e p r o p e r i n i t i a l q u a n t i t i e s o f e l e c t r o l y t e s and f l u i d r e q u i r e d i n t r e a t m e n t . The t h i r d i s a symptom d i a g n o s i s program t h a t i s augmented by d i a g n o s t i c d a t a i n t h e l i t e r a t u r e . A s i m i l a r b u t more s o p h i s t i c a t e d computer program i s r e p o r t e d i n o p e r a t i o n a t t h e U n i v e r s i t y o f M i s s o u r i . T h i s program, c a l l e d C o n s i d e r u s e s c a t h o d e r a y t u b e (T.V.) i n p u t - o u t p u t t e r m i n a l s . The m a j o r weakness i s t h e absence of p r i n t e d o u t p u t w h i c h c o u l d be r e q u i r e d f o r l e g a l r e a s o n s o r f o r a p a t i e n t ' s r e c o r d . The c o s t o f t h e s e programs i s r e p o r t e d as r e a s o n a b l e . A l l e n and Ottem e s t i m a t e t h a t The i n t r a v e n o u s a d d i t i v e program c o s t s under 35 c e n t s f o r e ach r u n p l u s $10 p e r month f o r program and d a t a s t o r a g e . The b u r n f o r m u l a program w h i c h i s p u r e l y c o m p u t a t i o n a l , c o s t s r o u g h l y 50 c e n t s p e r use p l u s $1 p e r month f o r r e q u i r e d s t o r a g e . The d i a g n o s t i c a s s i s t a n c e program c o s t s about 40 c e n t s * p e r c a l c u l a t i o n p l u s $2 p e r month f o r s t o r a g e . They s u g g e s t t h a t a f e a t u r e w h i c h w o u l d g r e a t l y i mprove computer programs wou l d be A c c e s s t o d a t a b a s e s f r o m v a r i o u s a u t h o r i t i e s f o r c o n t r o v e r s i a l s u b j e c t a r e a s . T h i s f e a t u r e would g i v e a computer ne t w o r k some o f t h e f l e x i b i l i t y now o f f e r e d t o t h e p h y s i c i a n by h a v i n g s e v e r a l m e d i c a l t e x t b o o k s , j o u r n a l a r t i c l e s , and s c i e n t i f i c documents a v a i l a b l e on p a r t i c u l a r t o p i c s . ORGANIZATION FOR INSTRUCTIONAL TECHNOLOGY A number o f r e c e n t a r t i c l e s p r o v i d e e v i d e n c e o f a t t e m p t s t o c r e a t e p r o p e r f a c i l i t i e s and e n v i r o n m e n t s f o r t h e e f f e c t i v e use o f mass media i n 96 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 s o b e i n g d i s c u s s e d and implemented a r e c e n t r a l i z e d systems t o e x p e d i t e the development and d i s t r i b u t i o n o f t h e i n s t r u c t i o n a l m a t e r i a l s and d e v i c e s on b o t h t h e r e g i o n a l and n a t i o n a l l e v e l s . R e g i o n a l : I n 1959 t h e U n i v e r s i t y o f U t a h d e v e l o p e d an A u d i o - V i s u a l K i t w h i c h c o u l d be s h i p p e d t o p h y s i c i a n s i n r u r a l c o m m u n i t i e s . C o n t a i n e d i n t h e k i t were m e d i c a l d i s c u s s i o n s on l o n g p l a y r e c o r d s , accompanying s c r i p t s ; and c o l o u r e d s l i d e s . T h i s m a i l s e r v i c e p r o v e d s u c c e s s f u l so o t h e r o r g a n i z a t i o n s d e v e l o p e d s i m i l a r programs (232) . The 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 i s d e v e l o p i n g a M o b i l e Van S e r v i c e ( 1 6 4 ) . I t s p u r p o s e i s \" t o p r o v i d e a m u l t i - m e d i a a p p r o a c h to c o n t i n u i n g e d u c a t i o n f o r p h y s i c i a n s and members of t h e a l l i e d h e a l t h p r o f e s s i o n s i n B r i t i s h C o l u m b i a , p a r t i c u l a r l y t h o s e who f i n d i t d i f f i c u l t t o l e a v e t h e i r p r a c t i c e s . \" The A l a s k a / W a s h i n g t o n RMP i s d e v e l o p i n g a u n i t w h i c h w i l l p r o d u c e and c o - o r d i n a t e a l l e d u c a t i o n a l m a t e r i a l s f o r p r o j e c t s i n t h e two s t a t e r e g i o n . I t i s a n t i c i p a t e d t h a t g r e a t e r e f f i c i e n c y w i l l be a c h i e v e d and c o n s i d e r a b l e money saved by c e n t r a l i z e d p r o d u c t i o n . More p a r t i c u l a r l y , however, t h e main emphasis of t h i s u n i t w i l l be t o \" p r o v i d e up t o d a t e i n f o r -m a t i o n t o t h e more i s o l a t e d r u r a l p h y s i c i a n by way o f modern c o m m u n i c a t i o n s t e c h n o l o g y ( 1 3 8 ) . Cooper (63) r e p o r t s t h e e s t a b l i s h m e n t o f an O f f i c e o f A u d i o - V i s u a l 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 ' C e n t e r a t t h e U n i v e r s i t y of C o l o r a d o . T o g e t h e r w i t h t h e U n i v e r s i t y ' s m u l t i - d i s c i p l i n a r y s t u d e n t l a b o r a t o r i e s ( u n i t t e a c h i n g l a b o r a t o r i e s ) , and t h e newly c o n s t r u c t e d O f f i c e o f R e s e a r c h i n H e a l t h S c i e n c e E d u c a t i o n , i t w i l l s e r v e as a c e n t r a l s o u r c e f o r p r o d u c t i o n , d i s t r i b u t i o n , and e v a l u a t i o n o f m u l t i m e d i a programs f o r t h e Colorado/Wyoming RMP. Among t h e 97 many e d u c a t i o n a l a p p r o a c h e s w h i c h have been e x p l o r e d , two p r o p o s e d p i l o t p r o j e c t s a r e o f p a r t i c u l a r i n t e r e s t . The f i r s t i s a v i d e o t a p e exchange program among h o s p i t a l s w i t h i n t h e Colorado/Wyoming r e g i o n whereby v i d e o t a p e r e c o r d i n g s made by t h e c l i n i c a l s t a f f o f h o s p i t a l s w i l l be exchanged on a w e e k l y b a s i s . The second w i l l be t h e p r o d u c t i o n o f a s e r i e s o f s i n g l e - c o n c e p t f i l m s and f i l m s t r i p s on o r a l c a n c e r , t h e a u d i o p o r t i o n s o f w h i c h w i l l be c a p a b l e o f a l t e r a t i o n i n s u c h a way t h a t t h e same f i l m s and f i l m s t r i p s w i l l s e r v e d e n t a l h y g e n i s t s , n u r s e s , p h y s i c i a n s , d e n t i s t s , o r p a t i e n t s ( 6 3 ) . The U n i v e r s i t y o f Saskatchewan (13) has d e c i d e d t h a t i t s m a j o r f o c u s f o r t h e n e x t s e v e r a l y e a r s w i l l be on t h e development and p r o m o t i o n o f impro v e d \" I n f o r m a t i o n R e t r i e v a l \" methods, and a f o u r s t a g e program has been o u t l i n e d : 1) t o a s s i s t community h o s p i t a l s i n t h e i r e f f o r t s t o p r o v i d e i m p r o v e d l i b r a r y f a c i l i t i e s ; 2) t o encourage and a s s i s t p h y s i c i a n s i n t h e improvement and \u00E2\u0080\u00A2 e x p a n s i o n o f d i r e c t t e l e p h o n e c o n s u l t a t i o n s , 3) t o e s t a b l i s h D i a l A c c e s s T e l e p h o n e L i b r a r y f a c i l i t i e s ; and 4) t o a s s i s t b ase l i b r a r i e s i n t h e i r e f f o r t s t o p r o v i d e r a p i d and e f f i c i e n t s u b j e c t and b i b l i o g r a p h i c r e t r i e v a l by b o t h manual and automated means. E f f o r t s t o d e v e l o p each phase ace p r o c e e d i n g s i m u l t a n e o u s l y . I n t h e A l b a n y RMP, community h o s p i t a l s a r e b e i n g d e v e l o p e d as p r o t o t y p e l e a r n i n g c e n t e r s f o r t h e use o f media and newer i n s t r u c t i o n a l t e c h n o l o g y . These a r e b e i n g s e t up i n t h r e e s i z e s : t h e s m a l l e s t a r e f o r h o s p i t a l s w i t h s t a f f s o f up t o t w e n t y d o c t o r s and f e a t u r e sound t a p e s , t e l e p h o n e d i a l a c c e s s p r o g r a m s , r a d i o r e c e i v e r s w h i c h w i l l a l l o w two-way r a d i o c o n f e r e n c e s , and o t h e r r e l a t e d v i s u a l m a t e r i a l s . The medium s i z e d c e n t e r s f o r h o s p i t a l s o f f r o m twenty t o f i f t y p h y s i c i a n s w i l l i n c l u d e i n a d d i t i o n t h e m e d i c a l , j u k e b o x . The l a r g e s t h o s p i t a l s w i l l have v i d e o t a p e p r o j e c t o r s as w e l l . These l e a r n i n g 98 c e n t e r s a r e b e i n g e s t a b l i s h e d e i t h e r as an i n t e g r a l p a r t o f the m e d i c a l l i b r a r y o r a r e l o c a t e d a d j a c e n t t o a l i b r a r y and a r e under t h e c o n t i n u o u s s u p e r v i s i o n o f l i b r a r y p e r s o n n e l . A c c o r d i n g t o Woolsey ( 2 7 7 ) , M e d i c a l l i b r a r i e s can no l o n g e r e x i s t j u s t f o r t h e s t o r i n g and r e t r i e v a l o f p r i n t e d i n f o r m a t i o n . To be r e a l l y u s e f u l , a m e d i c a l l i b r a r i a n s h o u l d be on hand as an i n s t a n t c o n s u l t a n t . I f what you need i s n o t i m m e d i a t e l y a v a i l a b l e , t h e l i b r a r i a n s h o u l d d i g i t out q u i c k l y o r t h e i m p u l s e t o l e a r n may be l o s t . S i m i l a r l y , C a s t l e (41) r e p o r t s t h a t t h e I n t e r - m o u n t a i n RMP s t a f f have h e l p e d t o o r g a n i z e t h e f o l l o w i n g l e a r n i n g r e s o u r c e s i n t h e m a j o r community h o s p i t a l s : C o n f e r e n c e Room Eq u i p p e d W i t h : E s t a b l i s h e d U s u a l t e a c h i n g a i d s 18 A u d i o p l a y b a c k 10 T e l e v i s i o n p l a y b a c k f a c i l i t i e s 4 Two-Way R a d i o C o n n e c t i o n w i t h t h e U n i v e r s i t y M e d i c a l C e n t e r 32 M e d i c a l L i b r a r y and Exchange System w i t h U n i v e r s i t y R e s o u r c e s A u d i t e d M e d i c a l R e c o r d s System, I n t e g r a t e d w i t h E d u c a t i o n a l Programs (PAS MAP) 9 M e d i c a l E d u c a t i o n C o - o r d i n a t i o n , o r Core F a c u l t y 5 N a t i o n a l : As t h e v a r i o u s m e d i c a l c e n t e r s became i n c r e a s i n g l y i n v o l v e d i n p r o d u c i n g t e l e v i z e d p r o g r a m s , t h e f e a s i b i l i t y o f e s t a b l i s h i n g a c e n t r a l i z e d agency t o c o - o r d i n a t e programs and f i l m exchanges was e x p l o r e d . T h i s c u l m i n a t e d i n t h e e s t a b l i s h m e n t i n 1965 o f a N a t i o n a l A s s o c i a t i o n o f M e d i c a l T e l e v i s i o n B r o a d c a s t e r s w i t h h e a d q u a r t e r s i n U t a h . The o b j e c t i v e s o f t h i s A s s o c i a t i o n a r e : 1) t o promote t h e use o f b r o a d c a s t t e l e v i s i o n as a medium f o r c o n t i n u i n g e d u c a t i o n , and 2) encourage w i d e r c o - o p e r a t i o n i n program p l a n n i n g , p r o d u c t i o n , and d i s t r i b u t i o n ( 2 0 9 ) . A t t h e moment, v i d e o t a p e s a r e r e a d i l y a v a i l a b l e t h r o u g h 99 t h e s e r v i c e s o f t h i s A s s o c i a t i o n (AMTVB) and a c c o r d i n g t o B r a y t o n ( 2 9 ) , \"any m e d i c a l s c h o o l o r o r g a n i z a t i o n h a v i n g a c c e s s t o an ETV s t a t i o n o r l i n k up w i t h s u c h s t a t i o n s can now i n i t i a t e i t s own p o s t g r a d u a t e m e d i c a l t e l e v i s i o n b r o a d c a s t s e r i e s a t m i n i m a l c o s t . \" The N a t i o n a l M e d i c a l A u d i o v i s u a l C e n t e r (NMAC) i n A t l a n t a , G e o r g i a , l e n d s more t h a n 93,000 a u d i o v i s u a l i t e m s each y e a r t o members o f t h e h e a l t h p r o f e s s i o n s . The C e n t e r i s s a i d t o have t h e w o r l d ' s l a r g e s t m e d i c a l a u d i o v i s u a l c o l l e c t i o n . I n a d d i t i o n , t h e NMAC p r o d u c e s a l l t y p e s o f a u d i o v i s u a l m a t e r i a l s f o r h e a l t h p r o f e s s i o n s and s e r v e s as an i n t e r n a t i o n a l c l e a r i n g h o u s e f o r b i o m e d i c a l a u d i o v i s u a l i n f o r m a t i o n . The M e d i c a l L i t e r a t u r e A n a l y s i s and R e t r i e v a l System (MEDLARS) i s a c o m p u t e r i z e d b i b l i o g r a p h i c s y s t e m d e v e l o p e d by t h e N a t i o n a l L i b r a r y o f M e d i c i n e . I n u s e s i n c e 1964, t h i s s y s t e m i n d e x e s t h e m a j o r m e d i c a l j o u r n a l s u s i n g a computer t o s t o r e t h e i n f o r m a t i o n . Index M e d i c u s i s p r i n t e d d i r e c t l y f r o m t h e computer, t h u s by s c a n n i n g t h e s u b j e c t s e c t i o n o f t h i s l i s t i n g , a s e a r c h e r may d e t e r m i n e w h e t h e r h i s f i e l d o f i n t e r e s t i s a d e q u a t e l y c o v e r e d by MEDLARS. I f s o , t h e c o m p u t e r i z e d MEDLARS w i l l r e t r i e v e t h e l i t e r a t u r e r e l e v a n t t o h i s s p e c i f i c r e q u e s t . L a n c a s t e r (136) r e p o r t s t h a t \" o v e r 3,000 demand s e a r c h e s a r e now f o r m u l a t e d a n n u a l l y a t t h e N a t i o n a l L i b r a r y o f M e d i c i n e . A d d i t i o n a l s e a r c h e s a r e b e i n g h a n d l e d a t r e g i o n a l MEDLARS c e n t e r s i n t h e U n i t e d S t a t e s , t h e U n i t e d Kingdom, Sweden, and more r e c e n t l y i n Canada.\" A l t h o u g h n o t w i t h o u t i t s l i m i t a t i o n s , MEDLARS o f f e r s t h e most e x t e n s i v e and q u i c k e s t i n d e x i n g s e r v i c e p r e s e n t l y a v a i l a b l e on m e d i c a l l i t e r a t u r e . The I n t e r u n i v e r s i t y Communications C o u n c i l (EDUCOM) was o r g a n i z e d i n 1965. I t r e p r e s e n t s n o t o n l y t h e h e a l t h p r o f e s s i o n s , b u t a l s o a v a r i e t y o f u n i v e r s i t y d i s c i p l i n e s e q u a l l y i n t e r e s t e d i n d e v e l o p i n g and s h a r i n g e d u c a t i o n a l r e s o u r c e s i n h i g h e r e d u c a t i o n . A l t h o u g h b e g i n n i n g w i t h r e p r e s e n t a t i v e s f r o m 100 e i g h t u n i v e r s i t i e s , M i l l e r (163) r e p o r t e d e i g h t y - e i g h t p a r t i c i p a t i n g u n i v e r s i t i e s i n 1968. F u t u r e p l a n s o f t h i s o r g a n i z a t i o n i n c l u d e t h e development o f a m u l t i m e d i a e l e c t r o n i c n e t w o r k w h i c h w i l l f a c i l i t a t e s h a r i n g o f r e s o u r c e s and a c c e l e r a t e i n f o r m a t i o n p r o c e s s i n g . I n m e d i c i n e t h i s w i l l p r o v i d e r a p i d a c c e s s t o s p e c i a l i s t s and o t h e r e x p e r t s when t h e i r a d v i c e i s needed. The f o u r c r i t e r i a f o l l o w e d i n d e v e l o p i n g t h e n e t w o r k a r e : 1. That i t be i n t e r d i s c i p l i n a r y f o r a l l f i e l d s and n o t o n l y f o r t h e h e a l t h s c i e n c e s . 2. That i t s s e r v i c e s be a v a i l a b l e e v e r ywhere i n t h e U n i t e d S t a t e s , and e v e n t u a l l y , by e x t e n s i o n , everywhere i n t h e w o r l d . 3. That i t be a m u l t i m e d i u m n e t w o r k , n o t l i m i t e d t o computers o r f a c s i m i l e t r a n s m i s s i o n o f documents o r t e l e v i s i o n o r c o m p u t e r i z e d program i n s t r u c t i o n , b u t i n c l u d i n g a l l media o f e d u c a t i o n a l v a l u e w h i c h can be p u t on an e l e c t r o n i c n e t w o r k . 4. That whenever f e a s i b l e , a l l m a t e r i a l s be a v a i l a b l e r a p i d l y on demand, when d e s i r e d by t h e u s e r . 101 CHAPTER V I EVALUATION S i n c e t h e p r i m a r y o b j e c t i v e 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 i s t h e a c h i e v e m e n t o f l e a r n i n g t h a t w i l l r e s u l t i n i m p r o v e d p a t i e n t c a r e , i t i s n e c e s s a r y t o e v a l u a t e program a c t i v i t i e s . As Abrahamson (2) has s t a t e d , e v a l u a t i o n i s a \" c o n t i n u o u s p r o c e s s based upon c r i t e r i a c o - o p e r a t i v e l y d e v e l o p e d , and i s c o n c e r n e d w i t h t h e s t a t u s o f , and changes i n b e h a v i o r o f t h e l e a r n e r s . \" I n t h e s e t e r m s , e v a l u a t i o n has n o t been an i n t e g r a l p a r t 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 a l t h o u g h i t i s now becoming a m a t t e r o f c o n c e r n . There has been an i n c r e a s e i n t h e number o f e v a l u a t i o n s t u d i e s f o u n d i n t h e l i t e r a t u r e o v e r t h e p a s t few y e a r s b u t most o f t h e s e s u f f e r f r o m i n a d e q u a t e d e s i g n and measurement so t h a t t h e r e s u l t s a c h i e v e d a r e l a r g e l y i n c o n c l u s i v e . Such e v a l u a t i o n as has been r e p o r t e d i s p r i n c i p a l l y s u b j e c t i v e b u t t h e r e i s a p r o m i s i n g i n c r e a s e i n a t t e m p t s a t t h e o b j e c t i v e a ssessment o f l e a r n i n g . SUBJECTIVE ASSESSMENT Next t o a t t e n d a n c e r e c o r d s , t h e most commonly r e p o r t e d form o f e v a l u a t i o n i s t h e f o l l o w up q u e s t i o n n a i r e w h i c h s o l i c i t s p a r t i c i p a n t o p i n i o n w i t h r e g a r d t o a program (220) (2) ( 2 4 1 ) . The i n f o r m a t i o n u s u a l l y sought i n c l u d e s why p h y s i c i a n s a t t e n d e d , t h e i r i m p r e s s i o n s and o p i n i o n s w i t h r e s p e c t t o v a r i o u s a s p e c t s o f t h e program, and w h e t h e r t h e y f e l t t h e y a c h i e v e d t h e i r o b j e c t i v e s . S i n c e t h e s e i n s t r u m e n t s s o l i c i t u n v e r i f i e d s u b j e c t i v e o p i n i o n s about an e d u c a t i o n a l e v e n t t h e y a r e o f t e n r e f e r r e d t o as a \" h a p p i n e s s 102 i n d e x \" o r o p i n i o n n a i r e . W h i l e such i n s t r u m e n t s may be u s e f u l i n p l a n n i n g f u t u r e c o u r s e s , they p r o v i d e no evidence tha t l e a r n i n g r e a l l y took p l a c e . D o n n e l l y and N a t f u l i n (77) r e p o r t an experiment which i l l u s t r a t e s t h i s p o i n t : We r e c e n t l y conducted a somewhat l i m i t e d study of the v a l i d i t y o f the s o - c a l l e d happiness i n d e x . An a c t o r was h i r e d and programmed to speak i n c o h e r e n t l y on a t o p i c of i n t e r e s t to m e d i c a l e d u c a t o r s . . . H i s name, erroneous t i t l e s , and degrees were i n c l u d e d on the program seminar . He gave a h i g h l y t e c h n i c a l p r e s e n t a t i o n which c o n s i s t e d of n o t h i n g more than mere double t a l k . He spoke on a s u b j e c t about which he knew n o t h i n g . An a n a l y s i s of the substance of h i s p r e s e n t a t i o n i n d i c a t e d tha t i t c o n s i s t e d p r i m a r i l y of u n r e l a t e d examples and a few good j o k e s . F o l l o w i n g t h i s v e r y \" e n t e r t a i n i n g \" l e c t u r e , the audience ( c o n s i s t i n g p r i m a r i l y of i n s t r u c t o r s . . . ) was a d m i n i s t e r e d a r e p l i c a of one of the happiness q u e s t i o n n a i r e s . . . W i t h o u t e x c e p t i o n the group r a t e d the l e c t u r e and ensuing q u e s t i o n and answer p e r i o d h i g h l y i n every r e s p e c t . They . found i t i n t e r e s t i n g , i n f o r m a t i v e , and s t i m u l a t i n g . . . I n o t h e r w o r d s , the m e d i c a l educators i n at tendance were v e r y happy w i t h the i n s t r u c t i o n a l exper ience d e s p i t e the f a c t tha t the programmers had m i n i m i z e d the l e a r n i n g component. Whi le t h i s i s o b v i o u s l y an extreme example, most w r i t e r s agree t h a t i t i s not s u f f i c i e n t to c o n s i d e r a program s u c c e s s f u l s i m p l e \"because at tendance i s h i g h and c o m p l a i n t s are l o w \" (27 ) . More r e c e n t l y , v a r i o u s m o d i f i c a t i o n s of the happiness index have been r e p o r t e d . L e v i n s o n (140) e v a l u a t e s h i s one-week h e a l t h seminars by h a v i n g p a r t i c i p a n t s r a t e each l e c t u r e and a l l o t h e r aspects of the seminar on a f i v e - p o i n t s c a l e . They are a l s o asked to comment f r e e l y about the e x p e r i e n c e and to add a d d i t i o n a l comments to the e v a l u a t i o n sheet at the end of the week. S i x months l a t e r , through a m a i l q u e s t i o n n a i r e , each p a r t i c i p a n t i s a g a i n asked to e v a l u a t e the e x p e r i e n c e . T h i s t ime he i s asked what he t h i n k s he l e a r n e d at the seminar t h a t was most u s e f u l to h i m , what was l e a s t u s e f u l , how he a p p l i e d what he l e a r n e d , and what problems he had i n t h e i r a p p l i c a t i o n . 103 A l t h o u g h L e v i n s o n i s n o t e n t i r e l y s a t i s f i e d w i t h t h i s p r o c e d u r e o f e v a l u a t i o n , he r e p o r t s c o n s t r u c t i v e f e e d b a c k and s p e c i f i c examples o f changes i n m e d i c a l p r a c t i c e w h i c h p h y s i c i a n s have a t t r i b u t e d t o c o u r s e a t t e n d a n c e . From t h e f i e l d o f p u b l i c h e a l t h , P a r l e t t e (179) r e p o r t s e x p e r i m e n t a l s t u d i e s u s i n g p a i r e d q u e s t i o n n a i r e s , one answered by t h e p a r t i c i p a n t c o n c e r n i n g change i n h i m s e l f as he p e r c e i v e s i t , and t h e o t h e r , by h i s s u p e r i o r . The h y p o t h e s i s i s , \" t h a t t h e de e p e r t h e i n d i v i d u a l i n s i g h t s a r e , t h e more l i k e l y change w i l l o c c u r and be r e c o g n i z e d by h i s s u p e r i o r s and t h e r e f o r e t h e p a r t i c i p a n t ' s r e p o r t e d change i s more v a l i d . \" A n o t h e r v a r i a t i o n o f t h e o p i n i o n n a i r e i s t h e use o f a p e r s o n a l i n t e r -v i e w w i t h s m a l l r andomly s e l e c t e d groups o f p a r t i c i p a n t s p r i o r t o and f o l l o w i n g e a ch s e s s i o n o f t h e program. Meyer i s qu o t e d by Vaneslow as s a y i n g t h a t \" t h i s t e c h n i q u e i s e x c e e d i n g l y u s e f u l i n e l i c i t i n g p e r t i n e n t and c a n d i d comments f r o m p a r t i c i p a n t s \" ( 2 5 4 ) . Dohner (75) has d e v i s e d an i n s t r u m e n t w h i c h c a n be u s e d as an i n d e x o f t h e e f f e c t i v e n e s s o f s h o r t c o u r s e s . The i n s t r u m e n t used was a m o t i v a t i o n s c a l e , c o n s i s t i n g o f a s e t o f b i - p o l a r a d j e c t i v e s d e s i g n e d t o a s s e s s t h e d e g r e e o f e n t h u s i a s m o r m o t i v a t i o n as j u d g e d by t h e l e a r n e r s ' p e r c e p t i o n s of t h e g e n e r a l v a l u e and r e l e v a n c e o f c o u r s e o b j e c t i v e s and c o n t e n t i n m e e t i n g t h e i r l e a r n i n g h e e d s . E v i d e n c e o f t h e r e l i a b i l i t y o f t h e i n s t r u m e n t was p r o v i d e d by c o r r e l a t i n g each s c o r e d i t e m on t h e s c a l e w i t h p a r t i c i p a n t s ' q u e s t i o n n a i r e r e s p o n s e s . A l t h o u g h t h e r e s u l t s f r o m one p r e l i m i n a r y s t u d y i n d i c a t e t h a t t h e s c a l e w i t h f u r t h e r r e f i n e m e n t c o u l d p r o v i d e a v a l i d i n s t r u m e n t , t h e e x t e n t t o w h i c h t h e s c a l e p r e d i c t s a c t u a l changes i n a p a r t i c i p a n t ' s s u b s e q u e n t b e h a v i o r has y e t t o be v a l i d a t e d . A l t h o u g h t h e \" h a p p i n e s s i n d e x \" o r o p i n i o n n a i r e has no v a l i d i t y o r 1 0 4 r e l i a b i l i t y , i t i s p o s s i b l e t o enhance i t by u s i n g s c a l e d r e s p o n s e s s u c h as t h o s e r e p o r t e d above. T h i s f o r m o f e v a l u a t i o n i s e x c e e d i n g l y p o p u l a r w i t h program d i r e c t o r s e ven though i t i s of no r e a l v a l u e as a judgement on a program. I t w o u l d be a dvantageous i f t h o s 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 c o u l d d e v e l o p some s t a n d a r d o b j e c t i v e i n s t r u m e n t s t o a s s e s s o p i n i o n s about t h e i r p r o g r a m s . T h i s c o u l d be done w i t h l e s s t r o u b l e and expense t h a n i s now w a s t e d on i n v a l i d s u b j e c t i v e measures. OBJECTIVE EVALUATION The use o f o b j e c t i v e measures f o r e v a l u a t i o n i s i n c r e a s i n g . Such measures can p r o v i d e h a r d d a t a t o a s s e s s w h e t h e r programs a r e a c h i e v i n g t h e i r o b j e c t i v e s and e n a b l e program p l a n n e r s t o work w i t h g r e a t e r s e c u r i t y t h a t t h e e v a l u a t i o n has some v a l i d i t y . O b j e c t i v e i n s t r u m e n t s have been c o n s t r u c t e d t o measure s p e c i f i c c o n t e n t m a t e r i a l a c q u i r e d , a t t i t u d e development o r change, f e e l i n g s about i n s t r u c t i o n a l a c t i v i t i e s , j o b p e r f o r m a n c e , and p a t i e n t c a r e . T e s t i n g f o r t h e A c hievement o f L e a r n i n g The p r e - and p o s t - d e s i g n u s i n g p a p e r and p e n c i l t e s t s has become f a i r l y common 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 number o f w r i t e r s c o n s i d e r t h a t t h e p r a c t i c e i s r e a s o n a b l y w e l l a c c e p t e d by p h y s i c i a n s (244) ( 2 7 1 ) ( 7 4 ) . S i n c e most o f t h e s e t e s t s a r e teacher-made and based on s p e c i f i c i n f o r m a t i o n , t h e p r a c t i t i o n e r s a r e e x p e c t e d t o l e a r n , t h e r e s u l t s i n no way i d e n t i f y what t h e p h y s i c i a n s a c t u a l l y do l e a r n ( 2 0 5 ) . F u r t h e r m o r e , s t u d i e s have f o u n d t h a t n e i t h e r knowledge g a i n n o r s a t i s f a c t i o n n e c e s s a r i l y e n s u r e d e s i r a b l e changes i n b e h a v i o r . An e v a l u a t i o n o f an i n t e n s i v e p s y c h i a t r i c and n e u r o l o g y r e v i e w c o u r s e 105 r e p o r t e d by N a t f u l i n and Ware (170) i s i n t e r e s t i n g i n t h i s r e g a r d . I n t h i s s t u d y , t h e e x p e r i m e n t a l p o p u l a t i o n c o n s i s t e d o f t w e n t y - e i g h t p s y c h i a t r i s t s e n r o l l e d i n a p r ogram; t w e l v e o f t h e group were s t u d y i n g f o r s p e c i a l t y b o a r d e x a m i n a t i o n s w h i l e a n o t h e r t e n c o n s t i t u t e d a c o n t r o l group who were s t u d y i n g f o r c e r t i f i c a t i o n t h r o u g h t r a d i t i o n a l s e l f - s t u d y methods. The f o u r e v a l u a t i o n t e c h n i q u e s used were: 1) s i m u l a t e d A m e r i c a n Board e x a m i n a t i o n s ; 2) m u l t i p l e c h o i c e e x a m i n a t i o n s ; 3) i n t e r v i e w s ; and 4) s a t i s f a c t i o n q u e s t i o n n a i r e s . As h y p o t h e s i z e d , t h o s e i n t h e c o u r s e p a s s e d t h e b o a r d e x a m i n a t i o n s a t a p r o p o r t i o n -a t e l y h i g h e r r a t e t h a n d i d t h e c o n t r o l s , and e x p r e s s e d a h i g h e r l e v e l o f s a t i s f a c t i o n w i t h t h e i r b o a r d p r e p a r a t i o n . There was no s i g n i f i c a n t change i n t h e mean s c o r e s f o r t h o s e b o a r d e x a m i n e r s and e x p e r t s who a l s o t o o k t h e t e s t s . On t h e b a s i s of t h e s e f i n d i n g s , t h e s e r e s e a r c h e r s c o n c l u d e : W h i l e t h e d e b a t e o v e r p e e r r e v i e w , mandatory c o n t i n u i n g e d u c a t i o n , r e - c e r t i f i c a t i o n , and s e r i a l c e r t i f i c a t i o n programs become h o t t e r , m e d i c a l e d u c a t i o n ..must d e v e l o p more e f f e c t i v e e v a l u a t i o n o f t h e r e l a t i o n s h i p s a m o n g - c o n t i n u i n g e d u c a t i o n , s p e c i a l t y s k i l l s , and c l i n i c a l competence. I f c o n t i n u i n g e d u c a t i o n i n t e r e s t s c o r r e l a t e w i t h c l i n i c a l needs i n b o t h g e o g r a p h i c and s p e c i a l t y a r e a s o f m e d i c a l p r a c t i c e , more agreement may be r e a c h e d as t o what c l i n i c a l competence i s . . . I n t h i s r e s p e c t , M i l l e r (162) i d e n t i f i e d t h e c r i t i c a l components o f c l i n i c a l competence p e r t a i n i n g t o o r t h o p e d i c s t h r o u g h an a n a l y s i s o f o v e r 1,700 c r i t i c a l i n c i d e n t s c o n t r i b u t e d by p r a c t i s i n g o r t h o p e d i s t s . S i n c e t h e s e c o m p e t e n c i e s a r e r e l e v a n t t o most a r e a s o f m e d i c i n e , and w i t h a d d i t i o n a l r e f i n e m e n t c o u l d be used as t h e b a s i s f o r d e f i n i n g m e a s u r a b l e b e h a v i o r a l o b j e c t i v e s i n most f i e l d s o f p r a c t i c e , t h e y a r e r e - s t a t e d h e r e : 1. S k i l l i n g a t h e r i n g c l i n i c a l i n f o r m a t i o n : a. E l i c i t i n g h i s t o r i c a l i n f o r m a t i o n b. O b t a i n i n g i n f o r m a t i o n by p h y s i c a l e x a m i n a t i o n 2. E f f e c t i v e n e s s i n u s i n g s p e c i a l d i a g n o s t i c methods: a. O b t a i n i n g and i n t e r p r e t i n g x - r a y f i l m s b. O b t a i n i n g a d d i t i o n a l i n f o r m a t i o n by o t h e r means 106 Competence i n d e v e l o p i n g a d i a g n o s i s : a. A p p r o a c h i n g d i a g n o s i s o b j e c t i v e l y b. R e c o g n i z i n g c o n d i t i o n s Judgement i n d e c i d i n g on a p p r o p r i a t e c a r e : a. A d a p t i n g t r e a t m e n t t o i n d i v i d u a l c a s e s b. D e t e r m i n i n g e x t e n t and immediacy of t h e r a p e u t i c needs Judgement and s k i l l i n i m p l e m e n t i n g t r e a t m e n t : a. P l a n n i n g t h e o p e r a t i o n b. M a k i n g n e c e s s a r y p r e p a r a t i o n s f o r o p e r a t i o n c. M o d i f y i n g o p e r a t i v e p l a n s a c c o r d i n g t o s i t u a t i o n E f f e c t i v e n e s s i n t r e a t i n g emergency p a t i e n t s : a. H a n d l i n g p a t i e n t s b. P e r f o r m i n g emergency t r e a t m e n t Competence i n p r o v i d i n g c o n t i n u i n g c a r e : a. A t t e n t i o n p o s t o p e r a t i v e l y b. M o n i t o r i n g p a t i e n t ' s p r o g r e s s E f f e c t i v e n e s s o f p h y s i c i a n - p a t i e n t r e l a t i o n s h i p s : a. Showing c o n c e r n and c o n s i d e r a t i o n b. R e l i e v i n g a n x i e t y o f p a t i e n t and f a m i l y o A c c e p t i n g r e s p o n s i b i l i t y f o r t h e w e l f a r e o f t h e p a t i e n t : a. R e c o g n i z i n g p r o f e s s i o n a l c a p a b i l i t i e s and l i m i t a t i o n s b. R e l a t i n g e f f e c t i v e l y t o o t h e r m e d i c a l p e r s o n s U s i n g t h i s scheme, M i l l e r and h i s c o l l e a g u e s t h e n u n d e r t o o k a s y s t e m a t i c r e v i e w o f b o t h t h e o r a l and w r i t t e n p a r t s of c e r t i f y i n g e x a m i n a t i o n s f o r t h e A m e r i c a n B o a r d o f O r t h o p e d i c S u r g e o n s . T h i s s t u d y r e v e a l e d t h a t t e s t s i n b o t h s u b j e c t m a t t e r and p r o f e s s i o n a l s k i l l s were i n c o m p l e t e and s p o t t y . A c c o r d i n g l y , a new c e r t i f i c a t i o n program was d e v e l o p e d u s i n g t h e s e d e f i n e d c o m p e t e n c i e s as t h e b a s i s f o r t e s t c o n s t r u c t i o n . The s t u d y by M c G u i r e and h e r c o l l e a g u e s (149) i l l u s t r a t e s a n o t h e r w e l l known p r o b l e m o f e d u c a t i o n a l t e s t i n g , namely: t h a t l o s s of s k i l l s a l m o s t a l w a y s o c c u r s u n l e s s p e r i o d i c r e i n f o r c e m e n t i s p r o v i d e d t o m a i n t a i n t h e s k i l l . U s i n g one c o n t r o l and f o u r e x p e r i m e n t a l groups of 30 t o 40 p h y s i c i a n s , M c G u i r e e t a l sought t o d e t e r m i n e g a i n and r e t e n t i o n o f a u s c u l t a t o r y s k i l l s i n 4. 5. 6. 7. 8. 107 p h y s i c i a n s f o l l o w i n g a t w e l v e t o twenty h o u r i n t e n s i v e c o u r s e . P r i o r t o i n s t r u c t i o n , b o t h t h e c o n t r o l and e x p e r i m e n t a l groups were p r e - t e s t e d on t h e i d e n t i f i c a t i o n o f f i f t e e n unknown h e a r t s ounds. I m m e d i a t e l y f o l l o w i n g t h e i n s t r u c t i o n a l p r ogram, t h e f o u r e x p e r i m e n t a l groups were r e - t e s t e d . A t t h i s t i m e , a r e v i e w o f h o s p i t a l c h a r t s was u n d e r t a k e n f o r t h e c o n t r o l group and one e x p e r i m e n t a l group t o a s s e s s t h e i n f o r m a t i o n r e c o r d e d on p a t i e n t s h o s p i t a l i z e d w i t h c a r d i o - v a s c u l a r p r o b l e m s . On t h e t e s t a d m i n i s t e r e d i m m e d i a t e l y f o l l o w i n g t h e c o u r s e , t h e e x p e r i m e n t a l groups showed s t a t i s t i c a l l y s i g n i f i c a n t g a i n s compared t o t h e c o n t r o l g r o u p . A t s i x months, however, t h e mean s c o r e s were n o t s i g n i f i c a n t l y d i f f e r e n t f r o m t h e mean s c o r e o f t h e p r e - t e s t . M o r e o v e r , c h a r t r e v i e w s o f b o t h t h e c o n t r o l s and e x p e r i m e n t a l g r o u p s showed no s i g n i f i c a n t d i f f e r e n c e i n t h e r e c o r d i n g o f c a r d i a c f i n d i n g s . R i c h a r d s o n ( 1 4 9 ) , u s i n g a s t u d y s i m i l a r i n d e s i g n t o t h a t o f t h e M c G u i r e g r o u p , was a b l e t o d e m o n s t r a t e some a u s c u l t a t o r y s k i l l r e t e n t i o n -with two groups o f p h y s i c i a n s (N=16 and 1 5 ) , and w i t h a t h i r d g r o u p , (N=15), a mean g a i n o f f r o m 6.4 t o 12 s i x months a f t e r t r a i n i n g . He a t t r i b u t e s t h e s e d i f f e r e n t i a l f i n d i n g s t o t h e i n t e r m i t t e n t t r a i n i n g s c h e d u l e used i n h i s s t u d y as compared w i t h t h e i n t e n s i v e one s e s s i o n c o u r s e p r o v i d e d i n t h e M c G u i r e s t u d y . A number o f e x p l o r a t o r y s t u d i e s u s i n g t h e p r e and p o s t t e s t d e s i g n t o measure a t t i t u d e change a r e r e p o r t e d f r o m t h e f i e l d o f p s y c h i a t r y . I n h e r r e v i e w , L u c y Zabarenko (281) c o n c l u d e d t h a t \" t h e r e s u l t s a r e t a n t a l i z i n g l y s u g g e s t i v e b u t f a r fr o m c o h e r e n t . \" T u c k e r and R e i n h a r d t (277) i n a l o n g i -t u d i n a l s t u d y o f 219 v o l u n t e e r f l i g h t s u r g e o n s used s c a l e d q u e s t i o n n a i r e s t o measure a t t i t u d e change f o l l o w i n g a s i x month p o s t g r a d u a t e c o u r s e c o n s i s t i n g o f 48 l e c t u r e s and 8 t h r e e - h o u r i n t e r v i e w i n g s e s s i o n s . The q u e s t i o n n a i r e s , a d m i n i s t e r e d a t t h e b e g i n n i n g and a t t h e c o m p l e t i o n o f t h e c o u r s e , and a g a i n 108 eighteen months later, were designed to e l i c i t responses to some 44 frequently heard statements about psychiatry which were scored on a four point scale. The c r i t e r i a used to score the responses were established by four independent psychiatrists. The most significant findings were that \"while the physicians' attitudes toward psychiatrists, psychotherapy and mental illness changed very l i t t l e over time, they f e l t more confident and competent in treating psychiatric patients.\" These findings represent a sampling of opinions and attitudes of a group of student f l i g h t surgeons with regards to certain statements about psychiatry, and in no way provide conclusive evidence that any behavioural change occurred which was attributable to course attendance. Pearson and Young (181)used four specially devised scales to evaluate eight short term psychiatric seminars for general practitioners in eight different communities. Sponsored by WTCHE, the programs were a l l similar i n format and used mainly a non-directive approach. The scales used were designed to measure 1) role tolerance; 2) psychiatric orientation; 3) apostolic function; and 4) social distance. The c r i t e r i a used to score the scale were the scores achieved by the psychiatrist instructors. The scales were administered as pre and post tests to a total of 79 physicians. Although the findings were somewhat varied on the individual scales, s t a t i s t i c a l l y significant relationships were found between one or more scales and, on the basis of this, these researchers conclude that the course achieved \"attitude change i n the desired direction.\" On the other hand, Chassy and Heslin (181), using a similar research design, were unable to confirm attitude change in their study of 79 general practitioners who had attended another ten WICHE seminars. Commenting on these studies, Smith (181) states: 109 To d e c i d e s e m i n a r g o a l s i s a d i f f i c u l t enough m a t t e r b u t t o d e c i d e i n an o b j e c t i v e f a s h i o n whether t h e g o a l s have been a c h i e v e d i s i n my judgement, c o n s i d e r a b l y more d i f f i c u l t . P e r h a p s t h e most s a t i s f a c t o r y means o f e v a l u a t i o n i s v i a o b j e c t i v e m e a s u r i n g i n s t r u m e n t s . However l a u d a b l e t h e e v a l u a t i o n e f f o r t s o f my WICHE c o l l e a g u e s have been i n t h i s d i r e c t i o n , t h e y a r e t h e f i r s t t o a d m i t t h a t t h e i r a t t e m p t s have a s t r o n g element o f s u p e r f i c i a l i t y i n them. Can a q u e s t i o n n a i r e e v e r be d e v i s e d t o i n d i c a t e t h a t a p h y s i c i a n i s more p s y c h o l o g i c a l l y minded, h a s more human u n d e r s t a n d i n g , and has t h e t h e r a p e u t i c a b i l i t y t o h e l p h i s p a t i e n t toward f u r t h e r u n d e r s t a n d i n g o f h i m s e l f ? I f e e l t h a t t h e s e a r e e x t r e m e l y d i f f i c u l t t h i n g s t o measure and t o a s s e s s . Forman and h i s c o - w o r k e r s (100) a t t e m p t e d t o t e s t a t t i t u d e change f o l l o w i n g s h o r t t e r m p s y c h i a t r i c s e m i n a r s u t i l i z i n g s i m u l a t e d t a p e r e c o r d e d p a t i e n t i n t e r v i e w s . As a p r e - t e s t t h e p h y s i c i a n s (6 i n one t e s t s i t u a t i o n and 17 i n t h e o t h e r ) , were r e q u i r e d t o answer q u e s t i o n s r e l a t e d t o t h e s e i n t e r -v i e w s . T h i s p r o c e d u r e was r e p e a t e d a t t h e end o f t h e c o u r s e and t h e r e s u l t s o f t h e two t e s t s were compared. The same r e c o r d i n g s and q u e s t i o n n a i r e s were a l s o p r e s e n t e d t o t h e c r i t e r i o n group c o n s i s t i n g o f p s y c h i a t r i c r e s i d e n t s and p s y c h i a t r i c s t a f f p h y s i c i a n s . A l t h o u g h i t was f e l t t h a t a f a i r d e g r e e o f change o c c u r r e d i n t h e p h y s i c i a n s ' u n d e r s t a n d i n g and i n t e r e s t i n p s y c h i a t r y , r e s u l t s were i n c o n c l u s i v e as measured a g a i n s t t h e c r i t e r i o n g r o u p . E n e l o w and A d l e r (281) have d e f i n e d g o a l s more c l e a r l y , , and, i n s p i t e o f a l i m i t e d s a m p l e , t h e y r e p o r t more c o n c l u s i v e r e s u l t s . I n one s t u d y (90) d e s i g n e d t o measure t h e e f f e c t i v e n e s s o f a s e r i e s o f t e n p s y c h i -a t r i c c a s e c o n f e r e n c e s i n p r o d u c i n g c o g n i t i v e l e a r n i n g g a i n , a b e f o r e and a f t e r d e s i g n was u s e d , e m p l o y i n g u n s t r u c t e d r e s p o n s e s t o t h r e e s i m u l a t e d f i l m e d i n t e r v i e w s . The c r i t e r i a a g a i n s t w h i c h t h e f o u r t e e n p a r t i c i p a t i n g p h y s i c i a n s were r a t e d were t h e r e s p o n s e s o f t h e p s y c h i a t r i s t i n s t r u c t o r s . Of t h e t h r e e m a j o r h y p o t h e s e s t e s t i n g a t t a i n m e n t o f t h e s t a t e d o b j e c t i v e s , two were s u b s t a n t i a t e d a t a b e t t e r t h a n an .05 l e v e l o f s i g n i f i c a n c e . 110 Another s tudy i s r e p o r t e d by Enelow and A d l e r (87) of a t t i t u d e change f o l l o w i n g an advanced s u p e r v i s o r y psychotherapy course c o n s i s t i n g of 32 f o u r hour s e s s i o n s . They used f o u r Guttman s c a l e s to measure the f o u r dimensions of the p h y s i c i a n ' s r o l e i n the d o c t o r - p a t i e n t r e l a t i o n s h i p ( a u t h o r i t y ; s e l f -i n v o l v e m e n t ; e x p r e s s i o n of c o n c e r n ; and i n s t r u m e n t a l ) . These were a d m i n i s t e r e d to s i x p h y s i c i a n s b e f o r e and a t the end of the c o u r s e . A comparison of the two s e t s of scores r e v e a l e d t h a t d u r i n g the course the p h y s i c i a n s ' c o n c e p t i o n of the d o c t o r - p a t i e n t r e l a t i o n s h i p became more c o n s i s t e n t i n s u p p o r t , moderate i n r e l i a n c e on t e c h n i c a l p r o c e d u r e s , and h i g h i n s e l f - i n v o l v e m e n t . A f o l l o w up i n t e r v i e w undertaken s e v e r a l years l a t e r r e v e a l e d tha t a l l s i x p h y s i c i a n s had changed t h e i r s t y l e of i n t e r v i e w i n g p a t i e n t s , w i t h more emphasis on the p a t i e n t ' s b e h a v i o r and l e s s dependency on p s y c h o t r o p i c drugs and p s y c h i a t r i c r e f e r r a l s . Enelow and Myers (91) conclude t h a t \"change i n a t t i t u d e and p r a c t i c e w i l l occur f o r p h y s i c i a n s who take two or three years of p s y c h i a t r i c courses c u l m i n a t i n g i n the advanced s u p e r v i z e d psychotherapy c o u r s e . \" Measur ing Change i n Performance : B e l k i n elt a l (21) attempted to assess the e f f e c t s of a s h o r t t r a i n i n g program designed to a s s i s t the s t a f f of the C h i l d H e a l t h S t a t i o n i n New York C i t y to i n t e g r a t e mental h e a l t h p r i n c i p l e s i n t o t h e i r d a i l y p r a c t i c e . U s i n g a be fore and a f t e r e x p e r i m e n t a l d e s i g n , 48 p a r t i c i p a t i n g p h y s i c i a n s were randomly ass igned to an e x p e r i m e n t a l group and a c o n t r o l group . The e x p e r i -mental group was observed and scored i n d e t a i l w h i l e c o n d u c t i n g the c h i l d h e a l t h conference by two d i f f e r e n t observers p r i o r to the course and a g a i n one month a f t e r comple t ing t r a i n i n g . The c o n t r o l g r o u p , which had not gone through the program, was s i m i l a r l y observed . In o r d e r to v a l i d a t e the i n s t r u m e n t , observers were not t o l d whether the d o c t o r b e i n g observed was i n I l l the e x p e r i m e n t a l or c o n t r o l group, and the d o c t o r s were not t o l d why the observers were p r e s e n t . The s e r i e s of o b s e r v a t i o n s of performance and q u e s t i o n n a i r e responses i n d i c a t e d tha t w h i l e the t r a i n i n g program was r e l a -t i v e l y s u c c e s s f u l i n i n s t i l l i n g a knowledge o f mental h e a l t h p r i n c i p l e s and techniques of c o u n s e l l i n g , a comparison of e x p e r i m e n t a l and c o n t r o l groups suggested t h a t the program was l e s s s u c c e s s f u l i n a l t e r i n g p h y s i c i a n s ' behaviour by the a p p l i c a t i o n of the l e a r n i n g i n p r a c t i c e . Ro.ney and Roark (212) used p a t i e n t r e c o r d s as the pr imary source of da ta to e v a l u a t e the e f f e c t i v e n e s s of a c i r c u i t c o u r s e . The sample c o n s i s t e d of 1,092 p a t i e n t r e c o r d s of 41 p r a c t i s i n g p h y s i c i a n s , 24 of whom had a t tended one or more s e s s i o n s of the c o u r s e . The p h y s i c i a n s were asked to respond to statements concern ing 12 h e a l t h problems t h a t r e f l e c t e d the content of the course be ing s t u d i e d . They a l s o s e l e c t e d procedures p e r t i n e n t to the manage-ment of these h e a l t h problems from t h e i r m e d i c a l r e c o r d s . The use of these procedures as i n d i c a t e d by t h e p a t i e n t r e c o r d s was then compared f o r p a r t i c i p a n t s and n o n - p a r t i c i p a n t s both be fore and a f t e r the c o u r s e . Both groups gave c o r r e c t responses to the q u e s t i o n n a i r e and a l t h o u g h the f i n d i n g s suggested t h a t p h y s i c i a n s a t t e n d i n g the course were somewhat more competent i n the management of s e l e c t e d h e a l t h problems i n d i c a t e d by p a t i e n t r e c o r d s , the d i f f e r e n c e between the two groups was not s t a t i s t i c a l l y s i g n i f i c a n t . F o s t e r and Lass (102) a l s o used p a t i e n t r e c o r d s as a source of d a t a to e v a l u a t e a v i d e o t a p e d program on the use of d i u r e t i c s . Two matched h o s p i t a l s were u s e d , one s e r v i n g as the e x p e r i m e n t a l and the o t h e r as the c o n t r o l group . O b s e r v a t i o n s were made of p a t i e n t r e c o r d s i n both h o s p i t a l s f o r three weeks p r i o r to and three weeks f o l l o w i n g the showing of the v i d e o -tape i n the e x p e r i m e n t a l h o s p i t a l . The i n f o r m a t i o n sought was the ex tent to 112 which there would be an i n c r e a s e i n serum potass ium and sodium d e t e r m i n a t i o n s i n the e x p e r i m e n t a l h o s p i t a l as a r e s u l t of the v i d e o t a p e d program. The a n a l y s i s of p a t i e n t r e c o r d s found no s i g n i f i c a n t d i f f e r e n c e s . The d a t a d i d r e v e a l tha t p h y s i c i a n s i n the e x p e r i m e n t a l h o s p i t a l were f u n c t i o n i n g a t a s i g n i f i c a n t l y h i g h e r l e v e l than the c o n t r o l group p r i o r to the program. A c c o r d i n g l y , as noted by Abrahamson ( 1 ) , \"One can say tha t the o b j e c t i v e s f o r u s i n g t h a t program were i n a p p r o p r i a t e . . . i n a p p r o p r i a t e c e r t a i n l y f o r the p r a c t i c e needs of those p h y s i c i a n s \" . Measur ing Long Term R e s u l t s of C a r e : W h i l e the u l t i m a t e g o a l of a l l c o n t i n u i n g m e d i c a l e d u c a t i o n i s the improvement o f m e d i c a l c a r e , e f f o r t s to e s t a b l i s h c a u s e - e f f e c t r e l a t i o n s h i p s have proven both d i f f i c u l t and d i s a p p o i n t i n g . One e a r l y attempt was P e t e r s o n ' s s tudy (185) of 94 g e n e r a l p r a c t i t i o n e r s . P e t e r s o n and h i s team observed and q u a l i t a t i v e r a n k i n g s a g a i n s t the number of hours of c o n t i n u i n g e d u c a t i o n per p h y s i c i a n per y e a r . Some of the s u p e r i o r p h y s i c i a n s i n t h i s s tudy were found t o have taken l i t t l e c o n t i n u i n g e d u c a t i o n w h i l e some of the poores t were f r e q u e n t p a r t i c i p a n t s . T h i s suggests t h a t there was l i t t l e r e l a t i o n s h i p between the q u a l i t y of care and 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 more recent s tudy i n Kansas (141) d i s c l o s e d s i m i l a r f i n d i n g s . U t i l i z i n g an e p i d e m i o l o g i c a l approach , t h i s s t a t e w i d e survey attempted to r e l a t e p h y s i c i a n 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 to 1) reduced m a t e r n a l and p e r i n a t a l , d e a t h s , and 2) p h y s i c i a n s ' use of c e r t a i n s u r g i c a l p r o c e d u r e s . F i n d i n g s r e v e a l e d t h a t no such r e l a t i o n s h i p e x i s t e d . In f a c t , m a t e r n a l death r a t e s were h i g h e s t i n two r e g i o n s w i t h the h i g h e s t p h y s i c i a n p a r t i c i p a t i o n i n o b s t e t r i c a l programs of c o n t i n u i n g e d u c a t i o n and lowest i n the r e g i o n s where p h y s i c i a n s took the fewest hours of s t u d y . Moreover , i n 113 the two r e g i o n s w i t h the h i g h e s t t o n s i l l e c t o m y r a t e s , p h y s i c i a n s at tended no p o s t g r a d u a t e course on o t o l a r y n g o l o g y d u r i n g the ten year p e r i o d under s t u d y . I n a two year s tudy K o r c h i n (133) sought to determine whether an e x t e n s i v e p h y s i c i a n e d u c a t i o n program would a p p r e c i a b l y a l t e r a t t i t u d e s and improve p r a c t i c e i n r e l a t i o n to the m e d i c a l management and c o n t r o l of rheum at i c f e v e r . In t h i s p r o j e c t , 100 p h y s i c i a n s i n one county served as the e x p e r i m e n t a l group and were o f f e r e d a v a r i e t y of e d u c a t i o n a l o f f e r i n g s d u r i n g t h e course of one y e a r , w h i l e 50 p h y s i c i a n s i n a second county served as the c o n t r o l group and were o f f e r e d no e x t r a l e a r n i n g o p p o r t u n i t i e s . Data p e r t i n e n t to p h y s i c i a n s ' m e d i c a l knowledge and p r a c t i c e w i t h regards to rheum at i c f e v e r was ob ta ined by the use of b e f o r e and a f t e r i n t e r v i e w s i n the two c o u n t i e s and t h e d i f f e r e n t i a l responses scored and compared. W i t h o u t b e l a b o r i n g the obvious l i m i t a t i o n s of the r e s e a r c h d e s i g n , two f i n d i n g s of t h i s s tudy are wor th r e p o r t i n g : 1) those p h y s i c i a n s who were a l r e a d y p r a c t i s i n g medic ine at a h i g h l e v e l were more f a v o r a b l y i n c l i n e d toward t h e e d u c a t i o n a l programs and to p u b l i c h e a l t h measures i n g e n e r a l , and 2) i n b o t h c o u n t i e s , p h y s i c i a n s ' m e d i c a l knowledge r e g a r d i n g the d i a g n o s i s and c o n t r o l of rheumat ic f e v e r was h i g h , but t h e i r use of l a b o r a t o r y methods to c o n f i r m d i a g n o s i s and t h e i r use of p r o p h y l a c t i c drugs was i n a d e q u a t e . In s h o r t , t h e a p p l i c a t i o n of what the p h y s i c i a n s a l r e a d y knew seemed i n d i c a t e d (133) . O t h e r s r e p o r t i n g s i m i l a r f i n d i n g s were Tabennaus (244) , P e t e r s o n (185) , and C l u t e (46) . Indeed, i n C l u t e ' s s t u d y , a h i g h e r percentage of p h y s i c i a n s who s a i d i t \"was not p a r t i c u l a r l y d i f f i c u l t to keep up i n m e d i c i n e , were p r a c t i s i n g a low c a l i b r e of m e d i c a l c a r e . \" Commenting on t h i s f i n d i n g , H u s s a n e i n and Lewis (141) a s k : \"How can p h y s i c i a n s judge t h e i r need f o r c o n t i n u i n g e d u c a t i o n , i f they are not even aware of t h e i r own l i m i t a t i o n s as p r a c t i t i o n e r s ? \" 114 Program M o d e l s w i t h B u i l t I n E v a l u a t i o n : V a r y i n g f r o m t h e s e a p p r o a c h e s have been s e v e r a l r e c e n t a t t e m p t s t o h e l p p h y s i c i a n s i d e n t i f y t h e i r own d e f i c i e n c i e s b a s e d on p a t i e n t c a r e r e s e a r c h , and t h e n t o e v a l u a t e t h e e f f e c t o f e d u c a t i o n a l e f f o r t s d e s i g n e d t o h e l p overcome t h e s e d e f i c i e n c i e s . The f i r s t s t u d y u s i n g t h i s a p p r o a c h was t h a t r e p o r t e d by W i l l i a m s o n and h i s group ( 2 7 2 ) . The p u r p o s e o f t h i s p i l o t p r o j e c t was t o : 1) Measure p h y s i c i a n s ' r e s p o n s e s t o abnormal and u n e x p e c t e d r e s u l t s o f t h r e e r o u t i n e a d m i s s i o n t e s t s ( e v a l u a t i o n ) ; 2) d e t e r m i n e w h e t h e r t h e p h y s i c i a n s needed t o i mprove t h e i r r e s p o n s e s ( o b j e c t i v e s ) ; 3) p r o v i d e t h e r e q u i r e d e d u c a t i o n ( i n s t r u c t i o n ) ; and 4) r e - a s s e s s r e s p o n s e s t o t h e s e s c r e e n i n g t e s t s and e v a l u a t i n g and r e p e a t i n g t h e c y c l e as many t i m e s as r e q u i r e d t o a c h i e v e and measure t h e d e s i r e d l e v e l o f p r o f i c i e n c y . I n i t i a l a s sessment a c c o m p l i s h e d by means o f a c h a r t r e v i e w r e v e a l e d t h a t a p p r o x i m a t e l y t w o - t h i r d s o f t h e u n e x p e c t e d abnormal t e s t r e s u l t s went unheeded so a workshop-was h e l d t o d i s c u s s t h e f i n d i n g s . A l t h o u g h s u b j e c t i v e e v a l u a t i o n o f t h i s c o n f e r e n c e i n d i c a t e d t h a t t h e p h y s i c i a n s f o u n d t h e workshop s t i m u l a t i n g and i n f o r m a t i v e , f o l l o w up c h a r t r e v i e w s d i s c l o s e d c o n t i n u e d n e g l e c t o f l a b o r a t o r y r e p o r t s . A c c o r d i n g l y , t h e e d u c a t i o n a l a p p r o a c h was changed w i t h e f f o r t s d i r e c t e d t o w a r d a l t e r i n g t h e p h y s i c i a n s ' b e h a v i o r , p a t t e r n s . Removable f l u o r e s c e n t t a p e s t o o b s c u r e a b normal d a t a on t h e l a b o r a -t o r y r e p o r t s was used and t h i s r e s u l t e d i n a s i g n i f i c a n t improvement i n t h e p h y s i c i a n s ' r e s p o n s e t o t e s t r e s u l t s . T h i s change i n b e h a v i o r was m a i n t a i n e d by more t h a n one h a l f s i x months a f t e r t h e use o f t h e t a p e was d i s c o n t i n u e d . I n t h e second phase o f t h e p r o j e c t , t h e r e s e a r c h e r s (271) d e m o n s t r a t e d a method f o r i d e n t i f y i n g a r e a s r e q u i r i n g p r i o r i t y a t t e n t i o n as d i s c l o s e d by p a t i e n t c a r e r e s e a r c h . The method c o n s i s t e d o f t h r e e s t e p s : 1) r a n k i n g e a c h m e d i c a l c o n d i t i o n e n c o u n t e r e d a t t h e h o s p i t a l a c c o r d i n g t o e x p e c t e d 115 p a t i e n t d i s a b i l i t i e s ; 2) determine which were p r e v e n t a b l e or t r e a t a b l e i n the l i g h t of c u r r e n t m e d i c a l knowledge; and t h e n , 3) a s s e s s i n g the ex tent to which c u r r e n t m e d i c a l knowledge was b e i n g a p p l i e d w i t h regards to these c o n d i t i o n s . The a p p l i c a t i o n of t h i s p r i o r i t y system r e s u l t e d i n the i d e n t i -f i c a t i o n , o f s i x top r a n k i n g h e a l t h problems which then p r o v i d e d d i r e c t i o n f o r the development of the c o n t i n u i n g e d u c a t i o n program of the h o s p i t a l ' s m e d i c a l s t a f f . U s i n g an e l a b o r a t i o n of the C y b e r n e t i c model (see Table IV) Brown and h i s c o l l e a g u e s at Chestnut H i l l community h o s p i t a l have conducted s e v e r a l p i l o t p r o j e c t s w i t h good r e s u l t s . In one s t u d y , ten top r a n k i n g d i s e a s e s were i d e n t i f i e d and the h o s p i t a l s t a f f i n v o l v e d i n d e v e l o p i n g c r i t e r i a of performance i n the manage-ment of these h i g h p r i o r i t y d i s e a s e s . U s i n g these c r i t e r i a i n c o n j u n c t i o n w i t h c h a r t rev iews of p a t i e n t f o l l o w u p s , Brown and h i s group have been a b l e t o demonstrate the v a l u e of t h i s approach i n a r r i v i n g a t p r e c i s e o b j e c t i v e s whereby e d u c a t i o n a l e f f o r t s may be measured i n b e h a v i o r a l terms (32 ) . To i l l u s t r a t e , Brown r e p o r t s an i n v e s t i g a t i o n conducted i n the use of A n t i b i o t i c s . From s t u d i e s of those h e a l t h problems which the system of p r i o r i t y i n d i c a t e d as o f f e r i n g s i g n i f i c a n t p o t e n t i a l i t i e s f o r i m p r o v i n g p a t i e n t c a r e , i t became e v i d e n t t h a t s i n c e i n one m e d i c a l department a r e v i e w of f i f t y c o n s e c u t i v e r e c o r d s of p a t i e n t s r e v e a l e d o n l y a t h i r t y percent c o r r e c t usage of a n t i b i o t i c s , a program was r e q u i r e d to c o r r e c t the e d u c a t i o n a l d e f i c i t . The d e f i n e d o b j e c t i v e was, G i v e n the f i r s t S. p a t i e n t s to whom each member of the m e d i c a l department a d m i n i s t e r s a n t i b i o t i c s a f t e r December 1 , 1968, at l e a s t s i x of these p a t i e n t s w i l l need the a n t i b i o t i c and the proper d r u g , d o s e , r o u t e , and a c t i o n w i l l be u s e d . To f u r t h e r determine whether the e d u c a t i o n a l d e f i c i t was an i n f o r m -a t i o n a l or problem s o l v i n g d e f i c i e n c y , an examinat ion based on s i x t e e n of the TABLE IV THE BI-CYCLE: RELATION OF PATIENT-CARE AND EDUCATION CYCLES Mandate f o r , Change=Education D e p a r t m e n t a l R e c o g n i t i o n o f Improvement P o t e n t i a l r o b l e m O r i e n t e d R e c o r d R e c o r d A b s t r a c t L e a r n i n g E x p e r i e n c e CME PROGRAM E v a l u a t i o n o f L e a r n i n g P r a c t i c e E v a l u a t i o n P r o c e s s i n A u d i t Comm. = A c t u a l P r a c t i c e measured a g a i n s t C r i t e r i o n P r a c t i c e , M e d i c a l S c h o o l O b j e c t i v e s P r i o r i t y j P r o j e c t C r i t e r i o n P r a c t i c e D e s c r i p t i o n A u a i t Program A c t u a l P r a c t i c e D e s c r i p t i o n SOURCE: Brown, C , U h l , H., \"Mandatory C o n t i n u i n g E d u c a t i o n : Sense o r Nonsense?\" JAMA; 23:1663 (September, 1 9 7 0 ) . 117 c a s e s r e v i e w e d was t a k e n by 42 members o f t h e department s t u d i e d . The t e s t r e s u l t s i n d i c a t e d t h a t t h e p h y s i c i a n s had adequate knowledge, so f o u r c o n f e r e n c e s were h e l d i n w h i c h t h e p h y s i c i a n s d i s c u s s e d p a t i e n t management w i t h e x p e r t s . A p p r o p r i a t e l i t e r a t u r e was i n t r o d u c e d as n e c e s s a r y . A f o l l o w up s t u d y on t h e p e r f o r m a n c e o f p h y s i c i a n s , u s i n g c h a r t r e v i e w s and d a t a f r o m t h e pharmacy, r e v e a l e d changes i n dru g u s e and management p r a c t i c e s c o n s i s t e n t w i t h t h e ... b e h a v i o r a l change d e s i r e d . A m o d i f i c a t i o n o f t h i s a p p r o a c h was d e s c r i b e d by S t o r e y and h i s c o l l e a g u e s ( 1 0 4 ) . A group o f e x p e r t s f r o m a c r o s s t h e n a t i o n d e v e l o p e d a c r i t e -r i o n o f p e r f o r m a n c e f o r t h e t o p r a n k i n g h e a l t h p r o b l e m s . A number o f S i m u l a t e d P a t i e n t P roblems were t h e n d e v i s e d based on t h e s e p r i o r i t y h e a l t h p r o b l e m s w h i c h e n a b l e d a p h y s i c i a n t o t e s t h i s own p e r f o r m a n c e so. as t o i d e n t i f y d e f i c i e n c i e s w h i c h c o u l d s e r v e as t h e b a s i s f o r p l a n n i n g and e v a l u a t 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 * A n o t h e r program model w h i c h a t t e m p t s t o p r o v i d e i n d i v i d u a l i n s t r u c t i o n a c c o r d i n g t o o b j e c t i v e l y i d e n t i f i e d d e f i c i e n c i e s o f p r a c t i s i n g p h y s i c i a n s i s t h e P h y s i c i a n s ' P r o f i l e P r o j e c t i n o p e r a t i o n 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 ( 1 0 2 ) . The d e s i g n o f t h i s a p p r o a c h was t o : 1) g a t h e r d a t a p e r t i n e n t t o t h e p h y s i c i a n ' s p r a c t i c e ; 2) t e s t t h e p h y s i c i a n i n t h e ma j o r a r e a s o f h i s p r a c t i c e ; 3) p r o v i d e e d u c a t i o n a l c o n s u l t a t i o n and s t u d y r e l e v a n t t o h i s p r a c t i c e p r o f i l e , t e s t t h e r e s u l t s ; and t h e n 4) p r o v i d e f o r subsequent r e - p r o f i l i n g and t e s t i n g as a f o r m o f program e v a l u a t i o n . 1 I n t h e s t u d y r e p o r t e d , a m e d i c a l s e c r e t a r y v i s i t e d t h e o f f i c e s o f 37 v o l u n t e e r p h y s i c i a n s f o r a one-week p e r i o d , c o l l e c t i n g p a t i e n t d a t a w h i c h was coded t o p r o v i d e each p h y s i c i a n w i t h a p r a c t i c e p r o f i l e . The p h y s i c i a n s were t h e n t e s t e d t h r o u g h t h e use o f m u l t i p l e c h o i c e e x a m i n a t i o n s b a s e d on t h e i r 118 p r o f i l e s . For convenience , t e s t s were a d m i n i s t e r e d by way of p o r t a b l e t e l e t y p e equipment l i n k e d to the U n i v e r s i t y of W i s c o n s i n Computer C e n t e r . E d u c a t i o n a l c o n s u l t a n t s from the m e d i c a l cen ter then met w i t h each p h y s i c i a n t o p l a n a program of s tudy r e l a t e d to the p h y s i c i a n ' s p r o f i l e and t e s t r e s u l t s . A l t h o u g h t h i s s tudy d i s c l o s e d t h a t the t e s t i n g procedures r e q u i r e d r e f i n e m e n t , and the o v e r a l l program reduced i n c o s t s , the approach was f e a s i b l e j and the c o n t i n u a t i o n of the p r o j e c t was recommended. PROBLEMS OF EVALUATION The r e s e a r c h r e p o r t s t h a t have been concerned w i t h the e v a l u a t i o n of programs 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 u f f e r from major d e f i c i e n c i e s that are s l o w l y g a i n i n g r e c o g n i t i o n . A l t h o u g h v i r t u a l l y everyone concerned w i t h c o n t i n u i n g e d u c a t i o n agrees t h a t e v a l u a t i o n i s a good t h i n g , there i s no g e n e r a l awareness nor acceptance of the importance c f m a i n t a i n i n g o r d i n a r y s c i e n t i f i c c o n t r o l s i n c o n d u c t i n g e v a l u a t i o n s . Too many seem to be content w i t h c a s u a l and u n s y s t e m a t i c o p i n n i o n a i r e s t h a t have n e i t h e r v a l i d i t y nor r e l i a b i l i t y i n p r e f e r e n c e to the more d i f f i c u l t and r i g o r o u s s c i e n t i f i c approach to e v a l u a t i o n tha t can p r o v i d e u s a b l e d a t a . T h i s r e l u c t a n c e may s tem, i n p a r t , from the problem of i d e n t i f y i n g p r e c i s e i n s t r u c t i o n a l o b j e c t i v e s a n d , i n p a r t , from the problem of c o n s t r u c t i n g adequate r e s e a r c h d e s i g n s . The Problem of O b j e c t i v e s As noted e a r l i e r , there have been numerous surveys a t t e m p t i n g to d e f i n e the g e n e r a l i n t e r e s t s and f e l t l e a r n i n g needs of p h y s i c i a n s . More r e c e n t l y , s e l f - a s s e s s m e n t t e s t s have become i n c r e a s i n g l y p o p u l a r as a way of h e l p i n g p r a c t i t i o n e r s i d e n t i f y t h e i r own l e a r n i n g needs . A t the community l e v e l , s e v e r a l RMPS have conducted consumer surveys i n an attempt to i d e n t i f y 119 the h e a l t h needs of the community (275) (270) (255) . W h i l e u s e f u l , as s t a t e d by M i l l e r (265) , \"These types of e f f o r t s i n i s o l a t i o n do not n e c e s s a r i l y i d e n t i f y the r e a l l e a r n i n g n e e d s . \" Moreover , e q u a l l y apparent i n most of the s t u d i e s r e p o r t e d , i s the p r e v a l e n c e of v a g u e l y d e f i n e d o b j e c t i v e s which are not r e a d i l y t r a n s l a t e d i n t o measurable terms , or which are u n r e a l i s t i c i n r e l a t i o n to reasonable e x p e c t a t i o n s of achievement (243) . Too many programs attempt f a r too much f o r the t ime a v a i l a b l e , so t h a t the o b j e c t i v e s are g l o b a l r a t h e r than s p e c i f i c . Vaguely c o n c e p t u a l i z e d o b j e c t i v e s p r o v i d e no c r i t e r i a a g a i n s t which to measure r e s u l t s ; c o n s e q u e n t l y , i n o r d e r to e v a l u a t e 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 o b j e c t i v e s must be s t a t e d e x p l i c i t l y i n measurable terms and the programs l i m i t e d to those o b j e c t i v e s . Des ign Problems : An obvious weakness of e v a l u a t i o n s t u d i e s i s the inadequacy of the r e s e a r c h d e s i g n s . Most s t u d i e s s u f f e r from problems of c o n t r o l s such as inadequate sample s i z e , temporal change i n e d u c a t i o n a l outcomes, problems of measurement, and e x p e r i m e n t e r - p a r t i c i p a n t c o n s t r a i n t s , to name but a few. A l t h o u g h recent a t t e n t i o n has focussed on the s u c c e s s f u l program e v a l u a t i o n s r e p o r t e d by W i l l i a m s o n and Brown, u s i n g the m e d i c a l a u d i t , as warned by N . Vaneslow (254) , \"One c o u l d argue t h a t each succeeded l a r g e l y because of the p e r s o n a l char isma of the i n d i v i d u a l i n c h a r g e , and t h a t i t would be dangerous to assume t h a t e q u a l success c o u l d be a n t i c i p a t e d i n o t h e r s e t t i n g s . \" Moreover , s i n c e most care i s not g i v e n i n the h o s p i t a l but i n the p h y s i c i a n ' s o f f i c e , the use of such a method would need to i n c l u d e an a u d i t of the p h y s i c i a n ' s o f f i c e p r a c t i c e as w e l l ( 62 ) . Even more i m p o r t a n t l y , as p o i n t e d out at the recent Conference on E v a l u a t i o n , 120 We have been discussing the medical tangibles, pneumonia, the capacity to handle the acute coronary, or whatever you w i l l . What about insights into the emotional areas? Not just psychiatry but emotion in relation to i l l n e s s , in relation to l i f e and death... the kind of things that we do not really see even in the records... These are the things that go on between a physician and his patient, or the patient's relatives. Do we not need something in evaluating procedures here? It i s curious to note that the evaluation studies reviewed rarely made note of the research done in other areas that was relevant to the subject. Most of the design problems evident i n the evaluation of continuing medical education have been tested elsewhere\u00E2\u0080\u0094particularly in the general f i e l d of adult education. Such research makes i t unnecessary for continuing education in medicine to re-invent the wheel. Costs: Herzog (116) provides the most recent and detailed estimate of the cost factor in the evaluation of continuing medical education. He has analyzed and compared the cost of several approaches to evaluation showing the relative cost of each (Table IV). According to Herzog, \"The guiding principle in judging how much should be spent for evaluation i s that marginal costs should approach but not exceed marginal value of the information obtained.\" Even then he admits great d i f f i c u l t y in assessing effectiveness values versus costs but he does suggest -that since \"...studies on behavioral change or patient health status greatly exceed course costs, they can be j u s t i f i e d only as they relate to the objective of contributing to general knowledge.\" TABLE v ESTIMATED COST OF DIFFERENT EVALUATION TECHNIQUES FOR A HYPOTHETICAL ONE-WEEK SHORT COURSE Evaluation Technique Estimated Cost Fixed Course Cost Percent of Course Cost Participant Opinion Analysis $ 945 42,000 % 2 Pre-Post Examination of Knowledge 2,455 42,000 6 Mail Survey of Performance Change 47,640 42,000 113 \u00E2\u0080\u00A2 Survey and Observation of Behavior Change 155,850 42,000 371 End-Result Studies of Patient Health 212,350 42,000 506 SOURCE: \"Costs of Evaluation\"; Proceedings : Evaluation in Continuing Medical Education; Kansas City, Kansas, The University of Kansas Medical Center, August 1970, p.28 122 CHAPTER V I I SUMMARY AND CONCLUSIONS P r o f e s s i o n a l e d u c a t i o n i n the f i e l d of medic ine i s d i v i d e d i n t o three d i s t i n c t phases : 1) Undergraduate e d u c a t i o n l e a d i n g to the M . D . degree ; 2) graduate e d u c a t i o n c o v e r i n g the i n t e r n 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 tudy l e a d i n g to a l i c e n s e , a p r o f e s s i o n a l s p e c i a l t y , or to an academic degree ; and 3) c o n t i n u i n g e d u c a t i o n which i n c l u d e s those a c t i v i t i e s i n which p r a c t i s i n g p h y s i c i a n s engage to a c q u i r e the new knowledge and s k i l l necessary to keep c u r r e n t i n t h e i r p r o f e s s i o n . The f i r s t two phases have r e c e i v e d the major a t t e n t i o n of the p r o f e s s i o n over the years but c o n t i n u i n g e d u c a t i o n i s now becoming a mat ter of c e n t r a l c o n c e r n . T h i s concern i s not n e c e s s a r i l y new f o r some of the concepts c u r r e n t l y c o n s i d e r e d new have been r e c o g n i z e d and documented i n the l i t e r a t u r e over the pas t h a l f - c e n t u r y . A t f i r s t , c o n t i n u i n g e d u c a t i o n i n medic ine was concerned p r i m a r i l y w i t h 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 . In t h i s r e s p e c t , medic ine was f o l l o w i n g the t r a d i t i o n then c u r r e n t i n the l a r g e r f i e l d of a d u l t e d u c a t i o n . S ince 1930, the emphasis has s h i f t e d from r e m e d i a l e d u c a t i o n to the l e a r n i n g necessary to keep up t o date i n a r a p i d l y expanding p r o f e s s i o n a l body of knowledge. SUMMARY T h i s r e v i e w of the l i t e r a t u r e p u b l i s h e d from 1960 to 1970 has been concerned c h i e f l y w i t h the development of programs 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 . The m a t e r i a l reviewed has been d i s c u s s e d under f o u r main headings and i s summarized be low. 123 Participation: Although based on a limited number of available surveys this review of the perceptions of learning needs suggests that there are many reasons, both personal and professional, which determine how much continuing education a physician takes, and where and how he takes i t . While there i s some indication that specialists and physicians in metropolitan areas attend courses more often, age is the only variable which bears a significant relationship to attendance patterns. The recurring theme underlying a l l discussions, is that the physician, and more particularly those in general practice, are busy and their time cannot be wasted. At the same time, a multi-faceted continuing education need exists. While these needs, both general and specific to the practitioner's location and f i e l d of practice are identifiable, less evident are those related to the physician's individual practice. Furthermore, there is some indication that physicians' f e l t learning needs may not be those most pertinent to his immediate medical practice. Hence i t would seem that those programs which involve practitioners in identifying their \"real\" educational needs are more li k e l y to succeed than those programs predesigned and presented. Moreover, while physicians most often select the traditional methods and techniques, surveys suggest that familiarity with the different approaches, as well as age, and f i e l d of practice, are important variables influencing choice. Thus i t is apparent that a wide variety of approaches are indicated, taking into account these variables, and u t i l i z i n g those methods and techniques to which physicians fee l that they can respond. 124 Organization and Administration: Most medical schools, professional societies, hospitals, and voluntary agencies, are actively engaged in providing educational programs for practising physicians. The major problem confronting these sponsors i s the lack of a sound administrative and academic base capable of adapting programs to the nature and needs of physicians in practice. The areas of identified needs include: 1) improved methods of deter-mining real learning needs; 2) more clearly defined program objectives, both short and long term; 3) administrative arrangements which would f a c i l i t a t e the planning of interrelated program offerings scheduled to meet the varying needs and preferences of busy practitioners; 4) a more sound f i s c a l base which would permit more long term continuing education; and 5) the improvement of the quality of instruction provided. Despite these limitations, there are clearly discernible trends: 1) local and regional conditions more conducive to the establishment of a national plan; 2) greater standardization (minimal standards) of course offerings through the AMA's program of accreditation; 3) a greater concerted effort to motivate physicians to continue their education; and 4) a definite trend toward the decentralization of programs, using the community hospitals as one of the major foci of continuing medical education. Instructional Processes: In 1963, Miller (i>9) wrote, This may sound^.llk^ the repititious beating of an old and very tired horse, but the simple fact seems to be that continuing education today, like confc I tut f r\u00C2\u00BBj\u00C2\u00A3 education thirty years ago, i s obsessed with the notion t.hc*t exposure to the learned assures learning. Yet each generation tt\u00C2\u00BB\ I **covers the fact that in the end i t i s the learner who must <\r, f.he learning, and no amount of communication by lecturco, by hr.?,* , by film, by radio, or television, w i l l make the sligheot dlff>>r\u00C2\u00BB'^e unless he does something with what he receives. Both f.vn\u00C2\u00ABi,*rn and students have for too long allowed 125 themselves to be deceived by the comfort of i n s t r u c t i o n a l methods tha t r e q u i r e l i t t l e more than a student's presence, or by the gesture toward a c t i v e p a r t i c i p a t i o n embodied i n the question p e r i o d . In c o n t i n u i n g medical education, almost every method, technique, and device known to education i s p r e s e n t l y i n use. Y et, there i s l i t t l e evidence to suggest that any one media or technique c o n t r i b u t e s to more or b e t t e r l e a r n i n g . Moreover, c l o s e examination suggests that even the most v e r s a t i l e of the newer e d u c a t i o n a l technologies has been used l a r g e l y i n i s o l a t i o n , and mainly to provide p h y s i c i a n s access to new medical knowledge. As i t stands at the moment, the f i e l d of medicine has made a gr e a t e r investment than any other i n the use of i n s t r u c t i o n a l technology. U n f o r t u n a t e l y , \u00E2\u0080\u00A2 t h i s experimentation has not been w e l l grounded i n a d u l t l e a r n i n g nor has i t been s t u d i e d adequately to determine i t s p r e c i s e r o l e i n the achievement of l e a r n i n g and the r e s u l t a n t change i n improved p a t i e n t care. Consequently, there i s no hard data a v a i l a b l e to i n d i c a t e which kinds of i n s t r u c t i o n under what circumstances and f o r what kinds of p a r t i c i p a n t s best achieve the l e a r n i n g o b j e c t i v e s d e s i r e d . E v a l u a t i o n : E v a l u a t i o n i n c o n t i n u i n g medical education has been approached i n s e v e r a l ways: by counting attendance; by o b t a i n i n g p a r t i c i p a n t s ' r e a c t i o n s ; by t e s t i n g achievement; by measuring changes i n medical p r a c t i c e ; and by measuring end r e s u l t s of care. Measurement techniques have been as e q u a l l y v a r i e d . These i n c l u d e : \"The use of motion p i c t u r e f i l m i n t e s t i n g o b s e r v a t i o n ; an erasure technique a l l o w i n g the t e s t i n g of c l i n i c a l problem-solving; the a p p l i c a t i o n of c e r t a i n s i m u l a t i o n techniques i n t e s t i n g d i a g n o s i s ; the s u b s t i t u t i o n of non-patient 126 for a real one to f a c i l i t a t e testing of c l i n i c a l performance\" (2); and more recently, the use of the medical audit. Despite these efforts, this review of studies on evaluation has found a general lack of substantive research and can but repeat the discouraging conclusion of many writers in the f i e l d (141) (237) (275) (177) (206) (161) that continuing medical education may not be having a demonstrable effect on medical care. From experience in the area of general adult education, perhaps Knowles (132) offers the best advice: Fundamentally the issue as to how much and what kind of evaluation a given adult educator w i l l engage in w i l l be resolved by referring to his philosophy of education...indeed, his very definition of education. If he defines i t as a process of educating a person, of taking responsibility 'for making changes in a human being'...then he does certainly incur an obligation to measure as precisely as possible what he is doing to that person and subject his findings to ethical review. His evaluation w i l l also be greatly concerned with efficiency,... .with getting data to determine whether or not he i s producing maximum change in the shortest possible time at the least cost. His dominant theme w i l l be quantification. But i f he defines education as a process of f a c i l i t a t i n g and providing resources for self-directed inquiry and self-development, he incurs an obligation to involve the participants i n collecting data that w i l l enable them to assess the effectiveness of the programs in helping them accomplish their objectives. His dominant theme is involvement. CONCLUSIONS In considering the expansion of continuing education i n medicine, one of the more promising recent developments has been the American Medical Associ-ation's accreditation program. Although i t i s s t i l l too early to assess i t s overall effect on the f i e l d , ultimately i t should help to establish minimum standards, thereby improving the quality of program offerings. Equally important i s the growing trend toward making the community hospital the major foc i of continuing education. 127 Extensive experimentation i n the use of the mass media a l s o promises to extend c o n t i n u i n g education beyond the confines of the u n i v e r s i t y campus and i t has helped to focus a t t e n t i o n on t h e i r p o t e n t i a l f o r s e l f - i n s t r u c t i o n . Despite these and other . p o s i t i v e f e a t u r e s , many negative trends p e r s i s t . The m a j o r i t y of programs have been designed to a s s i s t p h y s i c i a n s i n keeping up w i t h advances i n medical knowledge, even though the research suggests that the a p p l i c a t i o n of new knowledge may be l e s s c r u c i a l than the u t i l i z a t i o n of what i s already known about good medical p r a c t i c e . I t would seem th a t more - s e q u e n t i a l l y planned, c l i n i c a l l y o r i e n t e d programs are i n d i c a t e d , and f a c u l t y equipped to f a c i l i t a t e l e a r n i n g r a t h e r than simply to communicate more i n f o r -mation. At the same time, other types of f l e x i b l y organized programs are re q u i r e d i n order to help busy p h y s i c i a n s meet t h e i r i n d i v i d u a l requirements f o r l e a r n i n g . There i s an obvious need f o r more s t u d i e s on the impact of ed u c a t i o n a l programs measured i n terms of c l e a r l y defined o b j e c t i v e s and s t u d i e s on the o v e r a l l e f f e c t of c o n t i n u i n g education on the q u a l i t y of p a t i e n t care. Because of the complexity and expense i n v o l v e d , the combined e f f o r t s of organ-i z e d medicine i s e s s e n t i a l . Other challenges f a c i n g the p r o f e s s i o n i n c l u d e the c o n t i n u i n g e x p e r i -mentation and e v a l u a t i o n of d i f f e r e n t i n s t r u c t i o n a l techniques along w i t h the newer e d u c a t i o n a l media. The many i n f o r m a t i o n sources such as j o u r n a l s , c o n s u l t a t i o n s , and time on teaching s e r v i c e s , which p h y s i c i a n s i n d i c a t e are wide l y used as a means of keeping current need to be more c a r e f u l l y s t u d i e d . Indeed, i t would seem that the term \" c o n t i n u i n g education\" must be expanded to i n c l u d e not only formal courses, but these and the many m o d a l i t i e s through which p h y s i c i a n s may seek t h e i r own c o n t i n u i n g l e a r n i n g . As s t a t e d 128 by Houle (282) \" I f the p r a c t i c e of l e a r n i n g i n groups can be s t u d i e d , why cannot i n d i v i d u a l study?\" (282). The many o r g a n i z a t i o n s i n v o l v e d i n c o n t i n u i n g medical education must share the r e s p o n s i b i l i t y f o r d e v i s i n g a t o t a l system, whereby a l l i n s t r u -ments f o r l e a r n i n g may be i n t e g r a t e d i n t o a comprehensive ongoing program of c o n t i n u i n g education f o r the p r a c t i s i n g p h y s i c i a n . As suggested by Bloom, \"The competence to organize c o n t i n u i n g education i s a v a i l a b l e , but has never been a p p l i e d \" (20). > The need to co-ordinate the p r e - p r o f e s s i o n a l program w i t h c o n t i n u i n g medical education r e q u i r e s s e r i o u s c o n s i d e r a t i o n . There i s l i t t l e evidence that an ongoing c u r r i c u l u m from undergraduate to c o n t i n u i n g education has been e s t a b l i s h e d . Even more important i s the need to i n c u l c a t e e a r l y i n the medical student's c a r e e r , the concept of l i f e l o n g l e a r n i n g as a p a r t of h i s general p r o f e s s i o n a l o r i e n t a t i o n . The study and p r a c t i c e of medicine i s based on the s c i e n t i f i c process and, at l e a s t i n theory, those engaged i n the f i e l d are t r a i n e d to s o l v e problems through use of the s c i e n t i f i c method. Therefore, i t i s c u r i o u s that so l i t t l e of the s c i e n t i f i c method has been a p p l i e d to the d e s i g n , management or e v a l u -a t i o n of c o n t i n u i n g education i n medicine. 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Woolsey, F . , \"Community Hospital Learning Centers \", Proceedings: Conference Workshop on RMPS, vol. 2, U . S. Department of Health, Education, and Welfare, Washington, D. C , January 17-19, 1968, pp. 103 - 106. 277. Woolsey, F . , \"Continuing Education: The Key Word Now is Fun\", Medical Economics, (April, 28, 1969), pp. 117-180, 185-186. 278. Woolsey, F . , \"Two Way Radio Conferences -- A New Method for Post-graduate Education\", General Practitioner, vol. 19, (April, 1959), pp. 185 - 189. 279. Woolsey, F . , \"Two Years of Experimenting with Two-Way Radio Conferences for Postgraduate Medical Education\", Journal of Medical Education, vol. 33, (June 1958), pp. 474-482. 280. Youmans, J . , . \"Experience with a Postgraduate Course for Practitioners: Evaluation of Results\", Association of American Medical Colleges Journal, vo l . 10, (May, 1935), pp. 154-173. 281. Zabarenko, L . , \"Education of the Graduate Physician, an Evaluation\", American Journal of Psychiatry, vol. 122, (Nov. 1965), pp. 500-504. 282. Zabarenko, L . , Zabarenko, R. , \"A Suggested Method of Studying Small Group Seminars in Psychiatry, \" Journal of Nervous and Mental Diseases, vol. 143, (Sept., 1966), pp. 239 - 247. P A R T T H R E E 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 I S T R Y 152 153 CHAPTER V I I I THE PROFESSION AND CONTINUING EDUCATION The i n d i v i d u a l i s t i c n a t u r e o f d e n t a l p r a c t i c e and i t s r e l a t i v e i s o l a t i o n f r o m t h e m a i n s t r e a m o f g e n e r a l h e a l t h s e r v i c e s has s e v e r a l i m p o r t a n t i m p l i c a t i o n s f o r t h e development o f c o n t i n u i n g e d u c a t i o n . COMPOSITION AND DISTRIBUTION L i k e p h y s i c i a n s , d e n t i s t s a r e n o t b e i n g p r o d u c e d i n s u f f i c i e n t numbers t o m a i n t a i n what i s c o n s i d e r e d by some t o be an optimum r a t i o o f d e n t i s t s t o p o p u l a t i o n (56) ( 4 2 ) . D e s p i t e e f f o r t s t o expand d e n t a l s c h o o l programs ( 5 6 ) , p o p u l a t i o n growth w i l l c o n t i n u e t o o u t s t r i p t h e p r o d u c t i o n o f d e n t i s t s . I n Canada, an e q u a l l y p e s s i m i s t i c d e n t i s t - p o p u l a t i o n r a t i o i s p r o j e c t e d f o r t h e y e a r s ahead ( 3 9 ) . P o p u l a t i o n r a t i o s do n o t n e c e s s a r i l y r e f l e c t an a c c u r a t e p i c t u r e o f t h e a v a i l a b i l i t y o f d e n t a l s e r v i c e s . S t u d i e s have shown t h a t t h e use o f d e n t a l a u x i l i a r i e s can s i g n i f i c a n t l y i n c r e a s e t h e p r o d u c t i v i t y o f d e n t i s t s . I n b o t h Canada and t h e U n i t e d S t a t e s , governments recommend t h a t d e n t a l a u x i l i a r i e s be t r a i n e d t o p e r f o r m a g r e a t e r r ange o f d u t i e s t h a n t h e y a r e p r e s e n t l y p e r m i t t e d t o p e r f o r m (42) ( 3 9 ) . A n o t h e r i m p o r t a n t f a c t o r i n f l u e n c i n g t h e a v a i l a b i l i t y o f d e n t a l s e r v i c e s i s t h e 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 o f d e n t i s t s f r o m r e g i o n t o r e g i o n . As i n m e d i c i n e , t h e d i s t r i b u t i o n o f d e n t i s t s i n N o r t h A m e r i c a v a r i e s 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 . 154 Thus, i n t h e U n i t e d S t a t e s t h e h i g h e s t d e n t i s t - p o p u l a t i o n r a t i o s a r e f ound i n t h e l a r g e u r b a n c o m m u n i t i e s o f t h e N o r t h E a s t and t h e l e a s t i n t h e South (42). S i m i l a r l y , i n Canada t h e h i g h e s t d e n t i s t p o p u l a t i o n r a t i o s e x i s t i n t h e l a r g e u r b a n c o m m u n i t i e s of B r i t i s h C o l u m b i a and O n t a r i o and t h e l e a s t i n Newfoundland (59). A l t h o u g h s p e c i a l i z a t i o n has o c c u r r e d w i t h i n t h e d e n t a l p r o f e s s i o n , o n l y a s m a l l p r o p o r t i o n o f d e n t i s t s a r e p r a c t i s i n g a s p e c i a l t y . M c F a r l e n e (59) r e p o r t e d t h a t i n 1962 o n l y 3.8 p e r c e n t of t h e d e n t i s t s i n N o r t h A m e r i c a were . p r a c t i s i n g a r e c o g n i z e d s p e c i a l t y . W h i l e t h e r e a r e no r e c e n t n a t i o n a l f i g u r e s , a s u r v e y i n O n t a r i o f o u n d t h a t o n l y 6 p e r c e n t o f t h e d e n t i s t s were i n s p e c i a l t y p r a c t i c e i n 1968 (74). M o r e o v e r , a r e p o r t i n 1965 by 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 r y r e v e a l e d t h a t l e s s t h a n 10 p e r c e n t o f g r a d u a t i n g d e n t i s t s were g o i n g on t o o b t a i n g r a d u a t e d e g r e e s o r c e r t i f i c a t i o n i n one of t h e s p e c i a l i t i e s o f d e n t i s t r y (68). Hence, w h i l e i t i s e x p e c t e d t h a t s p e c i a l i z a t i o n w i l l i n c r e a s e a p p r e c i a b l y i n t h e f u t u r e (66) , i t i s n o t now a s i g n i f i c a n t f a c t o r a f f e c t i n g t h e a v a i l a b i l i t y o f d e n t i s t s . P r a c t i c e A r r a n g e m e n t s : As i n m e d i c i n e , d e n t i s t s a l s o p o o l t h e i r f a c i l i t i e s and p e r s o n n e l i n o r d e r t o meet th e i n c r e a s i n g demands on t h e i r s e r v i c e s (59) (48) . T h e r e i s a l s o some e v i d e n c e t h a t h o s p i t a l d e n t i s t r y i s i n c r e a s i n g (35) (48). G e n e r a l l y s p e a k i n g , however, most d e n t i s t s a r e s t i l l engaged i n i n d e p e n d e n t o f f i c e p r a c t i c e (39) (43), a n d , as p o i n t e d o u t i n t h e 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 , \"Because t h e y a r e so i n d e p e n d e n t , d e n t i s t s may f i n d i t r e l a t i v e l y d i f f i c u l t t o keep up w i t h t h e development o f d e n t a l t e c h n i q u e s , and t h e y may n o t be as exposed t o t h e k i n d s o f q u a l i t y c o n t r o l s t h a t p h y s i c i a n s e x p e r i e n c e t h r o u g h h o s p i t a l and o t h e r c o n t r o l i n s t i t u t i o n s r e q u i r e d f o r t h e t r e a t m e n t o f t h e i r p a t i e n t s \" (74). 155 Patterns of Work: Hall (39) noted that about one third of the 216 dentists interviewed worked a 40 to 44 hour week. For the rest, there was a wide variation from a high of 55 to a low of 35 hours per week. Of the 155 general practitioners in the sample, 54 percent had at least one f u l l time dental assistant while 69 percent of the 61 specialists had one or more f u l l time assistants. Only 6 percent of the total sample made any use of dental hygienists and 46 percent of those not employing hygienists f e l t the idea was a good one but knew l i t t l e i about the occupation or were not at a l l enthusiastic about the re-organization that would be required to introduce one into the office. The findings of the Ontario study (74) suggest that despite the growing importance, of specialization and preventive oral medicine, most of the dentists' work i s s t i l l \"largely devoted to routine repair and replacement of decayed teeth, f i t t i n g dentures, and the treatment of common periodontal disease.\" According to this report, and implied in others (39) (59) (42), \"The dental profession has not responded easily to changing public attitudes and needs, to new methods, or to the new ways of preparing dental personnel to provide these services.\" Both from within and without the profession the proposal that continuing education be used as a vehicle for re-orienting dental personnel to overcome these deficiencies (72) is being advanced more and more frequently. More specifically, at a recent national workshop sponsored by the American College \u00E2\u0080\u00A2of Dentists (72) i t was recommended: 1. That continuing education should not be limited to those subjects directly related to dentistry, but include areas that might have \"spin off\" benefits, e.g., sociologically oriented courses to provide better understanding of the needs, fears, and desires of the underprivileged, as well as patient groups which require special care in their treatment such as the chronically i l l , aged, and handicapped. 156 2. That d e n t a l s o c i e t i e s , s c h o o l s , and o t h e r a g e n c i e s d e v e l o p c o n t i n u i n g e d u c a t i o n programs i n k e e p i n g w i t h t h e p r e v e n t i v e c o n c e p t o f p r a c t i c e , r e g a r d l e s s o f t h e s t u d e n t group f o r whom i n s t r u c t i o n i s p l a n n e d . 3. T hat d e n t a l s c h o o l s implement programs w h i c h w i l l p r o v i d e t r a i n i n g i n t h e management and a d m i n i s t r a t i o n o f t h e t o t a l d e n t a l h e a l t h team f o r t h e u n d e r g r a d u a t e as w e l l as t h e c o n t i n u i n g e d u c a t i o n s t u d e n t . \u00E2\u0080\u00A2 .. W h i l e t h e s e recommendations c a p s u l e t h e major a r e a s r e q u i r i n g a t t e n t i o n i n f u t u r e p r o g r a m s , p l a n n i n g must a l s o t a k e i n t o a c c o u n t t h e o p i n i o n s o f t h e consumers o f c o n t i n u i n g e d u c a t i o n . Hence, i n r e c e n t y e a r s , a number o f s u r v e y s have been c o n d u c t e d i n an e f f o r t t o i d e n t i f y d e n t i s t s ' p e r c e p t i o n s o f t h e i r l e a r n i n g needs.. NEED FOR CONTINUING EDUCATION I n d e n t i s t r y t h e terms \" g r a d u a t e , \" \" p o s t g r a d u a t e , \" and \" c o n t i n u i n g \" e d u c a t i o n have been d e f i n e d by t h e C o u n c i l on D e n t a l E d u c a t i o n 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 (46) as f o l l o w s : G r a d u a t e E d u c a t i o n : r e f e r s t o t h o s e programs w h i c h i n c l u d e a p l a n n e d sequence o f c o u r s e s l e a d i n g t o an advanced d e g r e e , su c h as a M a s t e r o f S c i e n c e , t h e M a s t e r o f S c i e n c e i n D e n t i s t r y , o r t h e D o c t o r o f P h i l o s o p h y . P o s t g r a d u a t e E d u c a t i o n : r e f e r s t o t h o s e programs w h i c h i n c l u d e a p l a n n e d sequence o f c o u r s e s and i n s t r u c t i o n t h a t do n o t l e a d t o an advanced d e g r e e , b u t f o r w h i c h t h e s t u d e n t may be awarded a c e r t i f i c a t e . C o n t i n u i n g E d u c a t i o n : r e f e r s t o t h o s e s i n g l e c o u r s e s o f s h o r t d u r a t i o n (one o r two days t o s e v e r a l weeks on e i t h e r a f u l l t i m e o r i n t e r m i t t e n t b a s i s ) , w h i c h a r e o f f e r e d t o p r o v i d e p r a c t i s i n g d e n t i s t s w i t h i n f o r m a t i o n about new developments i n d e n t a l t e c h n i c s and t h e s c i e n c e o f p r a c t i c e . . A l t h o u g h t h e s e a r e t h e d e f i n i t i o n s g e n e r a l l y e n d o r s e d by t h e d e n t a l p r o f e s s i o n , i n p r a c t i c e t h e terms \" c o n t i n u i n g e d u c a t i o n \" and \" p o s t g r a d u a t e e d u c a t i o n \" a r e o f t e n used i n t e r c h a n g e a b l y r e s u l t i n g i n c o n s i d e r a b l e c o n f u s i o n . 157 In order to present this report according to the terminology used by the Council, programs of f u l l time study intended \"primarily to prepare dentists for specialty practice and/or for teaching in a c l i n i c a l area\" (66 ) , were defined as postgraduate education and excluded from this review. On the other hand, since i t appears to be common practice in dentistry to award certificates and/or credits for attendance at continuing education courses, \"non-academic\" credit courses were added to the foregoing Council's definition of continuing education and included in this review. As a further c l a r i f i c a t i o n of terminology (12) i t might be well to note that a continuation program in dental education includes the following: Seminars: A seminar i s a group effort in study or research conducted under the leadership of one or more persons possessing special knowledge in the area of study. Study Clubs: A study club i s an organized effort on the part of individuals to pool their knowledge and interest for the benefit of a l l participants. Study clubs may be of two kinds.: 1) .Where the objective i s basically instructional, and 2) where the objective i s basically investigative. Scientific Programs and Exhibits: Scientific programs are programs offered by organizations or institutions that offer lectures or discussions on various subjects of interest to the practitioners in an effort to keep the practitioners abreast of developments. Scientific exhibits offer further opportunity for this depending more on the visual aspects of the educational process. Extension Courses: Extension courses or programs offered by educational institutions are distinguished largely by the fact that they are made available outside the f a c i l i t i e s of the school, such as a branch or by mail. Intramural Courses: Intramural courses or programs are those located in the universities' dental schools. According to most writers, continuing dental education as presently constituted was a product of the second World War (57) (49) (55) (4). Up to that time there appears to have been few attempts to offer systematically any planned learning opportunities for dental practitioners. The return to 158 c i v i l i a n l i f e f o l l o w i n g World War I I of a l a r g e number of d e n t i s t s , coupled w i t h the r e v o l u t i o n a r y advances i n a l l the h e a l t h s c i e n c e s , f o r c i b l y demon-s t r a t e d the need f o r s p e c i f i c programs 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 response to these needs, the W.K. K e l l o g g Foundat ion p r o v i d e d f i n a n c i a l a s s i s t a n c e to d e n t a l s c h o o l s f o r the development of r e f r e s h e r - t y p e p r o g r a m s . , thus b r i n g i n g the u n i v e r s i t i e s ' d e n t a l s c h o o l s i n t o the mainstream of 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 . A conference on c o n t i n u i n g e d u c a t i o n was h e l d i n 1948 by seven d e n t a l s c h o o l s which had been r e c i p i e n t s of F o u n d a t i o n g r a n t s , and t h i s appears to have been the f i r s t o f a number of n a t i o n a l conferences and workshops which have been h e l d subsequent ly to \" s t u d y the problems r e l a t e d to the e s t a b l i s h m e n t and c o n d u c t i n g of programs of 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 \" (55) (19) (91) (72) . However, as noted by Mann (55) i n 1964: Many of the 1948 problems r e m a i n , and t o t a l l y s a t i s f a c t o r y answers or s o l u t i o n s to them have not y e t been d e v e l o p e d . . . T o \u00E2\u0080\u0094 d a y , and p r o b a b l y more important than f i f t e e n years ago, c o n s i d e r a t i o n must be g i v e n to the q u e s t i o n s of what p r o p e r l y c o n s t i t u t e s a t o t a l program of c o n t i n u i n g e d u c a t i o n f o r the d e n t a l p r o f e s s i o n . What are the a c c e p t a b l e methods of c o n t i n u i n g e d u c a t i o n tha t are or should be a v a i l a b l e w i t h i n reasonable d i s t a n c e or expense? What can a d e n t i s t do by h i m s e l f w i t h j o u r n a l s or t e a c h i n g d e v i c e s , and what can be done by t e l e v i s i o n ? Should a t o t a l program have o r g a n i z a t i o n or should i t depend upon independent g r o u p s , a g e n c i e s , and i n s t i t u t i o n s to p r o v i d e a s u f f i c i e n t l y broad spectrum or p o t e n t i a l exper ience to care f o r the p r o f e s s i o n ' s needs? I f o r g a n i z a t i o n i s d e s i r a b l e , who should a d m i n i s t e r i t ? These q u e s t i o n s are s t i l l major concerns i n 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 t o d a y . In d e n t i s t r y , as i n a l l the h e a l t h p r o f e s s i o n s , there has been much d i s c u s s i o n about these problems but few s c i e n t i f i c s t u d i e s on the ways and means of 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 d e n t i s t s . P r o b a b l y the most s i g n i f i c a n t n a t i o n a l s tudy was tha t p u b l i s h e d i n 1960 by the C o u n c i l on E d u c a t i o n of the American D e n t a l A s s o c i a t i o n (46 ) . I t 159 p r o v i d e d a comprehensive r e p o r t on the changing n a t u r e of d e n t a l p r a c t i c e , and on the g e n e r a l s t a t u s of d e n t a l e d u c a t i o n i n c l u d i n g c o n t i n u i n g e d u c a t i o n . I n 1964 the Committee on Advanced E d u c a t i o n of the American A s s o c i a t i o n of D e n t a l Schools p u b l i s h e d the f i n d i n g s of a survey of d e n t a l s c h o o l programs, f a c u l t y , and p a r t i c i p a n t s ( h e r e i n a f t e r r e f e r r e d to as the 1963 S u r v e y ) , which a l s o p r o v i d e d c o n s i d e r a b l e i n f o r m a t i o n r e g a r d i n g 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 . A t h i r d n a t i o n a l survey of note was tha t by the American P u b l i c H e a l t h A s s o c i a t i o n (51) i n 1964. T h i s s tudy sought to determine the g e n e r a l s t a t u s of 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 p u b l i c h e a l t h , and more p a r t i c u l a r l y , to i d e n t i f y the c o n t i n u i n g e d u c a t i o n needs of d e n t a l p e r s o n n e l i n p u b l i c h e a l t h s e r v i c e s . I n a d d i t i o n to t h e s e , over the past few years there have been a number of r e g i o n a l surveys d e f i n i n g the expressed l e a r n i n g needs of d e n t i s t s (63) (89) (1) (24) (65) ( 6 ) , and a few p i l o t p r o j e c t s on e x t r a m u r a l programs a l o n g w i t h those u s i n g the newer e d u c a t i o n a l media (27) (37) (32) ( 3 ) . G e n e r a l l y speak ing however, much of what has been w r i t t e n over the pas t decade have been o p i n i o n s and v i e w p o i n t s , p a r t i c u l a r l y w i t h r e f e r e n c e to the main p r e - o c c u p a t i o n of the d e n t a l p r o f e s s i o n , \"mandatory c o n t i n u i n g e d u c a t i o n \" (20) (25) (20)(30) (36 ) . 160 CHAPTER IX PARTICIPATION IN CONTINUING EDUCATION Although there is no accurate data available about participation in continuing dental education in general, there is some data that suggests factors which may affect participation including location, field, patterns of practice, income, age, and the uses of information sources. Most writers estimate that in any given year less than 25 percent of the dentists in the United States participate in continuing education programs (6) (29) (43) (88). Two national surveys provide estimates of 40 percent (63) and 49 percent (84) respectively, but local surveys tended to be less optimistic. A survey of 34 percent of the dentists in Kenrucky (24) revealed that 26 percent had attended one continuing education course during 1967-1968, 32 percent had attended two or three courses during this period, 25 percent had attended four or more courses, while 27 percent reported no course attendance. On the other hand, a review of attendance records at the University of Kentucky revealed that over a seven year period, the average annual attendance in programs offered at the university equalled the oft quoted national average of 12 percent (6). In Minnesota, a 1963 survey (64) based on approximately two-thirds of the practising dentists in that state disclosed that roughly 43 percent had taken at least one course in the past two years, while approximately 17 percent had not taken a course for ten or more years. Similarly, a recent survey conducted by the University of California found that of the 102 respondents, 77 percent had taken courses within the past two years (1). 161 These d a t a s u g g e s t t h a t 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 d e n t a l e d u c a t i o n v a r i e s w i t h t h e n a t u r e o f t h e sample p o p u l a t i o n s u r v e y e d , t h e c o u r s e s p o n s o r -s h i p , and o t h e r r e l a t e d f a c t o r s . L o c a t i o n : I t would appear t h a t t h e g e o g r a p h i c a l r e g i o n i n w h i c h t h e d e n t i s t p r a c t i c e s i s a s s o c i a t e d w i t h p a r t i c i p a t i o n i n c o u r s e s . I t has been f o u n d t h a t d e n t i s t s i n t h e U n i t e d S t a t e s l i v i n g i n t h e west and i n t h e e a s t a r e more l i k e l y t o have t a k e n c o u r s e s t h a n t h o s e i n o t h e r r e g i o n s (65) (84). But t h i s can be m i s l e a d i n g s i n c e t h e h i g h e s t p e r c e n t a g e o f d e n t i s t s w i t h i n r e a s o n a b l e a c c e s s t o d e n t a l s c h o o l s a r e t h o s e l o c a t e d i n t h e w e s t e r n and e a s t e r n s t a t e s . R o u g h l y one h a l f o f t h e n a t i o n ' s d e n t i s t s a r e p r a c t i s i n g i n l o c a t i o n s r e l a t i v e l y remote f r o m d e n t a l s c h o o l s . I n g e n e r a l , most s t u d i e s r e v e a l t h a t w h i l e d e n t i s t s w i l l t r a v e l l o n g d i s t a n c e s s e e k i n g d e s i r a b l e c o u r s e s (41) ( 5 ) , t h e m a j o r i t y p r e f e r c o u r s e s c l o s e r t o home. The 1963 s u r v e y o f d e n t a l s c h o o l programs (65) f o u n d t h a t 46.8 p e r c e n t o f t h e c o u r s e p a r t i c i p a n t s had t r a v e l l e d no more t h a n 100 m i l e s . F i e l d o f P r a c t i c e : D e n t i s t s i n s p e c i a l t y p r a c t i c e have been found t o t a k e o r t o have t a k e n more c o n t i n u i n g e d u c a t i o n c o u r s e s t h a n t h o s e i n g e n e r a l p r a c t i c e (89) (1). I n t h e n a t i o n a l s t u d y r e p o r t e d by O'Shea (65), 86 p e r c e n t o f t h e s p e c i a l i s t s r e p o r t e d h a v i n g t a k e n c o u r s e s whereas o n l y 60 p e r c e n t o f g e n e r a l p r a c t i t i o n e r s had done s o . Among t h e s p e c i a l i s t s , more o r t h o d o n t i s t s were fo u n d t o have t a k e n c o u r s e s t h a n t h o s e i n o t h e r s p e c i a l t i e s . T h i s s t u d y a l s o r e v e a l e d t h a t d e n t i s t s who engaged i n t e a c h i n g and/or r e s e a r c h , were more l i k e l y t o p a r t i c i p a t e i n c o n t i n u i n g e d u c a t i o n t h a n t h o s e who engaged o n l y i n p r a c t i c e . 1 6 2 P a t t e r n s o f P r a c t i c e : Q u e s t i o n n a i r e r e s p o n s e s f r o m o v e r 4000 d e n t i s t s i n t h e s i x New E n g l a n d S t a t e s (89) r e v e a l e d t h a t d e n t i s t s i n p a r t n e r s h i p and/or l o c a t e d i n a d e n t a l b u i l d i n g , were more l i k e l y t o have t a k e n c o u r s e s t h a n t h o s e i n s o l o p r a c t i c e o r l o c a t e d i n n o n - d e n t a l b u i l d i n g s . On t h e o t h e r hand, O'Shea (65) f o u n d t h a t n e i t h e r p r a c t i c e a r r a n g e m e n t s n o r o f f i c e l o c a t i o n were r e l a t e d t o c o u r s e a t t e n d a n c e ; however, 72 p e r c e n t o f t h e d e n t i s t s w i t h two o r more a u x i l i a r y a i d e s had t a k e n c o u r s e s as compared t o 53 p e r c e n t w i t h no a u x i l i a r i e s . I n a d d i t i o n , 72 p e r c e n t o f t h e d e n t i s t s who s c o r e d h i g h on t h e use o f p r e v e n t i v e p r o c e d u r e s had t a k e n c o u r s e s i n c o n t r a s t t o o n l y 54 p e r c e n t s c o r i n g l o w on t h e i r u s e . A s i m i l a r t r e n d was a l s o n o t e d w i t h r e s p e c t t o t h e v a r i e t y o f modern equipment i n u s e , \"The more such e q u i p -ment t h e d e n t i s t h a d , t h e more l i k e l y he was t o have t a k e n c o u r s e s and t o have t a k e n them r e c e n t l y . \" Income, Age: S e v e r a l s t u d i e s r e v e a l t h a t d e n t i s t s i n the' h i g h e r income b r a c k e t s a r e more l i k e l y t o t a k e c o u r s e s (1) (89) ( 6 5 ) . I n t h e C a l i f o r n i a s t u d y , 66 p e r c e n t o f t h e r e s p o n d e n t s e a r n i n g $11,000 t o $15,000 had t a k e n c o u r s e s compared w i t h 80 p e r c e n t i n t h e $16,000 t o $30,000 income b r a c k e t , ( 1 ) . S i m i -l a r l y , i n New E n g l a n d 57 p e r c e n t o f t h e d e n t i s t s whose income was i n t h e $20,000 o r more b r a c k e t r e p o r t e d c o u r s e a t t e n d a n c e v e r s u s 39 p e r c e n t o f t h o s e whose n e t income was l e s s ( 8 9 ) . A n a t i o n a l s u r v e y by 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 (84) found t h a t d e n t i s t s i n t h e 30 t o 50 age r a n g e were found t o e n r o l l i n c o u r s e s o f c o n t i n u -i n g e d u c a t i o n w h i l e beyond 50 t h e r e was a s t e a d y d e c l i n e i n p a r t i c i p a t i o n . 163 Use of Information Sources: Unlike physicians who tend to rank formal courses first or second in order of importance, dentists tend to rate reading, meetings, conventions, study clubs, and informal contacts with colleagues higher (90) (89) (63) (64) (23) (67) . An exception to this rank ordering was found in California (1) where respondents rated continuing education courses as the most important way of keeping up with new developments. While this survey was based on a sample of University of California Alumni and may be biased, this difference may be the result of the fact that the State of California has been very active in the field of continuing dental education (1). O'Shea (63) found that a greater proportion of respondents who rated formal courses as the most important method of keeping current were also more likely to have taken one or more courses. Moreover, he found that dentists who used other means of keeping up were also more likely to have taken refresher courses. Attendance at local, state, and regional meetings showed a lesser relationship to course attendance than did participation in study groups and membership in general and specialty dental societies. While reading is heavily endorsed as a way of keeping up to date, the Minnesota survey (64) revealed that 63 percent of the responding dentists spent less than five hours a month reading dental journals. In contrast, attendance at study clubs and discussion groups was fairly high, with approxi-mately two-thirds reporting attendance at 40 or more meetings in six months. A recent survey by the American Dental Association (84) revealed that 36 percent of the dentists responding belonged to study clubs that met regularly. Of this number, dentists in the North West region reported the highest study club membership (44.3 percent) while dentists in the New England states reported the lowest membership (28.7 percent). 164 S u r v e y s o f d e n t i s t s i n C o l o r a d o and Wyoming r e v e a l e d t h a t s o c i e t y m e e t i n g s and s t u d y c l u b s were most o f t e n used as s o u r c e s o f c o n t i n u i n g e d u c a t i o n by d e n t i s t s up t o age 55. T h e r e a f t e r , j o u r n a l s became more i m p o r t a n t . I t was a l s o f o u n d t h a t young g r a d u a t e s tended t o r a t e t h e i r own p r a c t i c e s \"a v e r y 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 \" ( 2 3 ) . Reasons f o r A t t e n d i n g o r N o t : D a t a g l e a n e d f r o m s u r v e y s s u g g e s t s t h a t f r o m 70 t o 90 p e r c e n t o f t h e d e n t i s t s a r e w i l l i n g t o p a r t i c i p a t e i n programs o f c o n t i n u i n g e d u c a t i o n (89) (23) ( 2 4 ) . I n C a l i f o r n i a ( 1 ) , 80 p e r c e n t o f t h e r e s p o n d e n t s s t a t e d t h a t i n t e r e s t i n t h e s u b j e c t was t h e m a j o r f a c t o r m o t i v a t i n g a t t e n d a n c e , 73 p e r c e n t l i s t e d t h e improvement o f o f f i c e p r a c t i c e and p r o c e d u r e s , 23 p e r c e n t i n d i c a t e d a p r o f e s s i o n a l o b l i g a t i o n , 5 p e r c e n t were m o t i v a t e d by membership i n t h e Academy o f G e n e r a l D e n t i s t r y , and. 4 p e r c e n t a t t e n d e d as a r e s u l t o f a s u g g e s t i o n from a c o l l e a g u e . I n Kentucky ( 2 4 ) j 86 p e r c e n t o f t h e r e s p o n d e n t s l i s t e d s u b j e c t m a t t e r c o v e r e d as t h e most i m p o r t a n t s t i m u l u s t o c o u r s e a t t e n d a n c e , 39 p e r c e n t were drawn by t h e r e p u t a t i o n o f t h e c l i n i c i a n i n s t r u c t o r , 34 p e r c e n t by c o u r s e l o c a t i o n , 17 p e r c e n t by t h e t i m e o f y e a r , and 13 p e r c e n t were m o t i v a t e d by t h e l o w c o s t o f t h e c o u r s e . On t h e o t h e r hand t h e most f r e q u e n t l y c i t e d d e t e r r e n t s t o c o u r s e a t t e n d a n c e ( n o t n e c e s s a r i l y i n o r d e r ) a r e : l a c k o f t i m e , d i s t a n c e (89) (24) ( 1 ) , c o s t s ( 2 4 ) , u n i n t e r e s t i n g t o p i c s ( 1 ) , and no c o u r s e s a v a i l a b l e ( 2 3 ) . S p o n s o r s : D e n t a l s c h o o l s s p o n s o r e d t h e m a j o r i t y o f c o u r s e s a t t e n d e d by d e n t a l p r a c t i t i o n e r s w i t h d e n t a l s o c i e t i e s r a n k i n g second (63) (24) ( 6 4 ) . C o m m e r c i a l o r g a n i z a t i o n s , h o s p i t a l s , c l i n i c s , and o t h e r m i s c e l l a n e o u s g r o u p s a c c o u n t e d 165 f o r b u t a s m a l l p e r c e n t a g e o f t h e c o u r s e s t a k e n . On t h e o t h e r hand, d e n t i s t s g i v e f i r s t p r e f e r e n c e t o c o u r s e s s p o n s o r e d by d e n t a l s o c i e t i e s w i t h d e n t a l s c h o o l s r a t i n g second (23) ( 8 9 ) , and a few i n d i c a t e t h a t t h e y p r e f e r s m a l l group s p o n s o r s s u c h as s t u d y c l u b s ( 2 3 ) . S c h e d u l i n g o f Programs: D e n t i s t s a r e more o r l e s s unanimous i n . t h e i r p r e f e r e n c e f o r c o u r s e s s c h e d u l e d on Wednesday (11) (47) (23) o r week-ends (73) ( 2 3 ) . The m a j o r i t y a l s o e x p r e s s a p r e f e r e n c e f o r s h o r t c o u r s e s l a s t i n g t h r e e days o r l e s s (11) (47) ( 2 3 ) . A s u b s t a n t i a l number i n d i c a t e t h a t t h e y w o u l d be w i l l i n g t o a t t e n d c o u r s e s s c h e d u l e d on an i n t e r m i t t e n t b a s i s w e e k l y o r m o n t h l y o v e r a p e r i o d o f t i m e (24) (23) (47) . The c h o i c e o f l o c a t i o n f o r c o u r s e s v a r i e s w i d e l y . The most f r e q u e n t l y c i t e d l o c a t i o n s i n c l u d e : u n i v e r s i t y d e n t a l s c h o o l s ; l o c a l h o t e l s ; l o c a l Vicsp^ t s X s y oir c X i ^ i i c s \" \u00C2\u00A3Hicl coimrnjiTiity c c l l s ^ s s (89) (23) \u00E2\u0080\u00A2 Xn Nsv? En^XcincLj d s n t i s t s i n s t a t e s w i t h a d e n t a l s c h o o l ( M a s s a c h u s e t t s and C o n n e c t i c u t ) , c i t e d t h e s c h o o l as t h e most f r e q u e n t l y chosen l o c a t i o n . T u i t i o n F e e s : The m a j o r i t y o f d e n t i s t s do n o t q u e s t i o n t u i t i o n f e e s (47) ( 2 4 ) . C o s t i s a d e t e r r e n t more i n terms o f t h e l o s s o f income and t r a v e l expenses t h a n t h e f e e i n i t s e l f . One s t u d y found t h a t 63 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 t h e c o s t o f c o u r s e s was about r i g h t , 25 p e r c e n t t h o u g h t t h e y were t o o e x p e n s i v e , and 10 p e r c e n t i n d i c a t 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 c o u r s e s w o u l d be a t t r a c t i v e even i f t h e c o s t s were s l i g h t l y h i g h e r ( 2 4 ) . F e l t L e a r n i n g Needs: A l t h o u g h v a r y i n g somewhat i n r a n k o r d e r , t h e c o u r s e t o p i c s most f r e q u e n t -l y c h o s e n by d e n t i s t s i n New E n g l a n d (89) r e f l e c t t h e s u b j e c t s r a n k e d h i g h e s t 166 in most other surveys (73) (11) (23) (1) (63) (64). These include: crown and bridge, complete dentures, periodontics, operative dentistry, and practice administration. In addition, other topics cited frequently include: diagnosis and treatment of emergencies (73) (23) , and the use of dental auxiliaries (73). In New England (89),dental public health, hospital dentistry, and the care of special problems were the least preferred topics. The Kentucky study (24) solicited dentists' opinions with respect to course offerings and content for auxiliary personnel. This revealed that 64 percent would like courses offered for dental assistants, and 35 percent i n d i -cated that they would be interested in participating in courses with their assistants. The most important courses for dental assistants were f e l t to be: office management, chairside assisting, dental health education, and dental radio-graphic technicians, in that order. Courses which were f e l t to be most important for dental hygienists were: dental health education and the use of mechanical scaling devices. Preventive dentistry and fluorides in dentistry were given top priority for hygienists in one study (24). Most of the program directors who responded in the Dental Public Health Survey (51) in 1964 indicated that the greatest training needs were in the areas of public health administration and health education. Local, program directors also rated training in c l i n i c a l procedures high in their l i s t of p r i o r i t i e s . Instruction: Dentists express a general preference for teaching techniques which f a c i l i t a t e personal contacts. In New England (89), the techniques most pre-ferred were demonstration..63 percent; participation..58 percent; lectures..51 percent; and discussion..46 percent. Least preferred were non-personalized 167 methods such as t e l e v i s i o n . . 1 8 p e r c e n t , movies..13 p e r c e n t ; c o r r e s p o n d e n c e . . 4 p e r c e n t , and t e a c h i n g machines..3 p e r c e n t . W i t h the e x c e p t i o n o f t e l e v i s i o n w h i c h r a n k e d r e l a t i v e l y h i g h i n i n t e r e s t v a l u e i n s e v e r a l s t u d i e s (23) ( 2 4 ) , t h i s l i s t more o r l e s s r e f l e c t s d e n t i s t s ' p r e f e r e n c e s w i t h r e s p e c t t o i n s t r u c -t i o n a l t e c h n i q u e s . The l a c k o f f a m i l i a r i t y w i t h a v a i l a b i l i t y o f e d u c a t i o n a l media may be a s i g n i f i c a n t f a c t o r i n t h e low l e v e l o f c h o i c e f o r t h e media. I n t h e WICHE (Western I n t e r s t a t e Commission on H i g h e r E d u c a t i o n ) s u r v e y ( 9 0 ) , i t was fo u n d t h a t o l d e r d e n t i s t s tended e i t h e r t o be unaware o f t h e d i f f e r e n t s o u r c e s o f i n f o r m a t i o n o r d i s i n t e r e s t e d i n t h o s e n o t a v a i l a b l e . Younger d e n t i s t s on t h e o t h e r hand, were more aware o f t h e i r need f o r a v a r i e t y o f d i f f e r e n t o p p o r t u n i t i e s n o t a v a i l a b l e t o them. The i n s t r u c t i o n a l p r o c e s s e s n o t a v a i l a b l e b u t d e s i r e d were: d e m o n s t r a t i o n c l i n i c s . . 5 2 . 9 p e r c e n t ; t e l e v i s i o n . . 5 1 . 7 p e r c e n t ; 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 . . 5 0 . 8 p e r c e n t ; group d i s c u s s i o n . . 4 7 . 2 p e r c e n t ; r a d i o . . 4 2 . 8 p e r c e n t ; and l e c t u r e s o r s y m p o s i a s p o n s o r e d by l o c a l h o s p i t a l s . . 4 2 . 6 p e r c e n t . I n s t r u c t o r s : I n t h e K e n t u c k y s t u d y ( 2 4 ) , \" r e s p o n d e n t s were a s k e d t o e v a l u a t e u n i v e r s i t y f a c u l t y members as i n s t r u c t o r s f o r c o n t i n u i n g e d u c a t i o n c o u r s e s . F o r t y - f i v e p e r c e n t o f t h e r e s p o n d e n t s t h o u g h t t h a t u n i v e r s i t y f a c u l t y d i d a b e t t e r j o b o f o r g a n i z i n g and p r e s e n t i n g m a t e r i a l t h a n d i d d e n t a l p r a c t i t i o n e r s , b u t 55 p e r c e n t t h o u g h t t h a t f r e q u e n t l y f a c u l t y members were t o o academic i n t h e i r a p p r o a c h , c o n c e n t r a t i n g on r e s e a r c h r a t h e r t h a n p r a c t i c e m a t t e r s . Some 16 p e r c e n t t h o u g h t t h a t f a c u l t y were n o t as a p p e a l i n g as n a t i o n a l l y r e c o g n i z e d s p e c i a l i s t s . 168 CHAPTER X PROGRAM ADMINISTRATION AND ORGANIZATION The nature and structure of dentistry as a profession coupled with the geographical distribution of its members has created problems that are barriers to the systematic development of continuing education in dentistry. Although these barriers are by no means insurmountable, they do account, in part, for the slow growth of continuing education in the profession. ADMINISTRATION Continuing education programs in dentistry are sponsored by dental schools, medical schools, general and specialty professional societies, hospitals, graduate dental institutes, affiliate member institutions of the American Association of Dental Schools, and by private groups of dentists in a locality. Of these, dental schools are the principal sponsors of formal courses. In 1970 (13) (14) (15), dental schools in the United States and Canada offered 1,095 courses, as compared with 340 courses recorded as offered by a l l other sponsoring agencies. Of dental school offerings, in 1970 eighty-eight courses were designed specifically for dental auxiliaries which represents a substantial increase from 1965, when only 19 courses were offered to auxiliary personnel (16) (17) (18). Insofar as i t can be determined from course listings, some 60 to 70 percent of the courses limit enrollment to 50 or less and have stipulated the use of participative teaching techniques in addition to demonstration and 169 l e c t u r e s (13) (14) (15) (16) (17) . In p r a c t i c e , however, i t i s r e p o r t e d t h a t a h i g h percentage of the courses use c h i e f l y n o n - p a r t i c i p a t i v e i n s t r u c t i o n a l techniques (10) (5) (45) . I n 1970, over 80 percent of the courses o f f e r e d were of l e s s than f i v e d a y s ' d u r a t i o n and were des igned f o r g e n e r a l p r a c t i t i o n e r s . T u i t i o n fees ranged from none to $700 f o r one twelve day course on O r a l R e h a b i l i -t a t i o n . The most f r e q u e n t l y o f f e r e d courses were : P r o s t h o d o n t i c s . . 2 5 2 ; O r t h o d o n t i c s . . 1 3 6 ; and P e r i o d o n t i c s . . 9 8 , w i t h o n l y 36 courses o f f e r e d on P r e v e n t i v e D e n t i s t r y . A survey (78) of over 200 c o n t i n u i n g e d u c a t i o n programs i n the S t a t e of Massachuset ts i n 1968 d i s c l o s e d comparable f i n d i n g s . The m a j o r i t y of programs b e i n g o f f e r e d were s h o r t term and h e a v i l y weighted towards c l i n i c a l s u b j e c t s . T h i s s tudy a l s o found t h a t 85 percent of a l l d e n t a l s o c i e t y meetings w i t h an e d u c a t i o n a l content were i n the G r e a t e r Boston m e t r o p o l i t a n a r e a . A 1963 survey (76) of 36 d e n t a l s c h o o l programs r e v e a l e d t h a t the m a j o r i t y of courses b e i n g o f f e r e d were l o c a t e d i n the u n i v e r s i t i e s . These few s c h o o l s r e p o r t i n g f a c i l i t i e s o ther than campus l o c a t i o n s l i s t e d l o c a l h o t e l s , m o t e l s , and r e s o r t a r e a s . A survey (51) of 46 d e n t a l s c h o o l s i n the U n i t e d S ta tes and Canada d i s c l o s e d t h a t i n 1965 o n l y 8 s c h o o l s o f f e r e d 16 courses f o r d e n t a l p u b l i c h e a l t h p e r s o n n e l . T u i t i o n f o r these ranged from none to $50, w i t h l i t t l e r e l a t i o n s h i p between the amount of the fee and the l e n g t h of the c o u r s e . A l l courses were a v a i l a b l e to d e n t i s t s and some to d e n t a l h y g i e n i s t s . A d m i n i s t r a t i v e Arrangements : The 1963 Survey (76) r e v e a l e d t h a t i n many d e n t a l s c h o o l s c o n t i n u i n g e d u c a t i o n programs were organized on a r a t h e r i n f o r m a l b a s i s . In 12 s c h o o l s the r e s p o n s i b i l i t y f o r p l a n n i n g and implementa t ion was d e l e g a t e d to the chairman 170 o f t h e p o s t g r a d u a t e d i v i s i o n , w h i l e i n 5 s c h o o l s programs were d i r e c t e d by t h e dean o f t h e d e n t a l s c h o o l , w i t h c o u r s e i m p l e m e n t a t i o n b e i n g d e l e g a t e d t o an a d v i s o r y committee o r d i r e c t o r o f c o n t i n u i n g e d u c a t i o n . I n a n o t h e r 5 s c h o o l s t h e a s s i s t a n t dean was a l s o t h e d i r e c t o r o f c o n t i n u i n g e d u c a t i o n . 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 a p a r t - t i m e c h a i r m a n who had a d d i t i o n a l t e a c h i n g r e s p o n s i -b i l i t i e s i n t h e u n d e r g r a d u a t e d i v i s i o n o f t h e s c h o o l . I n most c a s e s , s a l a r i e s f o r t h o s e i n c h a r g e 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 came from t h e r e g u l a r s c h o o l b u d g e t , b u t i n no c a s e was a s u p p l e m e n t a r y s a l a r y g i v e n t o f u l l o r p a r t t i m e f a c u l t y p a r t i c i p a t i n g i n programs, a l t h o u g h g u e s t l e c t u r e r s f r o m e l s e w h e r e were p a i d an h o n o r a r i a i n most i n s t a n c e s . A l t h o u g h d e t a i l e d i n f o r m a t i o n c o n c e r n i n g t h 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 o t h e r s p o n s o r i n g a g e n c i e s were n o t a v a i l a b l e , i n t h e 1960 S u r v e y o f D e n t i s t r y (46), 25 o f t h e 38 s t a t e s o c i e t i e s w h i c h r e s p o n d e d f e l t t h a t t h e y d i d n o t have a p p r o p r i a t e c o m m i t t e e s f o r c o - o r d i n a t i n g o r i m p l e m e n t i n g programs i n c o n t i n u i n g e d u c a t i o n a t t h e s t a t e , d i s t r i c t , o r l o c a l l e v e l . More r e c e n t l y t h e r e i s some i n d i c a t i o n t h a t d e n t a l s o c i e t i e s a r e becoming i n c r e a s i n g l y i n v o l v e d i n c o n t i n u i n g e d u c a t i o n i n * c o n j u n c t i o n w i t h d e n t a l s c h o o l s , d e p a r t m e n t s o f p u b l i c h e a l t h , and o t h e r s p o n s o r i n g a g e n c i e s (76). The g e n e r a l i m p r e s s i o n i s t h a t i n most c a s e s 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 s i n d i v i d u a l l y s p o n s o r e d (53) (34). I n s t r u c t o r s and F a c i l i t i e s : L a c k o f s u i t a b l e f a c i l i t i e s and q u a l i f i e d i n s t r u c t o r s have been i d e n t i -f i e d as two o f t h e m a j o r p r o b l e m s i n 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 (46) (62), and t h e s i t u a t i o n does n o t appear t o be i m p r o v i n g o v e r t i m e . A l t h o u g h t h e r e have been many a r t i c l e s a d v o c a t i n g t h e use o f h o s p i t a l s , m o b i l e c l a s s r o o m s , t e l e v i s i o n , a n d o t h e r f a c i l i t i e s w h i c h may make c o n t i n u i n g e d u c a t i o n more r e a d i l y a c c e s s i b l e t o p r a c t i s i n g d e n t i s t s , t h e i r u s e has been l i m i t e d (77) (52). 171 Both Harris (40) and Romano (77) revealed that with the exception of dental society meetings, television has scarcely been used for continuing dental education. Similarly, except for several recent pilot projects in the use of programmed instruction and teaching machines, self-instructional and other educational devices have yet to be explored. There are many reports of attempts to upgrade instructor qualifications through in-service training programs; however, i t appears that the majority of these are inadequate (43) (92) (79). Shepro (80) investigated teacher education i n dentistry and found that most graduate and postgraduate courses on teaching placed a major emphasis on dentistry rather than on the science of learning and instruction. He concluded: \"It is necessary therefore, to educate more teacher teachers before adequate in-service courses can be estab-lished\" (80). Finances: Most dental school programs are relatively self-supporting except for overhead expenses. In the 1963 Survey (76) only 4 of the reporting schools indicated that they were operating at a d e f i c i t , while 26 schools reported that they had surpluses from time to time. O'Shea and Black (63) believe that this heavy reliance on tuition to cover costs has contributed to the tendency i n continuing dental education to \"provide courses solely to accommo-date what the dentist may want rather than what he may need\". . This market economy approach to continuing education also accounts in some measure for the paucity of innovative programs in continuing dental education. In 1956, Levy (52) warned: We are aware of the fact that education rarely pays for i t s e l f ; the author personally feels that even on a postgraduate level i t should not. If the benefits to be derived from extension education are to be continued, however, the dental profession 172 must realize that no one institution can afford to bear a l l the cost, and that the profession must take a greater responsibility for finding ways and means of sharing the cost. In this respect, while the language of Public Law 89-239 in the United States, \"permits and even urges indirectly that dentistry be included in the policy structure of\" the regional medical programs... since the inception of the regional medical programs there has been l i t t l e formal inclusion of dentists in the programs and l i t t l e project development by dental agencies\" (33). Indeed, with the exception of several very recent pi l o t projects, the findings of this review suggest that neither governments nor voluntary agencies have played a significant role in f a c i l i t a t i n g the development of continuing dental education. Publicity and Promotion: Programs are publicized primarily through course listin g s published in the January, May, and September editions of the Journal of the American Dental Association. Monthly announcements providing more detailed information on coming educational events are also published in the \"News on Dentistry\" section of this journal. In addition, specialty journals, brochures, special pamphlets, word of mouth, and personal communications, are other commonly used methods of publicizing course offerings (83) (10). To encourage dentists to attend courses, sponsors of programs also report the use of various incentive plans, including credits toward certificates or fee discounts varying proportionately with the number of course hours of instruction attended (76) (86) (58). The University of Pittsburgh School of Dentistry has formed a Post Graduate Scholars Association. On completion of 100 hours of instruction a dentist is considered a \"member\" and is entitled to a 20 percent reduction'in tuition; after 300 hours he becomes a \"scholar\", 173 e n t i t l e d to a 50 percent r e d u c t i o n i n f e e s . These courses may a l s o be used f o r c r e d i t i n the Academy of Genera l D e n t i s t r y , which r e q u i r e s 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 e d u c a t i o n as a c o n d i t i o n of membership. Another i n t e r e s t i n g p l a n i s o f f e r e d by the S t . L o u i s U n i v e r s i t y School of D e n t i s t r y . To encourage the young d e n t i s t to c o n t i n u e h i s e d u c a t i o n , the d e n t a l s c h o o l g i v e s each new graduate f i v e C e r t i f i c a t e 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 . The f i r s t e n t i t l e s the d e n t i s t to a f r e e course and the o t h e r f o u r p r o v i d e f o r h a l f t u i t i o n . These c e r t i f i c a t e s are v a l i d f o r the f i r s t two c a l e n d a r y e a r s a f t e r g r a d u a t i o n (58 ) . Some d e n t a l s c h o o l s o f f e r courses under a s p e c i a l d i v i d e n d p l a n des igned s p e c i f i c a l l y f o r members of the Academy of G e n e r a l D e n t i s t r y (37) . PROGRAM PLANNING 'Mo^t of the urograms 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 f o l l o w the t r a d i -t i o n a l p a t t e r n s encountered i n a l l a d u l t e d u c a t i o n . Program p l a n n i n g appears to r e l y h e a v i l y on p a r t i c i p a n t o p i n i o n n a i r e s . There are many d e s c r i p t i o n s of q u e s t i o n n a i r e s used to ask p a r t i c i p a n t s what they l i k e d or d i d not l i k e about a c o u r s e , or what they would l i k e i n c l u d e d i n f u t u r e c o u r s e s . Other than one a r t i c l e by Barker (5) s t r e s s i n g the need f o r more c l e a r l y d e f i n e d o b j e c t i v e s , t h i s s e a r c h of the l i t e r a t u r e y i e l d e d no r e p o r t s of attempts to i d e n t i f y r e a l l e a r n i n g needs s y s t e m a t i c a l l y , nor were any s t u d i e s found which attempted to r e l a t e p a r t i c i p a t i o n to a c t u a l changes or improvement i n d e n t a l p r a c t i c e . Darby and Weiss (22) r e f e r to present course o f f e r i n g s as \"an unorganized and u n s y s t e m a t i c e d u c a t i o n a l smorgasbord from which the i n d i v i d u a l d e n t i s t must choose what he t h i n k s w i l l be most u s e f u l to h i m . \" They note tha t r e l e v a n t programs f o r c o n t i n u i n g e d u c a t i o n must be d i r e c t e d towards a l i f e t i m e of 174 l e a r n i n g c o n s i s t e n t w i t h t h r e e b a s i c p r i n c i p l e s : 1. Comprehensive w e l l o r g a n i z e d and s e q u e n t i a l programs. 2. E q u a l e d u c a t i o n a l o p p o r t u n i t i e s f o r a l l d e n t i s t s . . . o p p o r t u n i t i e s t h a t a r e a c c e s s i b l e , c o n v e n i e n t , and c o n t i n u o u s l y a v a i l a b l e . 3. L e a r n i n g e x p e r i e n c e s t h a t a r e c o m p a t i b l e w i t h sound l e a r n i n g t h e o r y and p r i n c i p l e s . To f u l f i l l t h e s e r e q u i r e m e n t s , t h e y c a l l 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 p l a n , much l i k e t h a t p r o p o s e d i n t h e D r y e r R e p o r t (28) f o r t h e f i e l d o f m e d i c i n e . To a c h i e v e t h i s l o n g r a n g e g o a l t h e y s t r e s s t h e need f o r c o o r d i n a t e d a c t i o n by a l l o f f i c i a l and v o l u n t a r y b o d i e s c o n c e r n e d w i t h 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 . No p a t t e r n o f c o - o r d i n a t i o n has y e t been e s t a b -l i s h e d t h a t w o u l d be a p p l i c a b l e e v e r y w h e r e , n o r does i t seem l i k e l y t h a t s u c h o v e r a l l programming w i l l be p o s s i b l e i n t h e n e a r f u t u r e . I n d e e d , as n o t e d by F u r s t m a n ( 3 4 ) , \" i t has been i m p o s s i b l e t o c o - o r d i n a t e a l l programs i n any g i v e n s t a t e - . \" One s t e p i n t h i s d i r e c t i o n was r e p o r t e d r e c e n t l y by t h e D e n t a l S o c i e t y o f t h e S t a t e o f New Y o r k (9) w h i c h announced t h e e s t a b l i s h m e n t o f a Bureau o f P o s t G r a d u a t e I n f o r m a t i o n w h i c h w i l l c o m p i l e and d i s s e m i n a t e d a t a on: 1) o f f i c i a l l y r e c o g n i z e d t e a c h i n g f a c i l i t i e s and programs; and 2) c u r r e n t q u a l i f i c a t i o n s and p o s t g r a d u a t e e d u c a t i o n o f l i c e n s e d d e n t i s t s i n t h e S t a t e o f New Y o r k . T h i s i n f o r m a t i o n s h o u l d a s s i s t s p o n s o r s i n e l i m i n a t i n g d u p l i c a t i o n and i t s h o u l d u l t i m a t e l y f a c i l i t a t e i n some measure t h e d e s i g n i n g o f programs f o r 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 . From t h e few program d e s c r i p t i o n s found i n t h e l i t e r a t u r e , t h e f o l l o w i n g examples i l l u s t r a t e t he v a r i e d a p p r o a c h e s w h i c h have been t r i e d -or a r e c u r r e n t l y i n use i n 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 . Study C l u b s : S t u d y c l u b s a r e a method o f a d u l t e d u c a t i o n u n i q u e t o t h e f i e l d o f d e n t i s t r y . They began s p o n t a n e o u s l y as a s y s t e m a t i c way f o r a s m a l l group o f 175 d e n t i s t s t o p r o v i d e f o r 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 . Two c h a r a c t e r i s t i c s o f s t u d y c l u b s make them p a r t i c u l a r l y e f f e c t i v e : 1) t h e members a r e i n v o l v e d i n p l a n n i n g t h e i r own e d u c a t i o n , and 2) as s m a l l i n f o r m a l p r i m a r y groups t h e y p r o v i d e f o r member i n t e r - a c t i o n and f a c i l i t a t e t h e use o f i n s t r u c t i o n a l t e c h n i q u e s w i t h h i g h l e a r n e r p a r t i c i p a t i o n ( 8 7 ) . Many s t u d y c l u b s p r o v i d e t h e i r own programs and i n s t r u c t i o n drawn f r o m t h e membership of t h e group w h i l e i n o t h e r c a s e s t h e y seek e x p e r t i n s t r u c t i o n from e l s e w h e r e . The o r g a n i z i n g c o n c e p t o f t h e s t u d y c l u b i s n o t new i n a d u l t e d u c a t i o n as c o m p a r a b l e g r o u p s have e x i s t e d f o r c e n t u r i e s f o r d i f f e r e n t p u r p o s e s . B e n j a m i n F r a n k l i n o r i g i n a t e d s u c h a group i n P h i l a d e l p h i a w h i c h became known as The J u n t o . I n e v e r y c a s e , t h e n as now, t h e s t u d y group i s a s i g n i f i c a n t , method f o r p r o v i d i n g a f u n c t i o n a l o p p o r t u n 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 t h a t meets t h e r e a l needs o f i t s p a r t i c i p a n t s . I n t h e G u i d e p u b l i s h e d by 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 i n 1958 ( 1 2 ) , t h e number and l o c a t i o n o f many s t u d y c l u b s was r e p o r t e d , i n c l u d i n g t h i r t y t h a t met r e g u l a r l y i n S e a t t l e , W a s h i n g t o n . O t h e r r e g i o n s r e p o r t i n g numerous s t u d y c l u b s were S o u t h e r n C a l i f o r n i a , Oregon, and the mid-west. I n r e c e n t y e a r s , d e n t a l s c h o o l s and s o c i e t i e s a r e s p o n s o r i n g and e n c o u r a g i n g t h e f o r m a t i o n o f s t u d y c l u b s ( 7 ) . The U n i v e r s i t y o f Oregon p l a n s and o p e r a t e s programs f o r s t u d y c l u b s , i n c l u d i n g t h e s e l e c t i o n o f i n s t r u c t o r s , c o u r s e d e s c r i p t i o n s , and f e e s as w i t h i t s r e g u l a r s h o r t c o u r s e s . The members o f a c l u b d e f i n e t h e i r own g o a l s and p l a n d e f i n i t e programs f o r t h e y e a r w i t h u n i v e r s i t y p e r s o n n e l . D u r i n g r e c e n t y e a r s , twenty-two such c l u b s met a t t h e u n i v e r s i t y and two i n a V e t e r a n s ' H o s p i t a l ( 8 7 ) . A t t h e U n i v e r s i t y o f I l l i n o i s , M a s s l e r (57) r e p o r t s : . . . s t u d y g r o u p s o f 8 t o 15 p r a c t i t i o n e r s r e g i s t e r a t t h e s t a r t o f e a c h academic y e a r and each group d e t e r m i n e s t h e c o u r s e o f s t u d y i t d e s i r e s t o p u r s u e . The g r o u p s meet e i t h e r once a month f o r a f u l l 176 academic year or once a week for a f u l l academic quarter. Outstanding men are recruited to meet with the groups. Pavone (68) describes the University of California study club program as : ...one of the most exciting developments in continuing education for the general practitioner...These school-operated groups participate i n discussions, seminars, c l i n i c a l investigation, review of literature and c l i n i c a l evaluation of materials and procedures. They offer one of the greatest potentials for short-term advanced training that has been conceived. Regional Programs: The University of Oregon School of Dentistry has initiated a regional program which brings instruction to dentists throughout the state. Called Friday Special, classes are held one Friday afternoon of each month at six different regional centers. One dentist\" in each area serves as co-ordinator and confirms attendance as well as participating in organizing the program i n other ways. Courses have been presented as seminars, but future plans include a c l i n i c a l approach (60). The University of Pittsburgh Dental School is conducting a similar but more extensive program in 15 regional centers distributed throughout the state and i n surrounding states. College classrooms, private dental offices, hotel rooms and hospitals serve as teaching f a c i l i t i e s . Teaching techniques include' closed cir c u i t television, demonstrations, and lectures. The number of dentists attending any given program is reported to vary from 8 to 35. Local representatives are invited to the university campus once a year to review the past year's program and to assist in planning for the coming year (38). Since 1964, the dental staff of a rural hospital in Poughkeepsie, New York, has been a f f i l i a t e d with a metropolitan teaching hospital. During a 177 t e n day e d u c a t i o n a l program p a r t i c i p a n t s from t h e r u r a l h o s p i t a l spend a p e r i o d o f t i m e o b s e r v i n g and p a r t i c i p a t i n g i n s e l e c t e d s p e c i a l t y a r e a s a t t h e m e t r o -p o l i t a n h o s p i t a l . R e c i p r o c a l l y , t h e s t a f f o f t h e u r b a n h o s p i t a l v i s i t t h e r u r a l h o s p i t a l t o p a r t i c i p a t e i n a one day and one e v e n i n g symposium i n t h e f i v e c o u n t y a r e a s e r v e d by t h e h o s p i t a l . S u b j e c t i v e l y , \" i t i s f e l t t h a t t h i s a f f i l i a t i o n i s c o n t r i b u t i n g t o t h e i n d i v i d u a l ' s 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 and i s s t i m u l a t i n g r e s e a r c h m o t i v a t i o n i n t h e p a r t i c i p a n t d e n t i s t s who r e t u r n t o S t . F r a n c i s H o s p i t a l t o s h a r e t h e i r n e w l y a c q u i r e d s k i l l s and e n t h u s i a s m w i t h n o n - p a r t i c i p a t i n g d e n t i s t s \" ( 3 2 ) . H o s p i t a l Programs: As h o s p i t a l d e n t i s t r y i n c r e a s e s i n i m p o r t a n c e , a number o f s p o n s o r s a r e o f f e r i n g s p e c i a l h o s p i t a l o r i e n t a t i o n programs f o r p r a c t i s i n g d e n t i s t s . I n 1969, t h e P e n n s y l v a n i a D e n t a l A s s o c i a t i o n i n i t i a t e d a s e r i e s o f h o s p i t a l t r a i n i n g c o u r s e s w h i c h were f i n a n c e d by t h e U.S. P u b l i c H e a l t h S e r v i c e . S i x c o u r s e s o f 10 t o 12 t r a i n e e s e ach were c o n d u c t e d i n f i v e P e n n s y l v a n i a h o s p i t a l s . Each c o u r s e p r o v i d e d a minimum o f 18 h o u r s o f i n s t r u c t i o n w h i c h i n c l u d e d l e c t u r e s and d e m o n s t r a t i o n s on t h e use o f d r u g s , l a b o r a t o r y t e s t s , o p e r a t i n g room p r o c e d u r e s , ' a n d s i m i l a r m a t t e r s . E v a l u a t i o n forms f i l l e d o u t by t h e p a r t i c i p a n t s i n d i c a t e d t h a t t h e c o u r s e s were h e l p f u l , and many f e l t t h a t t h e y s h o u l d be l o n g e r ( 4 8 ) . The Glenwood H i l l s H o s p i t a l and t h e E a s t e r S e a l S o c i e t y i n M i n n e s o t a a r e a l s o c o - s p o n s o r i n g a s i m i l a r t y p e o f h o s p i t a l o r i e n t a t i o n program. An e v a l u a t i o n o f t h i s two day program d i s c l o s e d t h a t d e n t i s t s who had p a r t i c i p a t e d i n t h e s e m i n a r s were p r o v i d i n g more h o s p i t a l t r e a t m e n t f o r t h o s e p a t i e n t s r e q u i r i n g i t ( 3 5 ) . 178 P r o f e s s i o n a l M e e t i n g s : The 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 ' s A n n u a l S e s s i o n i s p r o b a b l y t h e most co m p r e h e n s i v e c o n t i n u i n g e d u c a t i o n program o f f e r e d i n d e n t i s t r y . E x t e n d i n g o v e r a number o f d a y s , i t s p u r p o s e i s t o keep p r a c t i s i n g d e n t i s t s a b r e a s t o f t h e l a t e s t d e v e l o p m e n t s i n d e n t i s t r y . The f o r m a t i n c l u d e s p a n e l s , f o r u m s , s y m p o s i a , i n d i v i d u a l e s s a y s , c l i n i c a l l e c t u r e s , t a b l e c l i n i c s , p l u s a v a r i e t y o f s c i e n t i f i c e x h i b i t s . A t t e n d a n c e a t t h e s e i s r e p o r t e d t o be 10,000 o r more ( 7 5 ) . T e l e v i s i o n Programs: . W i t h f i n a n c i a l s u p p o r t from t h e W.K. K e l l o g g F o u n d a t i o n , t h e U n i v e r s i t y o f I l l i n o i s C o l l e g e o f D e n t i s t r y i s c r e d i t e d w i t h t h e f i r s t u s e o f c l o s e d c i r c u i t i n t e r s t a t e t e l e v i s i o n . T h i s p rogram, c o n s i s t i n g o f 4 w e e k l y s e s s i o n s , was accompanied by a d d i t i o n a l s u p p l e m e n t a r y m a t e r i a l s . As r e p o r t e d by L e v y f^*)} f-Vii_G n r Q o r s m i UPC o u p o D e c f n ^ otro-v-y r.T^y SXC\u00C2\u00B0p*~ ^ G T t h e C O S t w h i c h W H S c o n s i d e r e d p r o h i b i t i v e . A c c o r d i n g t o H a r r i s ( 4 0 ) , t h e U n i v e r s i t y o f P i t t s b u r g h S c h o o l o f D e n t i s t r y was t h e f i r s t t o e x p e r i m e n t w i t h open c i r c u i t t e l e v i s i o n i n 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 1960. T h i s program c o n s i s t e d o f 4 one hour d e n t a l c l i n i c s r e c o r d e d on v i d e o t a p e and t e l e c a s t on 4 c o n s e c u t i v e Sunday e v e n i n g s d u r i n g o f f a i r t i m e . A l t h o u g h t h e e f f e c t i v e n e s s o f t h i s program was c o n s i d e r e d f a v o u r a b l e , George r e p o r t s ( 3 8 ) , t h a t i t was d i s c o n t i n u e d because' o f l a c k o f f u n d s . I n 1967 B a l l a n t y n e (3) r e p o r t e d a s e r i e s o f t h r e e w e e k l y programs s p o n s o r e d by t h e Oregon D e n t a l A s s o c i a t i o n , and t e l e c a s t o v e r open c i r c u i t t e l e v i s i o n i n P o r t l a n d , Oregon. T h i s program was d e s i g n e d e x p r e s s l y f o r d e n t i s t s b u t was open t o p u b l i c v i e w i n g . A s a m p l i n g o f 45 d e n t i s t s by q u e s t i o n n a i r e i n d i c a t e d t h a t 44 p e r c e n t t h o u g h t t h e program was good, 31 p e r c e n t 179 e x c e l l e n t , and t h e r e m a i n d e r f a i r t o p o o r . I n c o n c l u d i n g h i s r e p o r t , B a l l a n t y n e comments: Much o f t h e s u c c e s s o f t e l e v i s i o n programs depends on t h e a b i l i t y o f t h o s e p r e s e n t i n g t h e m a t e r i a l t o p r o j e c t t h e m s e l v e s and command t h e a t t e n t i o n and i n t e r e s t o f t h e v i e w e r s . D r a w i n g t h e c l i n i c i a n s f r o m l a y members o f t h e d e n t a l a s s o c i a t i o n p r e s e n t s d i f f i c u l t i e s . The use o f t e l e v i s i o n r e q u i r e s t h a t a l l c o n c e r n e d l e a r n s p e c i a l s k i l l s and t e c h n i q u e s t o be e f f e c t i v e . S i n c e 1968 T u f t s U n i v e r s i t y S c h o o l o f D e n t a l M e d i c i n e has been c o n d u c t i n g an open c i r c u i t t e l e v i s i o n s e r i e s c a l l e d B o s t o n D e n t a l R e p o r t s , f a s h i o n e d a f t e r t h e B o s t o n M e d i c a l R e p o r t s . The programs a r e p r o d u c e d t h r o u g h t h e f a c i l i t i e s o f B o s t o n ' s e d u c a t i o n a l t e l e v i s i o n s t a t i o n and d i s t r i b u t e d t o e d u c a t i o n a l t e l e v i s i o n s t a t i o n s i n New E n g l a n d by t h e E a s t e r n E d u c a t i o n a l Network. A i d e d by s u p p o r t f r o m t h e U.S. P u b l i c H e a l t h S e r v i c e s D i v i s i o n o f D e n t a l H e a l t h and The A m e r i c a n Cancer S o c i e t y , t h e p i l o t s e r i e s c o n s i s t e d o f t h r e e 30 m i n u t e c o l o u r programs w h i c h were made a v a i l a b l e l a t e r t o d e n t a l g r o u p s and s t u d y c l u b s ( 8 5 ) . A c c o r d i n g t o D a l e ( 2 1 ) , program e f f e c t i v e n e s s w i l l be a s s e s s e d i n a number o f ways: 1) a u d i e n c e p a r t i c i p a t i o n ; 2) knowledge g a i n ; 3) u t i l i z a t i o n o f new m a t e r i a l s , t e c h n i q u e s , and equipment; and 4) changes i n c o n c e p t s o f d e n t a l p r a c t i c e s u c h as work s i m p l i f i c a t i o n , p r e v e n t i v e d e n t a l p r o c e d u r e s i n d e n t a l p r a c t i c e , p a t i e n t e d u c a t i o n , o r changes i n r e f e r r i n g p a t i e n t s t o s p e c i a l i s t s . A l s o i n c l u d e d i n f u t u r e p l a n s a r e \" t h e use o f s a t e l l i t e d e n t a l t e a c h i n g teams w i t h a c c e s s i b l e m o b i l e o r f i x e d d e n t a l u n i t s f o r d e m o n s t r a t i o n s o r p a r t i c i p a t i o n u s i n g modern t e a c h i n g a i d s f o r r u r a l d e n t i s t s who a r e t o o busy o r r e l u c t a n t t o t r a v e l d i s t a n c e s f o r a s s e m b l e d e d u c a t i o n . \" D r i n n a n and Greene (27) r e p o r t on consumer e v a l u a t i o n o f an open c i r c u i t t e l e v i s i o n s e r i e s . C o n s i s t i n g o f t e n o n e - h a l f hour programs, t h e s e r i e s was b r o a d c a s t f r o m f o u r u p s t a t e e d u c a t i o n a l t e l e v i s i o n s t a t i o n s a s s o c i a t e d w i t h t h e 178 Professional Meetings: The American Dental Association's Annual Session is probably the most comprehensive continuing education program offered in dentistry. Extending over a number of days, i t s purpose is to keep practising dentists abreast of the latest developments in dentistry. The format includes panels, forums, symposia, individual essays, c l i n i c a l lectures, table c l i n i c s , plus a variety of s c i e n t i f i c exhibits. Attendance at these i s reported to be 10,000 or more (75). Television Programs: With financial support from the W.K. Kellogg Foundation, the University of I l l i n o i s College of Dentistry i s credited with the f i r s t use of closed ci r c u i t interstate television. This program, consisting of 4 weekly sessions, was accompanied by additional supplementary materials. As reported by Levy f 1\"V>T_Q r^7~ocr**\u00C2\u00A3iTTi T.TSIC c n ^ p o c c f n ^ iti every way except for the cost which W2.s considered prohibitive. According to Harris (40), the University of Pittsburgh School of Dentistry was the f i r s t to experiment with open ci r c u i t television in continuing dental education in 1960. This program consisted of 4 one hour dental c l i n i c s recorded on videotape and telecast on 4 consecutive Sunday evenings during off air time. Although the effectiveness of this program was considered favourable, George reports (38), that i t was discontinued because of lack of funds. In 1967 Ballantyne (3) reported a series of three weekly programs sponsored by the Oregon Dental Association, and telecast over open cir c u i t television in Portland, Oregon. This program was designed expressly for dentists but was open to public viewing. A sampling of 45 dentists by questionnaire indicated that 44 percent thought the program was good, 31 percent 180 New Y o r k Network and one i n New Y o r k C i t y . Programs were announced i n l o c a l d e n t a l s o c i e t y j o u r n a l s , t h e p r e s s , and i n t e l e v i s i o n program g u i d e s . Of t h e 425 d e n t i s t s r e s p o n d i n g t o a q u e s t i o n n a i r e , o n l y 205 o r 48 p e r c e n t o f t h e r e s p o n d e n t s i n d i c a t e d t h a t t h e y had known about the programs. About 25 p e r c e n t o f t h e s e l e a r n e d o f t h e s e r i e s t h r o u g h t h e newspaper, 25 p e r c e n t t h r o u g h t h e i r d e n t a l s o c i e t y b u l l e t i n , and t h e r e s t by t e l e v i s i o n program g u i d e s o r by word o f mouth from c o l l e a g u e s . O n l y 117 (58 p e r c e n t ) o f t h o s e who knew about t h e s e r i e s c o u l d r e c e i v e t h e t r a n s m i s s i o n s on t h e i r t e l e v i s i o n r e c e i v e r s . F o r t y -f i v e d e n t i s t s i n d i c a t e d t h e y had watched t h e f i r s t p rogram, 42 watched t h e s e c o n d , and 39 watched t h e t h i r d . O n ly f o u r had watched a l l t e n programs and 18 had seen o n l y one. The main r e a s o n g i v e n by t h o s e n o t w a t c h i n g was t h e i n c o n v e n i e n t b r o a d c a s t t i m e . I n d i s c u s s i n g ways t o improve m o t i v a t i o n t o p a r t i c i p a t e i n t e l e v i z e d p r o g r ams, t h e a u t h o r s recommend: 1) t h a t upon showing e v i d e n c e o f v i e w i n g t h e programs d e n t i s t s be g r a n t e d c r e d i t s w h i c h c o u l d be a p p l i e d toward c o n t i n u i n g e d u c a t i o n r e q u i r e m e n t s ; 2) t h a t d e n t a l s o c i e t i e s o r d e n t a l s c h o o l s c o n t e m p l a t i n g p r o d u c i n g t e l e v i s i o n programs seek t h e s e r v i c e s o f a p r o f e s s i o n a l c o n s u l t a n t , a t e l e v i s i o n d i r e c t o r p r o d u c e r ; and 3) t h a t s p e c i a l e f f o r t s be made t o p u b l i c i z e and a c q u a i n t p o t e n t i a l v i e w e r s w i t h d e t a i l s c o n c e r n i n g t h e programs. D i B a g g i o (26) r e p o r t s t h a t t h e l a u n c h i n g o f t h e l a r g e s t s t a t e e d u c a t i o n a l t e l e v i s i o n n e t w o r k i n K e n t u c k y has r e s u l t e d i n a m u l t i d i s c i p l i n a r y a p p r o a c h t o e d u c a t i o n a l t e l e v i s 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 and t h e a l l i e d h e a l t h g r o u p s . The c o - s p o n s o r e d s e r i e s d f t e l e v i z e d programs c a l l e d PANMED began i n O c t o b e r , 1969. A l t h o u g h i n i t i a l l y p l a n n e d as a s e r i e s o f 15 pr o g r a m s , i n w h i c h a l l t h e d i s c i p l i n e s w o u l d be r e p r e s e n t e d , t h e p r e s s u r e o f t i m e r e s u l t e d i n t h e d e c i s i o n t o use e x i s t i n g t a p e s and m o t i o n p i c t u r e s f o r i n i t i a l p rograms. I n hopes t h a t 181 t h e h e a l t h p r o f e s s i o n a l s i n each d i s c i p l i n e w o u l d v i e w t h e e n t i r e s e r i e s , s c h e d u l e s o f programs were s e n t t o a l l h e a l t h p r o f e s s i o n a l s i n t h e s t a t e . A q u e s t i o n n a i r e was used t o e v a l u a t e t h e f i r s t f o u r shows. Of t h e 303 d e n t i s t s r e s p o n d i n g , 130 (42.99 p e r c e n t ) r e p o r t e d v i e w i n g p a r t one and 105 (34.6 p e r c e n t ) p a r t two. D i B a g g i o c o n c l u d e s : The r e s u l t s o f t h e s u r v e y seem t o s u p p o r t an e a r l i e r s t u d y o f c o n t i n u i n g e d u c a t i o n i n K e n t u c k y i n w h i c h i t was r e p o r t e d t h a t 12 p e r c e n t o f t h e s t a t e ' s d e n t i s t s a t t e n d c o n t i n u i n g e d u c a t i o n c o u r s e s . A p p a r e n t l y , t h i s p e r c e n t a g e cannot be a p p r e c i a b l y i n c r e a s e d by b r i n g i n g t h e programs i n t o t h e home (13 p e r c e n t watched t h e t e l e v i s i o n programs d e v o t e d t o d e n t i s t r y ) . C o r r e s p o n d e n c e : Programmed I n s t r u c t i o n : The U n i t e d S t a t e s N a v a l D e n t a l Corps has been o f f e r i n g c o n t i n u i n g e d u c a t i o n t h r o u g h c o r r e s p o n d e n c e s t u d y s i n c e 1957. T h i s c o n s i s t s o f g e n e r a l c o u r s e s on d e n t a l s p e c i a l t i e s and s h o r t e r t o p i c a l c o u r s e s w h i c h a r e s t r u c t u r e d i n a f o r m a t s i m i l a r t o t h a t used i n programmed l e a r n i n g . The t a r g e t a u d i e n c e i n c l u d e s r e s e r v e o f f i c e r s and t h o s e on a c t i v e d u t y . D u r i n g t h e f i r s t 5 y e a r t r i a l p e r i o d Heck and L a c k e y (44) e s t i m a t e d an e n r o l l m e n t o f 7,000 w i t h an 89 p e r c e n t c o m p l e t i o n r a t e . The D i v i s i o n o f D e n t a l H e a l t h o f the U n i t e d S t a t e s P u b l i c H e a l t h S e r v i c e has been e x p e r i m e n t i n g w i t h p i l o t p r o j e c t s u t i l i z i n g programmed i n s t r u c t i o n on i n d i v i d u a l and group t e a c h i n g m a c h i n e s . A t t h e D i v i s i o n ' s D e n t a l H e a l t h C e n t e r i n San F r a n c i s c o a team o f s p e c i a l i s t s p r e p a r e programmed m a t e r i a l s f o r machine p r e s e n t a t i o n . To d a t e , t housands o f d e n t i s t s have t a k e n t h e s e e x p e r i m e n t a l c o u r s e s w h i c h a r e now a v a i l a b l e on a w i d e v a r i e t y of s u b j e c t s ( 6 1 ) . F o r t h e p a s t s i x y e a r s t h e D i v i s i o n o f P e r i o d o n t o l o g y o f t h e U n i v e r s i t y o f C a l i f o r n i a S c h o o l o f D e n t i s t r y has been u s i n g programmed i n s t r u c t i o n i n i t s c o n t i n u i n g e d u c a t i o n p r o j e c t s . Under a g r a n t f r o m t h e U n i t e d S t a t e s P u b l i c H e a l t h S e r v i c e , i t i s d e v e l o p i n g s e l f - i n s t r u c t i o n a l m a t e r i a l s on P e r i o d o n t o l o g y 182 . s p e c i f i c a l l y designed f o r g e n e r a l p r a c t i t i o n e r s (69) . I n f o r m a t i o n R e t r i e v a l : The D e n t a l T r a i n i n g Center l o c a t e d i n the 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 i n Washington, D . C . , serves as a major resource c e n t e r f o r the p r o d u c t i o n and d i s t r i b u t i o n of a u d i o v i s u a l m a t e r i a l s . U s i n g the f a c i l i t i e s of the h o s p i t a l , the center has been d e v e l o p i n g 8mm. s i n g l e concept f i l m s i n such s p e c i a l i z e d areas as P e r i o d o n t o l o g y , o r a l s u r g e r y , p r o s t h o d o n t i c s , r a d i o -l o g y , o r a l d i a g n o s i s , and p a t i e n t e d u c a t i o n . By the end of 1968, i t was e s t i m a t e d tha t over 75 c a r t r i d g e f i l m s would be a v a i l a b l e to support the e d u c a t i o n a l programs f o r v e t e r a n s ' a d m i n i s t r a t i o n d e n t i s t s . I t was a l s o expected t h a t the f i l m s would be made a v a i l a b l e f o r purchase by i n t e r e s t e d i n d i v i d u a l s and groups (81 ) . The A u d i o - V i s u a l L i b r a r y of the American A s s o c i a t i o n of O r t h o d o n t i s t s i s c u r r e n t l y o f f e r i n g over n i n e t y d i f f e r e n t s l i d e - t a p e s and 16mm. f i l m s on d i f f e r e n t d e n t a l s u b j e c t s on a l o a n - r e n t a l b a s i s . I n 1967, more than 2,000 i n d i v i d u a l programs were d i s t r i b u t e d to o r t h o d o n t i s t departments a t d e n t a l s c h o o l s a l l over the w o r l d . P r e s e n t l y the A u d i o - V i s u a l Committee i s \" i n v e s t i g a t i n g the use of photograph book-tape programs f o r i n d i v i d u a l u s e , use of c a s s e t t e t a p e s , and o ther p o s s i b l e ways of expanding the v a l u e and use of the A u d i o - V i s u a l L i b r a r y \" (50 ) . The American D e n t a l A s s o c i a t i o n L i b r a r y , or Bureau of L i b r a r y and Indexing S e r v i c e (BLIS) l o c a t e d i n C h i c a g o , p r o v i d e s a two week l o a n s e r v i c e to a s s o c i a t i o n members anywhere i n the c o u n t r y . In 1968, 10,268 books , j o u r n a l s , m i c r o - f i l m s , and package l i b r a r i e s were r e p o r t e d i n c i r c u l a t i o n . Another important p a r t of the Bureau ' s f u n c t i o n i s the i n d e x i n g of d e n t a l j o u r n a l s , and more p a r t i c u l a r l y , i t s p r o d u c t i o n of the Index to D e n t a l L i t e r a t u r e , i n 183 c o - o p e r a t i o n w i t h the N a t i o n a l L i b r a r y of M e d i c i n e (71)\u00E2\u0080\u00A2 CURRENT AND RECURRING ISSUES AND TRENDS The most s i g n i f i c a n t development i n 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 over the past decade has been the i n c r e a s e d demand f o r a change i n s t a t e d e n t a l laws which would make 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 a requirement f o r p r a c t i c e . At l e a s t f o u r s t a t e s , i n c l u d i n g New Y o r k , K e n t u c k y , Oregon and P e n n s y l v a n i a , have made 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 mandatory. C a l i f o r n i a , M i n n e s o t a , M i s s o u r i , and New Mexico are p r o p o s i n g changes i n the law tha t would a l s o make c o n t i n u i n g e d u c a t i o n mandatory (25 ) . The i s s u e remains h i g h l y c o n t r o v e r s i a l . S ince the precedent se t by the New York S ta te H e a l t h Department 's T i t l e XIX of the S o c i a l S e c u r i t y A c t , which \" p r e s c r i b e s the s tandards of c o n t i n u i n g e d u c a t i o n which d e n t i s t s must meet i n o r d e r to p a r t i c i p a t e i n the Medacaid program\" ( 2 ) , movement i n t h i s d i r e c t i o n seems i n e v i t a b l e . Reasons f o r and a g a i n s t mandatory c o n t i n u i n g e d u c a t i o n were summarized a t a recent conference sponsored by the P h i l a d e l p h i a County D e n t a l S o c i e t y (54) . In b r i e f , arguments i n f a v o u r were as f o l l o w s : Tax supported h e a l t h care programs are w i t h i n c r e a s i n g frequency r e q u i r i n g evidence of the competency of the p r o f e s s i o n a l s who w i l l render the s e r v i c e . Hence i f the p r o f e s s i o n does not set the s tandard and p r o v i d e the mechanisms, f o r e n s u r i n g competence, government agencies w i l l . The g e n e r a l i m p r e s s i o n i s tha t many d e n t i s t s are not keeping t h e i r knowledge up to d a t e . The t rend i s i n the d i r e c t i o n of more r i g i d requirements i n a l l segments of the p r o f e s s i o n , and t h i s t r e n d w i l l p r o b a b l y be c a r r i e d i n t o the f i e l d of c o n t i n u i n g e d u c a t i o n . The q u a l i t y of d e n t a l s e r v i c e s would improve and the image of d e n t i s t r y w i l l be enhanced i n the eyes of the p u b l i c . C o n v e r s e l y , arguments a g a i n s t mandatory c o n t i n u i n g e d u c a t i o n i n c l u d e : 184 C o n t i n u i n g e d u c a t i o n i s the r e s p o n s i b i l i t y of the i n d i v i d u a l d e n t i s t and the p r o f e s s i o n as a w h o l e . More c a r e f u l l y planned q u a l i t y e d u c a t i o n would p r o v i d e the i n c e n t i v e f o r i n d i v i d u a l d e n t i s t s to p a r t i c i p a t e . Compulsion of any k i n d tha t would tend to coerce a group i n t o f o r c e d e d u c a t i o n processes might r e s u l t i n an a t t i t u d e of r e b e l l i o n tha t would not be conducive to m e a n i n g f u l l e a r n i n g . Attendance of c o n t i n u i n g e d u c a t i o n does not mean n e c e s s a r i l y tha t the knowledge ga ined w i l l be a p p l i e d i n p r a c t i c e . S e l f m o t i v a t e d l e a r n i n g i s more l i k e l y to l e a d to a thorough and c o n -s c i e n t i o u s performance of s e r v i c e . There i s a c t u a l l y no p o s i t i v e proof w i t h regards to how much c o n t i n u i n g e d u c a t i o n d e n t i s t s engage i n . T h i s i s p a r t i c u l a r l y t r u e w i t h regards to how much a d e n t i s t reads on h i s own, how many s c i e n t i f i c meetings he a t t e n d s , or how o f t e n he improves h i s knowledge through 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 . In i t s 1968 Annual Report (83) the C o u n c i l on D e n t a l E d u c a t i o n of the American D e n t a l A s s o c i a t i o n i s s u e d the f o l l o w i n g s ta tement : The C o u n c i l f e e l s s t r o n g l y that the f i n a l d e t e r m i n a t i o n of the r e q u i r e -ments and procedures to be u t i l i z e d by agencies of the d e n t a l p r o f e s s i o n to promote and assure cont inued competence must be the r e s p o n s i b i l i t y of s t a t e s o c i e t i e s and d e n t a l examining b o a r d s . I t should be the p r e r o g a t i v e of the boards and c o n s t i t u e n t s o c i e t i e s to determine the amount of c o n t i n u i n g e d u c a t i o n tha t should be expected of the. p r a c t i -t i o n e r s i n t h e i r s t a t e s . I t should be t h e i r p r e r o g a t i v e to dec ide whether c o n t i n u i n g e d u c a t i o n should be r e q u i r e d f o r l i c e n s u r e r e n e w a l . . . In t h i s r e s p e c t , a recent survey of s t a t e boards of d e n t a l examiners d i s c l o s e d tha t more than t w o - t h i r d s of the 43 responding boards f e l t tha t c o n t i n u i n g e d u c a t i o n should be v o l u n t a r y and expressed r e l u c t a n c e to pass l e g i s l a t i o n to make i t compulsory . Most boards i n d i c a t 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 f o r d e n t i s t s was not too s u c c e s s f u l . As one respondent put i t : I f e e l tha t AADE should encourage c o n t i n u i n g e d u c a t i o n , but there i s a problem of good programs and f a c i l i t i e s . I f the programs are r e a l l y good and o f f e r what p r a c t i t i o n e r s need you w i l l not have to pass laws and r e q u i r e d e n t i s t s to a t t e n d . Too many d e n t a l meetings o f f e r the same o l d l e c t u r e s and speeches tha t have been g i v e n over and over f o r years (38) . D i B a g g i o (25) suggests tha t a \" r e a l i s t i c s o l u t i o n would be to teach the d e n t i s t to s e l f - l e a r n , \" but adds r u e f u l l y , \"measurement of how w e l l he 185 does , p r e s e n t s c e r t a i n p r o b l e m s . \" I n 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 , needs and problems are by f a r more e v i d e n t than p r o g r e s s i v e t r e n d s . N e v e r t h e l e s s , a c c o r d i n g to Weclew (88): The ideas energing about c o n t i n u i n g e d u c a t i o n f o r the g e n e r a l p r a c t i t i o n e r seem to be t a k i n g the f o l l o w i n g p a t t e r n : Every e f f o r t should be made and every means e x p l o r e d to m o t i v a t e the p r a c t i t i o n e r to p a r t i c i p a t e i n c o n t i n u i n g e d u c a t i o n . R e l i c e n s u r e s h o u l d be r e g u l a t e d by the p r o f e s s i o n i t s e l f . A program and c u r r i c u l u m tha t would r a i s e the l e v e l of a l l of d e n t i s t r y should be d e v e l o p e d : 1. R e f r e s h e r courses should be planned to i n t e r e s t a l l d e n t a l graduates and should i n c l u d e a r e v i e w of b a s i c d e n t a l concepts and a resume of the newer c o n c e p t s . 2. More s o p h i s t i c a t e d courses should be o f f e r e d to those who have had the p r e l i m i n a r y c o u r s e s . 3. A program of c o n t i n u i n g e d u c a t i o n of y e a r l y courses to be a t tended throughout the d e n t i s t ' s e n t i r e p r o f e s s i o n a l career s h o u l d be p l a n n e d . 4. A pos tgraduate course t h a t w i l l l e a d to a c e r t i f i c a t e and d ip lomate i n g e n e r a l d e n t i s t r y should be d e v e l o p e d , w i t h the l e n g t h of time 186 CHAPTER X I SUMMARY 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 i s t r y has n o t d e v e l o p e d as e x t e n s i v e l y nor o v e r as l o n g a p e r i o d o f t i m e as has o c c u r r e d i n o t h e r h e a l t h p r o f e s s i o n s . T h i s i s due, i n p a r t , t o t h e i n d i v i d u a l i s t i c n a t u r e o f t h e p r o f e s s i o n and t o i t s r e l a t i v e i s o l a t i o n f r o m t h e m a i n s t r e a m o f t h e g e n e r a l h e a l t h s e r v i c e s . S u r v e y s i n d i c a t e t h a t w h i l e t h e r e i s a s h o r t a g e o f d e n t i s t s i n N o r t h A m e r i c a , t h e r e i s a l s o a p r o b l e m o f m a l d i s t r i b u t i o n and i n e f f e c t i v e u t i l i z a t i o n o f a v a i l a b l e d e n t a l manpower. F u r t h e r m o r e , t h e t r a d i t i o n a l framework w i t h i n w h i c h d e n t a l p r a c t i c e i s o r g a n i z e d s e r v e s as a b a r r i e r t o i n n o v a t i o n and change. A c c o r d i n g l y , t h e p r o p o s a l i s b e i n g advanced i n c r e a s i n g l y t h a t j c o n t i n u i n g e d u c a t i o n must s t r e s s : 1) new p r a c t i c e methods, such as group p r a c t i c e o r t h e use o f a u x i l i a r y p e r s o n n e l ; 2) g r e a t e r s o c i a l r e s p o n s i b i l i t y i n c l u d i n g c a r e o f s p e c i a l p r o b l e m s and p r e v e n t i v e d e n t i s t r y ; and 3) g r e a t e r i n t e g r a t i o n o f t h e b i o l o g i c a l s c i e n c e s . On t h e o t h e r hand, p r a c t i s i n g d e n t i s t s a r e r e q u e s t i n g s h o r t two t o t h r e e day c o u r s e s on \" b r e a d and b u t t e r t o p i c s w h i c h w i l l be o f immediate b e n e f i t t o them\" ( 3 8 ) . There i s some e v i d e n c e t h a t some d e n t a l p r a c t i t i o n e r s f e e l t h a t u n i v e r s i t y f a c u l t y a r e not. s k i l l e d i n t r a n s l a t i n g r e s e a r c h i n t o terms m e a n i n g f u l t o c l i n i c a l p r a c t i c e . PARTICIPATION The p a r t i c i p a t i o n p a t t e r n s o f d e n t i s t s a r e n o t m a t e r i a l l y d i f f e r e n t f rom t h o s e i n t h e o t h e r h e a l t h s c i e n c e s . The two ma j o r d e t e r r e n t s 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 e d u c a t i o n programs a r e a l a c k o f t i m e and d i s t a n c e . W h i l e 187 a l a c k o f t i m e i s q u e s t i o n e d by many (10) (31) (49) , t h e g e o g r a p h i c a l d i s p e r s i o n o f d e n t i s t s , b o t h w i t h r e s p e c t t o t h e i r p r a c t i c e and w i t h r e f e r e n c e t o t h e l o c a t i o n o f d e n t a l s c h o o l s , s u g g e s t s a need f o r d e c e n t r a l i z e d programs. I n a d d i t i o n , , s i n c e many d e n t i s t s i n d i c a t e a l a c k o f f a m i l i a r i t y w i t h t h e newer e d u c a t i o n a l media w h i c h c o u l d h e l p t o make e d u c a t i o n . m o r e c o n v e n i e n t , t h e r e s h o u l d be g r e a t e r use o f t h e s e i n 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 . ADMINISTRATION AND ORGANIZATION I n terms o f f a c u l t y , f i n a n c e s , and f a c i l i t i e s , c o n t i n u i n g e d u c a t i o n i s c g i v e n a s e c o n e d a r y p l a c e i n d e n t i s t r y . There i s a l s o c o n s i d e r a b l e e v i d e n c e t o s u g g e s t t h a t many s p o n s o r s a r e p r o v i d i n g c o u r s e s s o l e l y t o accommodate what t h e d e n t i s t may want, r a t h e r t h a n what he may need. T h i s a p p e a r s t o be r e l a t e d t o two p r o b l e m s : 1) t h e heavy dependence on t u i t i o n f e e s t o f i n a n c e p rograms; and 2) t h e d i f f i c u l t i e s i n h e r e n t i n p r e c i s e l y d e f i n i n g e d u c a t i o n a l n e eds. O t h e r major i n a d e q u a c i e s i d e n t i f i e d i n t h i s r e v i e w i n c l u d e : 1) t h e a l m o s t c o m p l e t e absence o f ' p r o g r a m e v a l u a t i o n ; 2) the l a c k o f i m a g i n a t i v e , i n n o v a t i v e program m o d e l s ; and 3) t h e p r e s s i n g need f o r d e c e n t r a l i z e d programs w h i c h would make c o n t i n u i n g e d u c a t i o n more r e a d i l y a c c e s s i b l e t o p r a c t i s i n g d e n t i s t s . M o r e o v e r , i f an i m p a c t i s t o be made on t h e p r e v e n t i v e and s o c i a l a s p e c t s o f d e n t i s t r y , o n g o i n g i n t e g r a t e d programs a r e r e q u i r e d . T h i s c a l l s f o r much g r e a t e r c o - o p e r a t i o n among t h e v a r i o u s a g e n c i e s p r e s e n t l y o f f e r i n g programs. D e s p i t e t h e s e and many o t h e r s h o r t c o m i n g s , i t w o u l d seem t h a t t h e i n c r e a s i n g t r e n d toward making 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 , has had some p o s i t i v e e f f e c t s on the development o f t h e f i e l d . Foremost i t has f o r c e d t h e p r o f e s s i o n a l a s s o c i a t i o n s , d e n t a l c o l l e g e s , and o t h e r a g e n c i e s r e s p o n s i b l e f o r stemming t h e t i d e of p r o f e s s i o n a l o b s o l e s c e n c e t o s e a r c h f o r new methods and a p p r o a c h e s t o t h e p r o c e s s of c o n t i n u i n g e d u c a t i o n . 188 REFERENCES 1. Adler, N . , \"Survey of Continuing Education\", Journal of the California Dental Association, 45: 132 - 136, (Fall, 1969). 2. Ast, O . , \"Qualifications of Dentists Under the New York State Medicare Program\", Journal of the American College of Dentists, 36: 179-185, (July, 1969). 3. Ballantyne, G . , \"Oregon Experiment: Continuing Dental Education Through Television\", Oregon Dental Journal, 2:4 - 5, (October, 1967). 4. Baralt, A . R . , \"Continuing Education\", Journal of the American Dental Association, 70:41-45, (January, 1965). 5. Barker, B . , \"Administration and Evaluation of Continuing Educational Programs\", Journal of the American College of Dentists, 36: 171-178, (July, 1969). 6. BiBaggio, J . , \"Continuing Education at the University of Kentucky: Report of a Seven Year Experience\", Journal of the American Dental Association, 78: 1007-1009, (May, 1969). 7. Brandt, S., \"The Bull Study Group\", Journal of Practical Orthodontics, 2: 389-396, (October, 1968). 8. Brehn, W . , \"President's Message\", International Journal of Orthodontists. (September, 1967), p. 87. 9. \"Bureau to Disseminate Data on Continuing Education\", Journal of the American Dental Association, 76:742-743, (April, 1968). 10. Burkett, L . , \"Responsibility of Dental Educational Institutions for Offering Continuing Education Programs\", Journal of Dental Education, 28:324-328, (September, 1964). 11. Cohen, M . , \"Another Front-- Continuing Education\", Harvard Dental Alumni Bulletin, 28: 75-77, (December, 1968). 12. Committee on Continuing Education of the'American College of Dentistry, An Outline for a Continuing Educational Program for the Dental Profession, The American College of Dentists, St. Louis, 1958. 13. \"Continuing Education: Course Listing for February 1970 Through May 1970\", Journal of the American Dental Association, 80: 360-388, (January, 1970). 14. \"Continuing Education: Course Listing for June 1970 Through September 1970\", Journal of the American Dental Association, 80: 1070-1078, (May, 1970). 15. \"Continuing Education: Course Listing for October 1970 Through June 1971\", Journal of the American Dental Association, 81: 701-722, (September, 1970). 189 16. \"Continuing Education Courses Sponsored by Educational Institutions\", Journal of . the American Dental Association, 70:161-163, (January, 1965)? 17. \"Continuing Education Courses Sponsored by Educational Institutions\", Journal of the American Dental Association, 70: 1518-1528, (June, 1965). 18. \"Continuing Education Courses Sponsored by Educational Institutions\", Journal of the American Dental Association, 71:901-915. (October, 1965). 19. Continuing Education in Dentistry: Report of the 86th Annual Meeting of the American Association of Dental Examiners, New York City, October, 1969. 20. \"Continuing Education: A Survey of State Dental Examining Boards\", Journal of the Massachusetts Dental Society, 18:230-233, (Fall, 1969). 21. Dale, P. , \"Dental Obsolescence, , New England Dental Reports\", Bulletin of the Academy of General Dentistry, (June, 1968), pp. 49-53. 22. Darby, D . , Weiss, R. , \"Continuing Education Outside the Dental School Setting\", Journal of the American Dental Association, 70:1488-1496, (June, 1965). .23. Darby, D . , \"The Dentist and Continuing Education--Attitudes and Motivations\", Journal of the American College of Dentists, 36:165-170. 24. DiBaggio, J \" A t t i t u d e s of Kentucky Dentists Toward Continuing Education, Results of Questionnaire Survey\", Journal of the American Dental Association, 80:1042-1044, (May, 1970). 25. DiBaggio, J . , \"Developments in Mandatory Continuing Education\", Journal of Dental Education, 34:141-144, (June, 1970). 26. DiBaggio, J . A . , \"A Multi-Disciplinary Approach to Televised Continuing Education for the Health Professions\", Journal of the American Dental Association, 82:151-153, (January, 1971). 27. Drinnan, A . , Greene, G . , \"Continuing Education for Dentists Using Open Circuit Television\", New York State Dental Journal, 35:203-310, (April, 1969). 28. Dryer, B . , \"Lifetime Learning for Physicians\u00E2\u0080\u0094Principles, Practices, and Proposals\", Journal of the American Medical Association, 180:108-111, (May 26, 1962y 29. Editor: \"Continuing Competence Through Continual Postgraduate Study\", New York State Dental Journal, 28:262-263, (June-July, 1962). 190 30. Editorial: Compulsory Continuing Education\", New York State Dental Journal, 35:415-416, (August-September, 1969). 31. Editorial: \"Continuing Education\", Journal of the American Dental Association, 73:562-563, (September, 1966). 32. Engelman, M . , et a l . , \"Educational Affiliation Between the Dental Staff of a Rural Hospital and a Metropolitan Teaching Complex\", Journal of Oral Surgery, 22:499-503, (November, 1964). . 33. Friedrich, R . , \"Dentistry's Role in New National Health Legislation: RMPS\", Journal of the American Dental Association, 77:864-869, (October, 1968). 34. Furstman, E . , \"In Focus: Continuing Education and Licensure\", Journal of the Southern California Dental Association, 36:230, (July, 1968). 35. Garfin, L . , \"AnEvaluation of Hospital Dental Seminars\", North West Dentistry, (May-June, 1969), pp. 167-168. 36. Garson, P . , \"I Protest Dentists Go Back to School\", Dental Management, 8:34-46, (January, 1968). 37. George,A. , \"Continuing Education Extension Programs\", Journal of the American Dental Association. 69:731.-733, (December, 1964). 38. George, W. A . , \"Continuing Dental Education\", Workshop of Dental Examiners and Dental Educators, Chicago, Illinois, February 13-14, 1970. 39. Hall, Q . , Utilization of Dentists in Canada, Royal Commission on Health Services, Queen's Printer, Ottawa, 1965. 40. Harris , J . J . , A Survey of Television in Medicine to Determine Its Utility as a Means of Continuing the Medical Education of Physicians, E d . D . Thesis, New York University, University Microfilms, Ann Arbor, Michigan, 1964. 41. Harris, S. , \"Report of a Survey of Continuing Education Programs\", Journal of Dental Education, 28:316-323, (September, 1964). 42. Health Manpower: Action to Meet Community Needs, Report of the Task Force on Health Manpower, Public Affairs ; Press, Washington, D . C . , 1967. 43. Health Manpower Perspective, Public Health Service Publication Number 1667, U . S. Printing Office, Washington, 1967. 191 44. Heck, C . , Lackey, M . , \"Report on a Navy Program in Continuing Education\", Journal of American Dental Association, 67:307-311, (February, 1962). 45. Hillenbrand, H . , \"New Focus on Continuing Education\", J ournal of the American Dental Association, 79: 88-91, (July, 1969). 46. Hollinshead, B. , (Director), The Survey of Dentistry, American Council on Education, Washington, D. C , 1961. 47. Holmes, G . , \"Continuing Education in Dentistry\", Journal of the American Dental Association, 61:63-68, Quly, 1960). 48. \"Hospital Procedure Training Courses Popular\", Journal of the American Dental Association, 78:984, (May, 1969). \" 49. Hozid, J . , \"Role of Continuing Education in Dental Obsolescence\", Journal of the American Dental Association, 78:1299-1303, (June, 1969). 50. Landau, J . , \"The ADA Library- - A Service for Dentists and Dental Students\", Journal of the American Dental Associan, 80:582-584, (March, 1970). 51. Law, F . , \"Continuing Education for Dental Public Health Personnel\", American Journal of Public Health, 55:1800-1806, (November, 1965). 52. Levy, S., \"Continuing Education for Dentists\", Journal of the American Dental Association, 58:55-61, (February, 1959). 53. Lovetfc, D. et a l . , \"Administration and Policies of Continuing Education\", Journal of Dental Education, 28:332-333, (September, 1964). 54. Malamed, E . , \"Continuing Education and Renewal of the Dental License: A Conference\", Journal of the American Dental Association, 80:331-334, (February, 1970). 55. Mann, W . , \"Purpose of the Workshop on Continuing Education\", Journal of Dental Education, 28:302-303, (September, 1964). 56. Manpower in the 1960's Health Manpower Source Book, Section 18, U . S. Department of Health, Education, and Welfare, Washington, D . C , 1964. 57. Massler, M . , \"Continuing Education Program to Meet Future Needs\", Journal of Dental Education, 34:145-150, (June, 1970). 192 58. McBride, T . , \"Incentives for Continuing Education\", Journal of the American College of Dentists, 33:147-149, (July, 1966). 59. McFarlane, B. A . , Dental Manpower in Canada, Queen's Printer, Ottawa, 1965. 60. \"New Package Deal In Continuing Education Outside Portland Oregon\", Journal of the Oregon Dental Assocation, 38:18-19, (December, 1968). 61. News of Dentistry: \"Programmed Instruction, Aids Dentist's Education\", Journal of the American Dental Association, 72:831-833, (April 1966). 62. Noye, H . , Batterson, G . , \"Analysis of Inservice Training Questionnaire\", Journal of Dental Education, 20:56-60, (January, 1956). 63. O'Shea, R . , Black, S., \" Short Courses for Dentists: Some Survey Results\", Journal of the American College of Dentistry, 32:32-41, (January 1965). 64. O'Shea, R. , Black, S., \"The Information Sources of Minnesota Dentists\", North-West Dentistry, (March-April, 1965), pp. 106-108. 65. O'Shea, R. , e t a l . , \"Taking Refresher Courses: Some Related Factors\", Journal of the American College of Dentists, 33:320-331, (October, 1965). 66. Ostrander, F . , \"Future Trends in Postgraduate Dental Education\", International Dental Journal, 18:844-850, (December, 1968). 67. Patterson, W ., \"Continuing Education: A Challenge to The Profession\" Journal of the American College of Dentists, 28:3-26, (March, 1960). ~ 68. Pavone, B. , \"Trends in Advanced Dental Education\", Bulletin of the Academy of General Dentistry, (December, 1966), pp. 52-59. 69. Pipe, P., Betz, P. , \"Approaches in Programmed Self Instruction for Dentists\", Journal of Dental Education, 35:59-65, (January, 1971). 70. Proceedings: Forty-Eighth Annual Session: Continuing Education, Miami Beach Florida, October 26, 1968. In Journal of the American College of Dentists, 36:154-205, (July, 1969). ~ 71. Reid, P . , \" A . A . O . Audio-Visual Library\", American Journal of Orthodontics, 55:80-81, '(January, 1969). 72. \"Reorientation of Personnel for Dental Health Services in the 1970's\", Journal of the American College of Dentists, 35:181-235, .(April, 1968). 193 73. Report of the American Dental Questionnaire, University of Alberta, Faculty of Dentistry, 1970, unpublished data. 74. Report of the Committee on the Healing Arts, Queen's Printer, Toronto, 1970. 75. \"Report of the 1964 Opinion Survey\", Journal of the American Dental Association, 71:90-95, (July, 1965). 76. \"Report on Survey of Continuing Education: 1962-1963\", Journal of Dental Education, 28:338-349, (September, 1964). 77. Romano, M . , \"Use of Television in Dental Education\", Journal of Dental Education, 28:432-492, (April, 1964). 78. Ryan, R. , Williams, A . , \"Dental Continuing Education in Massachusetts\", Journal of the Massachusetts Dental Society, 18:244-246, (Fall, 1969) 79. Schour, I., Massler, M . , \"Institutional Inservice Training Programs\", Journal of Dental Education, 25:232-241, (March, 1961). 80. Shepro, M . , \"Inservice Education of Dental Teachers\", Journal of Dental Education, 25:87-92, (March, 1961) 81. \"Single Concept 8mm Films Aid Training at VA Dental Center\", Journal of the American Dental Association, 77:1264-1266.(December, 1968). 82. Sullens, R. , Patterson, W. , \"The Dentist's Need to Continue His Education\", Journal of the American Dental Association, 60:319-322, (March, 1960). 83. Sullens, R . , \"What is the Present ADA Situation?', Journal of The American College of Dentists, 36:191-193, (July, 1969). 84. \"Survey of Dental Practice: Some Aspects of the Dentists' Professional Development\", Journal of the American Dental Association, 79:918-922, (October, 1969). 85. \"Tufts Presents Second Television Series for Dentists\", Journal of the American Dental Association, 78:727, (April, 1969)] 86. Walker, J . , \"Continuing Education at the Local Level\", Journal of the American Dental Association, 70:1197-1199, (May, 1965). 194 87. Weber, V . , \"News of Continuing Education Programs\", Journal of the Oregon Dental Association, 39:27-29, (September, 1969). 88. Weclew, T . , \"Continuing Education: Meeting the Practitioner's Need\", Journal of the American Dental Association, 72:1138-1140, (May, 1966). 89. Wechsler, H . , et 'al., \"Continuing Education and New England Dentists: A Questionnaire Survey\", Journal of the American Dental Association, 78:573-576, (March, 1969). 90. WICHE: Mountain States Regional Medical Programs, Report of a Survey of Continuing Education Needs for Health Professionals, Mountain States Regional Medical Programs, Boulder, Colorado, June, 1969. 91. \"Workshop on Continuing Education\", Journal of Dental Education, 28: 302-349, (September, 1964). 92. Wuehrmann, A . , \"Inservice Teacher Training in Dentistry\", Journal of Dental Education, 20:83-94, (March, 1956). P A R T F O U R 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 195 196 CHAPTER X I I THE PROFESSION AND CONTINUING EDUCATION F o r t h o s e f a m i l i a r w i t h t h e n u r s i n g p r o f e s s i o n , i t would seem s u p e r f l u o u s t o r e i t e r a t e t h e many w e l l known and w e l l documented p r o b l e m s i n n u r s i n g . N e v e r -t h e l e s s , i n o r d e r t o u n d e r s t a n d b o t h t h e l i m i t a t i o n s on and t h e needs i n c o n t i n u i n g e d u c a t i o n , i t i s n e c e s s a r y t o r e - e x a m i n e b r i e f l y some of t h e pr o b l e m s as w e l l as the t r e n d s i n con t e m p o r a r y n u r s i n g . NURSE COMPOSITION AND DISTRIBUTION N u r s e s c o m p r i s e t h e l a r g e s t s i n g l e group o f h e a l t h p r o f e s s i o n a l s , and even i g n o r i n g t h e v a s t number of p r a c t i c a l n u r s e s , o r d e r l i e s , and o t h e r a u x i l i a r y n u r s i n g p e r s o n n e l , t h e n u r s e - p a t i e n t r a t i o s i n Canada and t h e U n i t e d S t a t e s a r e among t h e h i g h e s t i n t h e w o r l d , 1:164 (76) and 1:302 (69) r e s p e c t i v e l y . M o r e o v e r , f o r t h e p a s t s e v e r a l y e a r s , employed r e g i s t e r e d n u r s e s have been i n c r e a s i n g a t a r a t e o f a p p r o x i m a t e l y 3 p e r c e n t p e r y e a r i n t h e U n i t e d S t a t e s ( 3 1 ) , and by 7 t o 8 p e r c e n t p e r y e a r i n Canada ( 3 0 ) . These f i g u r e s a r e l e s s i m p r e s s i v e when one c o n s i d e r s t h a t r o u g h l y one q u a r t e r o f t h e n u r s e s a r e employed p a r t - t i m e and t h a t t h e a t t r i t i o n r a t e i s h i g h i n n u r s i n g ( 5 7 ) . S i n c e n u r s i n g i s l a r g e l y a women's p r o f e s s i o n o f whom w e l l o v e r o n e - h a l f a r e m a r r i e d ( 7 6 ) , i t i s e x p e c t e d t h a t t h e s e t r e n d s w i l l c o n t i n u e i n f u t u r e . A t t h e same t i m e , a number o f s t u d i e s (101) (122) (57) d i s c l o s e t h a t a s i g n i f i c a n t p e r c e n t a g e o f i n a c t i v e n u r s e s would be w i l l i n g t o r e - e n t e r t h e work f o r c e , p r o v i d e d r e f r e s h e r c o u r s e s were made a v a i l a b l e . They a l s o s u g g e s t t h a t t h e m a j o r i t y o f i n a c t i v e n u r s e s a r e d i p l o m a g r a d u a t e s and most a r e s e e k i n g 197 p a r t - t i m e employment. As p o i n t e d out i n t h e r e c e n t r e p o r t o f t h e N a t i o n a l Commission on N u r s i n g and N u r s i n g E d u c a t i o n ( 6 9 ) , w h i l e r e - a c t i v a t i o n o f t h i s group may w e l l s a t i s f y c e r t a i n manpower n e e d s , i t does n o t n e c e s s a r i l y meet t h e need f o r n u r s e s w i t h advanced e d u c a t i o n a l p r e p a r a t i o n , n o r does i t n e c e s s a r i l y g u a r a n t e e a s t a b l e work f o r c e . I n 1968, 85.9 p e r c e n t of Canada's r e g i s t e r e d n u r s e s had no academic d e g r e e , 5 p e r c e n t had a b a c c a l a u r e a t e , and l e s s t h a n 1 p e r c e n t had a h i g h e r d e g r e e ( 3 0 ) . Comparably, i n 1966, o n l y 10.6 p e r c e n t o f t h e r e g i s t e r e d n u r s e s i n t h e U n i t e d S t a t e s had b a c c a l a u r e a t e s , and 2.5 p e r c e n t a h i g h e r d e g r e e ( 5 ) . On t h e o t h e r hand, t h e g e n e r a l c onsensus i s t h a t 25 t o 33 p e r c e n t o f t h e p r e s e n t p o s i t i o n s i n n u r s i n g r e q u i r e a t l e a s t a b a c c a l a u r e a t e (76) . These d a t a l e n d s u p p o r t t o t h e c o n c l u s i o n t h a t \" t h e p r o d u c t i o n o f a s u f f i c i e n t number o f n u r s e s may be l e s s o f a p r o b l e m t h a n t h e p r o d u c t i o n o f enough n u r s e s w i t h h i g h e r d e g r e e s f o r t h o s e p o s i t i o n s where i t i s f e l t t h a t s u c h p r e p a r a t i o n i s e s s e n t i a l \" (57).* Trends i n C o m p o s i t i o n and D i s t r i b u t i o n : Of t h e r e g i s t e r e d n u r s e s a t work t h e m a j o r i t y a r e employed by i n s t i t u t i o n s and a g e n c i e s , p a r t i c u l a r l y by h o s p i t a l s . I n d e e d , as shown i n T a b l e V I , t h e most s i g n i f i c a n t t r e n d o v e r t h e p a s t f o r t y y e a r s has been t h e d e c l i n e o f i n d e p e n -d e n t p r a c t i c e . I n s p i t e o f o t h e i n c r e a s i n g emphasis on community h e a l t h c a r e , i n 1968 o n l y 8 p e r c e n t o f employed n u r s e s i n Canada were engaged i n p u b l i c h e a l t h o r o c c u p a t i o n a l h e a l t h n u r s i n g , as compared t o 15 p e r c e n t i n 1930. R e cent employment s t a t i s t i c s on n u r s e manpower i n t h e U n i t e d S t a t e s s u g g e s t a s i m i l a r d i s t r i b u t i o n i n t h a t c o u n t r y ( 6 ) . The a v e r a g e a n n u a l t u r n o v e r r a t e f o r r e g i s t e r e d n u r s e s w o r k i n g g e n e r a l d u t y i n h o s p i t a l s i s 60 p e r c e n t i n Canada (75) , and 70 p e r c e n t i n t h e U n i t e d TABLE VI PERCENTAGE DISTRIBUTION OF EMPLOYED NURSES BY FIELD OF EMPLOYMENT IN CANADA 1930, 1960, 1968 Field of Nursing 1930 1960 1968 Private Duty 60 9 4 Hospitals/Nursing Schools 25 59 83 Public/Occupational Health 15 7 8 Other or Unspecified: Includes -Physician or Dentist Office: Other specified f i e l d 25 5 TOTAL 100 100 100 SOURCES:\" COUNTDOWN: 1969: Canadian National Statistics: Canadian Nurses' Association, Ottawa, p Kohn, R., Emerging Patterns of Health Care,. Ottawa: Royal Commission on Health Services; Queen's Printer, 1966, p.24. 199 S t a t e s (69) . U s i n g t h e o f t q u o t e d e s t i m a t e p r o v i d e d by Taub and M e l b i n of \"$500 t o r e p l a c e one n u r s e \" ( 1 0 8 ) , the economic i m p l i c a t i o n s o f t h e s e t u r n o v e r r a t e s i s o b v i o u s . E q u a l l y s i g n i f i c a n t , h o w e v e r , i s t h e l o s s i n terms o f n u r s e e f f e c t i v e n e s s , n o t o n l y t o t h e new s t a f f n u r s e but a l s o t o a l l t h o s e i n v o l v e d i n h e r o r i e n t a t i o n . As one i n - s e r v i c e c o - o r d i n a t o r w r i t e s , \" I n s e r v i c e e d u c a t i o n i s n o t a l u x u r y o r s o m e t h i n g n i c e t o have i n a h o s p i t a l , i t i s a n e c e s s i t y . Because o f a r a p i d t u r n o v e r o f p e r s o n n e l o u r a u d i e n c e i s a p a r a d e \" (113) . Because n u r s i n g i s a p r o f e s s i o n composed p a r g e l y o f f e m a l e w o r k e r s t h i s may a c c o u n t f o r t h e h i g h t u r n o v e r b u t a c c o r d i n g t o M u r r a y (75) , t h e t u r n -o v e r r a t e i n n u r s i n g i s anywhere f r o m 20 t o 30 p e r c e n t h i g h e r t h a n f o r o t h e r p r e d o m i n a t e l y f e m a l e o c c u p a t i o n s . I n h i s s t u d y , M u r r a y a t t e m p t e d t o i d e n t i f y t h o s e v a r i a b l e s a c c o u n t i n g f o r t h e r a p i d t u r n o v e r o f g e n e r a l s t a f f n u r s e s . He found t h a t w i t h t h e e x c e p t i o n o f younger n u r s e s who tended t o be more m o b i l e , no c l e a r p a t t e r n emerged. On t h e a v e r a g e , p a r t - t i m e n u r s e s were no more n o r l e s s s t a b l e t h a n f u l l t i m e s t a f f . Nor d i d s i z e o f h o s p i t a l o r s i z e of community n e c e s s a r i l y c o r r e l a t e w i t h j o b m o b i l i t y . He d i d c o n c l u d e t h a t \" n u r s i n g t u r n o v e r i s n o t a l l a c a s e o f b e i n g ' p u l l e d ' away f r o m a j o b ; a t l e a s t some of i t may be due t o b e i n g 'pushed' as a r e s u l t o f d i s s a t i s f a c t i o n w i t h a p a r t i c u l a r s i t u a t i o n . \" He recommended\u00E2\u0080\u0094as have many o t h e r s (89) (15) (69) \u00E2\u0080\u0094 t h a t \" s m a l l work groups be c r e a t e d t o f o s t e r a f e e l i n g o f autonomy and b e l o n g i n g , and t h a t p r o v i s i o n be made f o r i n s e r v i c e e d u c a t i o n w h i c h w o u l d i n c r e a s e p r o f e s s i o n a l development and make s t a f f more c a p a b l e o f c o n t r i b u t i n g t o t h e d e c i s i o n making p r o c e s s \" ( 7 5 ) . Changing P a t t e r n s o f P r a c t i c e : As new p a t t e r n s o f m e d i c a l c a r e e v o l v e , t h e r o l e o f t h e n u r s e i s c h a n g i n g . N u r s i n g i n h o s p i t a l has become i n c r e a s i n g l y m a n a g e r i a l , s p e c i a l i z e d , and 200 t e c h n i c a l , and many p a t i e n t c a r e p r o c e d u r e s f o r m e r l y c a r r i e d o u t by p h y s i c i a n s a r e now p e r f o r m e d by n u r s e s ( 6 2 ) . Whether-or n o t t h e n u r s e s h o u l d meet t h e s e e v e r i n c r e a s i n g demands i s d e b a t a b l e and many a t t e m p t s have been made t o c l a r i f y t h e \" u n i q u e \" f u n c t i o n s o f t h e n u r s e (95) b u t t h e r e s t i l l r e m a i n s c o n s i d e r a b l e c o n f u s i o n on t h e p a r t o f n u r s e s , p h y s i c i a n s , and o t h e r members o f t h e h e a l t h team as t o what i s t h e r o l e o f t h e n u r s e (109) (89) ( 7 5 ) . A d d i n g t o t h e p r o b l e m o f r o l e has been t h a t o f q u a l i f i c a t i o n s . There has been a s t r u g g l e w i t h i n t h e n u r s i n g p r o f e s s i o n o v e r t h e adequacy o f t h e two, t h r e e , o r f o u r y e a r p r e - p r o f e s s i o n a l e d u c a t i o n a l program. W h i l e much has been w r i t t e n c o m p a r i n g g r a d u a t e s from t h e d i f f e r e n t programs, t h e r e i s l i t t l e c o n c r e t e d a t a t o a s s e s s d i f e r e n c e s . A r e c e n t a n a l y s i s o f t e s t r e s u l t s by t h e N a t i o n a l Commission on N u r s i n g and N u r s i n g E d u c a t i o n ( 6 9 ) , d i s c l o s e d a c o n s i d e r a b l e o v e r l a p i n t h e s c o r e s a c h i e v e d by g r a d u a t e s o f a l l t h r e e t y p e s o f p r o g r a m s , and. w i t h a t l e a s t as much v a r i a t i o n w i t h i n e a c h . On t h i s i s s u e , t h e Commission s i m p l y c o n c l u d e s : W h i l e i t ' can be e x p e c t e d t h a t g r e a t e r d i f f e r e n c e s w i l l emerge i n a r e a s l i k e c l i n i c a l p e r f o r m a n c e . . . i t seems l i k e l y t h a t d i f f e r e n c e s w i t h i n t h e programs w i l l be a t l e a s t as g r e a t as d i f f e r e n c e s between them, and any h e a l t h c a r e f a c i l i t y t h a t employs n u r s e s must t a k e t h e s e v a r i a t i o n s i n t o a c c o u n t i n i t s o r i e n t a t i o n and i n d u c t i o n p r o c e d u r e s . I n t h e p r a c t i c e s e t t i n g any c o n s i d e r a t i o n o f i n d i v i d u a l d i f f e r e n c e s a p p e a r s t o be 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 . One r e c e n t s u r v e y o f e i g h t y d i r e c t o r s o f n u r s i n g s e r v i c e d i s c l o s e d t h a t t h e \" s t a n d a r d m e a s u r i n g s t i c k \" f o r a l l g r a d u a t e s was t h e i r a b i l i t y t o 'cope' and f u n c t i o n w i t h i n t h e t r a d i t i o n a l h i e r a r c h i a l s t r u c t u r e o f n u r s i n g s e r v i c e w h i c h i n e f f e c t means r a t i n g t h e n u r s e a c c o r d i n g t o t h e amount o f a d m i n i s t r a t i o n and o t h e r t a s k o r i e n t e d e x p e r i e n c e s she has had ( 3 5 ) . H a r r i n g t o n and T h e i s (50) found t h a t under s u c h 2 0 1 c i r c u m s t a n c e s , many b a c c a l a u r e a t e graduates- s u f f e r e d r o l e d e p r i v a t i o n . On t h e o t h e r hand, P r i c e (89) n o t e d t h a t a t a l l l e v e l s and r e g a r d l e s s o f e d u c a t i o n a l p r e p a r a t i o n , t h e r e was \"an u n i n t e n t i o n a l commitment on t h e p a r t o f t h e n u r s e s t o t h e p e r p e t u a t i o n o f t h e s y s t e m . \" Thus she c o n c l u d e s , \" B o t h p r e s e r v i c e e d u c a t i o n and h o s p i t a l o r g a n i z a t i o n must be changed t o improve t h e s i t u a t i o n . \" W h i l e t h e p r e s e n t o r g a n i z a t i o n o f n u r s i n g s e r v i c e s i s an a n a c h r o n i s m , t h e f u n d a m e n t a l d i f f i c u l t y i n a s s e s s i n g t h e s e p r o b l e m s i s t h e l a c k o f r e s e a r c h i n t o n u r s i n g p r a c t i c e . There i s \" l i t t l e o b j e c t i v e e v i d e n c e a v a i l a b l e upon w h i c h t o b a s e judgements as t o what i s t h e p r o p e r scope o f p r a c t i c e , what c l a s s and t y p e s o f p r a c t i t i o n e r s a r e needed, and what k i n d s and amounts o f e d u c a t i o n e a c h r e q u i r e s \" ( 9 3 ) . I n r e c e n t y e a r s u n i v e r s i t y g r a d u a t e programs i n n u r s i n g have f o c u s s e d on t h e p r e p a r a t i o n o f e x p e r t n u r s e p r a c t i t i o n e r s o r c l i n i c a l s p e c i a l i s t s who can h e l p d e f i n e n u r s i n g p r a c t i c e i n t h e c l i n i c a l a r e a s and c o n d u c t r e s e a r c h i n t o p a t i e n t care.. A l t h o u g h many c o n s i d e r t h i s one of the most p r o m i s i n g t r e n d s i n n u r s i n g , i t i s now b e i n g q u e s t i o n e d as t o whether a \" s u f f i c i e n t number o f c l i n i c a l s p e c i a l i s t s can be produced t o make a s i g n i f i c a n t i m p a c t on t h e o v e r a l l s y s t e m \" ( 7 8 ) . I n t h e meantime, as the need f o r h e a l t h s e r v i c e s a c c e l e r a t e s , p h y s i c i a n d i r e c t e d programs d e s i g n e d t o p r o d u c e n u r s e c l i n i c i a n s i n t h e a c u t e and ambu-l a t o r y c a r e s e t t i n g s have been i n c r e a s i n g , and w h i l e b o t h p h y s i c i a n s and n u r s e s appear t o a g r e e t h a t as h e a l t h c a r e needs change r o l e s must change, so t h a t t h e r o l e o f t h e n u r s e i s expanded, t h e r e i s l i t t l e agreement about t h e e d u c a t i o n a l p r e p a r a t i o n r e q u i r e d . A r e c e n t s t u d y i n O n t a r i o (97) d i s c l o s e d t h a t w h i l e n u r s i n g e d u c a t o r s b e l i e v e d t h a t t h e e x p e r t n u r s e c l i n i c i a n s h o u l d be p r e p a r e d a t t h e g r a d u a t e u n i v e r s i t y l e v e l , t h e O n t a r i o M e d i c a l A s s o c i a t i o n m a i n t a i n e d t h a t s u c h a p e r s o n need be o n l y a d i p l o m a g r a d u a t e , w i t h s e v e r a l y e a r s o f 202 o n - t h e - j o b t r a i n i n g r e s u l t i n g i n c l i n i c a l competence i n one a r e a o f n u r s i n g . A r e c e n t i n t e r p r o f e s s i o n a l s u r v e y i n t h e U n i t e d S t a t e s d i s c l o s e d s i m i l a r f i n d i n g s ( 9 8 ) . D e s p i t e t h e s e o p p o s i n g v i e w p o i n t s , b o t h g r o u p s a r e much more w i l l i n g t o compromise on b e h a l f o f optimum p a t i e n t c a r e , and t h i s r e c i p r o c i t y o f r o l e s i s e v i d e n t (65) ( 8 ) . W h i l e p r o f e s s i o n a l i s o l a t i o n i s m s w i l l n o t soon be r e s o l v e d , changes i n t h e r e c i p r o c a l r o l e s o f p h y s i c i a n s and n u r s e s i s a s i g n i f i c a n t t r e n d t h a t has i m p o r t a n t i m p l i c a t i o n s f o r 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 . CONCERN FOR CONTINUING EDUCATION The 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 (7) i n c l u d e s t h r e e t y p e s o f e d u c a t i o n a l a c t i v i t i e s under t h e term 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 * : 1. F o r m a l academic s t u d y i n programs l e a d i n g t o a b a c c a l a u r e a t e o r \u00E2\u0080\u00A2 h r p h p . r r l p c r p . p ; 2. S h o r t term c o u r s e s o r programs o f f e r e d by i n s t i t u t i o n s o f h i g h e r l e a r n i n g b u t n o t n e c e s s a r i l y d i r e c t e d t o w a r d a deg r e e ( t h e s e a r e g e n e r a l l y r e f e r r e d t o as \" c o n t i n u i n g e d u c a t i o n c o u r s e s \" ) , and; 3. Independent o r i n f o r m a l .study c a r r i e d on by t h e p r a c t i t i o n e r h e r s e l f u t i l i z i n g t h e l e a r n i n g o p p o r t u n i t i e s a v a i l a b l e t o h e r t h r o u g h h e r p r o f e s s i o n o r h e r e m p l o y i n g agency. T h i s r e v i e w i s c o n c e r n e d w i t h the l a t t e r two c a t e g o r i e s o f c o n t i n u i n g e d u c a t i o n , b u t more p a r t i c u l a r l y w i t h t h o s e n o n - c r e d i t c o u r s e s s p o n s o r e d by i n s t i t u t i o n s o f h i g h e r l e a r n i n g , and i n s e r v i c e e d u c a t i o n p r o v i d e d by e m p l o y i n g a g e n c i e s . Of t h e two t y p e s o f programs, i n s e r v i c e e d u c a t i o n i s t h e o l d e s t , and The term \" n u r s e \" as used i n t h i s r e p o r t r e f e r s t o t h o s e r e g i s t e r e d n u r s e s g r a d u a t e d f r o m h o s p i t a l s c h o o l s , j u n i o r c o l l e g e s , and u n i v e r s i t y s c h o o l s o f n u r s i n g . 203 p r o b a b l y s t i l l t h e most p r e v a l e n t f o r m 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 . P f e f f e r k o r n ' s h i s t o r i c a l r e v i e w (88) p u b l i s h e d i n 1928 p r o v i d e s e v i d e n c e t h a t as e a r l y as 1905 p o s t g r a d u a t e n u r s i n g c o u r s e s were b e i n g o f f e r e d i n a v a r i e t y o f m e d i c a l s p e c i a l t i e s . She r e p o r t s t h a t t h e s e programs were n o t w e l l d e v e l o p e d and t h a t many were b e i n g g i v e n m e r e l y t o i n c r e a s e t h e work f o r c e o f t h e h o s p i t a l . She f u r t h e r n o t e s t h a t e d u c a t i o n a l o p p o r t u n i t i e s f o r t h e g e n e r a l s t a f f n u r s e were a l m o s t n o n - e x i s t e n t . S t r a u b (107) r e v i e w e d t h e n u r s i n g l i t e r a t u r e between 1928 and 1960 b u t fou n d few a r t i c l e s r e l a t e d t o t h e i n s e r v i c e e d u c a t i o n o f n u r s e s . She n o t e d an i n c r e a s e i n t h e number o f p u b l i c a t i o n s f r o m 1950 t o 1960 and t h a t t h e main emphasis o f most o f t h e s e r e l a t e d t o t e c h n i q u e s o f program development o r program d e s c r i p t i o n s , and t h a t t h e r e s e a r c h was l i m i t e d t o d e s c r i p t i v e s u r v e y s o r o p i n i o n s o f p a r t i c i p a n t s about t h e programs. T h i s p r e s e n t r e v i e w c o v e r s t h e decade o f t h e s i x t i e s and fo u n d t h a t t h e c a l i b r e o f t h e p u b l i s h e d l i t e r a t u r e has changed v e r y l i t t l e . T here a r e many a r t i c l e s o f t h e t y p e , \"How we p l a n our program\" (99) (34) (61) ( 1 2 3 ) , and program d e s c r i p t i o n s c o n c l u d i n g \"We f e l t t h a t t h e t r a i n i n g program was v e r y s u c c e s s f u l \" (117) (71) (84) (104) ( 5 8 ) , b u t t h e r e i s l i t t l e o b j e c t i v e d a t a t o j u s t i f y t h e s e c o n v i c t i o n s . I n d e e d , r e c u r r i n g themes a r e pr o b l e m s s u c h as t h e r a p i d t u r n o v e r o f s t a f f , t h e d i f f e r i n g l e v e l s and p r e p a r e d n e s s o f n u r s e s , t h e demands o f a busy n u r s i n g s e r v i c e , and r e l u c t a n c e o f n u r s e s t o a t t e n d programs (89) (111) ( 3 6 ) . C o n t i n u i n g e d u c a t i o n as a component o f h i g h e r e d u c a t i o n i s v e r y r e c e n t i n n u r s i n g . I t was g e n e r a l l y a c c e p t e d i n t h e p a s t t h a t t h e m a j o r commitment o f t h e u n i v e r s i t y . s c h o o l o f n u r s i n g must be t o 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 programs ( 5 4 ) . A c c o r d i n g l y , a l t h o u g h c o n t i n u i n g e d u c a t i o n c o u r s e s a r e r e p o r t e d 204 t o be i n c r e a s i n g i n number ( 4 8 ) , t h e more s e q u e n t i a l , l o n g range programs a r e the p r o d u c t s o f a r e l a t i v e l y few u n i v e r s i t i e s . I n t h e U n i t e d S t a t e s , RMPS ( r e g i o n a l m e d i c a l programs funded under t h e terms o f P u b l i c Law 89-239) , and t h e Western Commission on H i g h e r E d u c a t i o n i n N u r s i n g (WCHEN) have a l s o been a c t i v e i n t h e development o f c o n t i n u i n g n u r s i n g e d u c a t i o n . I n 1968 M r s . S i g n e Cooper 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 h e l d t h e f i r s t n a t i o n a l m e e t i n g on 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 . The p r i m a r y p u r p o s e o f t h i s m e e t i n g was t o p r o v i d e a forum f o r t h e exchange o f i d e a s and developments r e l a t i v e t o t h e f i e l d ( 9 2 ) . I n 1969, c o n c u r r e n t w i t h the F o u r t e e n t h C o n g r e s s o f t h e I n t e r n a t i o n a l C o u n c i l o f Nur s e s h e l d i n M o n t r e a l , M r s . M a r g a r e t N e y l a n f r o m 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 c a l l e d a s i m i l a r m e e t i n g ( 9 1 ) . S u b s e q u e n t l y , two n a t i o n a l c o n f e r e n c e s have been h e l d s p e c i f i c a l l y f o r t h o s e n u r s e e d u c a t o r s w o r k i n g i n t h e f i e l d . The f i r s t o f t h e s e h e l d i n W i l l i a m s b u r g , V i r g i n i a i n 1969, f o c u s s e d on t h e l e a d e r s h i p r o l e o f i n s t i t u t i o n s o f h i g h e r l e a r n i n g i n c o n t i n u i n g n u r s i n g e d u c a t i o n ( 9 0 ) . The s e c o n d , h e l d a t S y r a c u s e U n i v e r s i t y , New Y o r k i n 1970, t o o k as i t s theme 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 f o r t h e i m p l e m e n t a t i o n o f change ( 5 1 ) . The t h i r d n a t i o n a l c o n f e r e n c e h e l d i n W i s c o n s i n i n O c t o b e r 1971 had as i t s m a j o r theme c r i t i c a l i s s u e s i n 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 . An i s s u e o f t h e 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 (51) was d e v o t e d t o p a p e r s d e v e l o p e d around t h e i s s u e s d i s c u s s e d a t t h e c o n f e r e n c e . I n b r i e f , t h e ma j o r c o n c e r n s as e x p r e s s e d i n t h e s e p a p e r s a r e as f o l l o w s : W i l l s h o r t t e r m c o u r s e s p r e s e n t l y p r e p a r i n g p e d i a t r i c n u r s e p r a c t i t i o n e r s p r e v e n t a r a p i d and n e c e s s a r y i n c r e a s e o f t h e n u r s i n g s p e c i a l i s t p r e p a r e d a t t h e g r a d u a t e l e v e l ? P r e s e n t g r a d u a t e programs a r e n o t p r e p a r i n g s u f f i c i e n t numbers o f e x p e r t n u r s e p r a c t i t i o n e r s . Can we a f f o r d t o i g n o r e t h e need? C o n t i n u i n g educatio.n i s f r a g m e n t e d , d i s o r g a n i z e d , u n r e l a t e d and h a p h a z a r d . Can t h e s e a c t i v i t i e s be c o - o r d i n a t e d i n a r e a s o n a b l e r a t i o n a l a p proach? The g r e a t p r o l i f e r a t i o n o f o p p o r t u n i t i e s i n p a r t r e f l e c t s an e x p r e s s e d e d u c a t i o n a l need by n u r s e s , b u t c o u l d more be a c c o m p l i s h e d t h r o u g h b e t t e r c o - o r d i n a t i o n ? 205 What a r e t h e unmet needs and e d u c a t i o n a l gaps? And whose r e s p o n s i b i l i t y i s i t t o meet t h e s e n e e d s . . . o r even t o i d e n t i f y t h e needs? Who pays f o r 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 ? G r a n t e d t h a t t h e l e a r n e r has some p e r s o n a l r e s p o n s i b i l i t y , what about t h e e m p l o y i n g agency? Does c o n t i n u i n g e d u c a t i o n make a d i f f e r e n c e ? When we can i d e n t i f y more s p e c i f i c a l l y how i m p r o v e d n u r s i n g c a r e r e s u l t s f r o m o u r v a r i o u s e d u c a t i o n a l a c t i v i t i e s , p e r h a p s we can e x p e c t more s u p p o r t , f i n a n c i a l and o t h e r w i s e . R e s e a r c h I n t e r e s t s : I n h e r r e p o r t of a n a t i o n a l s u r v e y o f a l l c o l l e g e s and u n i v e r s i t y s c h o o l s o f n u r s i n g i n t h e U n i t e d S t a t e s i n 1969, G w a l t n e y (90) i d e n t i f i e d t h e f o l l o w i n g r e s e a r c h underway i n t h e a r e a 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 n u r s e s : U n i v e r s i t y o f W i s c o n s i n : .1. A s t u d y o f The C o n t i n u i n g L e a r n e r i n N u r s i n g ; September 1, 1962-1963. 2. A S urvey o f I n a c t i v e N u r s e s E n r o l l e d i n R e f r e s h e r C o u r s e s ; September 1967, 1968. ( I n p r o g r e s s ) * 3. E v a l u a t i o n of t h e E f f e c t i v e n e s s of t h e N u r s i n g D i a l A c c e s s Program. ( I n p r o g r e s s ) * U n i v e r s i t y of N o r t h C a r o l i n a : A Study t o D e t e r m i n e Whether t h e P r e p a r a t i o n o f a N u r s e f o r C o r o n a r y Care Has an E f f e c t on t h e C o n d i t i o n o f P a t i e n t s a t D i s c h a r g e From C o r o n a r y Care U n i t s i n t h e S t a t e . I n c o l l a b o r a t i o n w i t h t h e S c h o o l o f P u b l i c H e a l t h . Dept. o f E p i demeology and t h e R e g i o n a l M e d i c a l Program. S y r a c u s e U n i v e r s i t y : F o l l o w i n g t h e p r o grams, Improved Management S k i l l s : Ah A p p r o a c h t o B e t t e r P a t i e n t C a r e ; The Dept. o f P s y c h o l o g y d i d t h e e v a l u a t i o n o f t h e program. S t . L o u i s U n i v e r s i t y : L i m i t e d l o c a l s u r v e y o f e d u c a t i o n needs (1965 and 1 9 6 8 ) . Committee on C o n t i n u i n g E d u c a t i o n Study on E v a l u a t i o n f o r m d a t a , 1968. Through l i b r a r y r e s e a r c h as w e l l as c o r r e s p o n d e n c e w i t h o v e r t h i r t y u n i v e r s i t i e 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 f o l l o w i n g a d d i t i o n a l s t u d i e s i l l u s t r a t e t h e n a t u r e o f c u r r e n t r e s e a r c h underway: Completed and A v a i l a b l e 206 A Survey o f I n a c t i v e N u r s e s i n Wa s h i n g t o n S t a t e . A s t u d y t o d e t e r m i n e t h e c h a r a c t e r i s t i c s o f i n a c t i v e n u r s e s , t h e i r r e a s o n s f o r n o t w o r k i n g i n n u r s i n g , t h e e x t e n t t o w h i c h t h e y r e p r e s e n t a p o t e n t i a l n u r s e s u p p l y , and t h e i r i n t e r e s t i n a r e f r e s h e r c o u r s e . Sponsored by t h e Washington S t a t e Department o f H e a l t h ; D i v i s i o n o f N u r s i n g ; U n i v e r s i t y o f W a s h i n g t o n , S c h o o l o f N u r s i n g ; 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, 1968. A Survey o f C o n t i n u i n g E d u c a t i o n Needs f o r H e a l t h P r o f e s s i o n a l s : I d a h o ; Montana; Nevada; Wyoming; Sponsored.by WICHE/Mountain S t a t e s R e g i o n a l M e d i c a l Program, 1969. N u r s i n g i n Id a h o : A Study o f N u r s i n g Needs and R e s o u r c e s ; Sponsored by t h e Idaho O f f i c e ; M o u n t a i n S t a t e s R e g i o n a l M e d i c a l Program; WICHE i n c o - o p e r a t i o n w i t h t h e Idaho S t a t e N u r s e s ' A s s o c i a t i o n , 1969. An E v a l u a t i o n o f a C o n t i n u i n g E d u c a t i o n Program; WICHE i n c o - o p e r a t i o n w i t h t h e Idaho S t a t e N u r s e s ' A s s o c i a t i o n , 1969. An E v a l u a t i o n o f a C o n t i n u i n g E d u c a t i o n Program i n N u r s i n g ; U n i v e r s i t y o f C o l o r a d o , B o u l d e r , C o l o r a d o ; 1960. E v a l u a t i o n o f R e g i o n a l C o n t i n u a t i o n E d u c a t i o n C o n f e r e n c e s . The E f f e c t i v e n e s s o f a L e a d e r s h i p Program i n N u r s i n g ; S u p p o r t e d by P u b l i c H e a l t h S e r v i c e G r a n t f r o m t h e D i v i s i o n o f N u r s i n g ; Bureau o f H e a l t h Mannower and I n s t i t u t e o f G e n e r a l M e d i c a l S c i e n c e s , U n i t e d S t a t e s P u b l i c H e a l t h S e r v i c e , 1967. 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 : A Study o f t h e Need f o r C o n t i n u i n g E d u c a t i o n f o r R e g i s t e r e d N u r s e s i n O n t a r i o ; Sponsored by t h e S c h o o l o f N u r s i n g o f t h e U n i v e r s i t y o f T o r o n t o i n c o - o p e r a t i o n w i t h t h e D i v i s i o n o f U n i v e r s i t y E x t e n s i o n , 1969. ( 2 5 ) . A R e p o r t o f a Q u e s t i o n n a i r e f o r T e a c h e r s o f N u r s i n g i n O n t a r i o ; A Study o f C o n t i n u i n g E d u c a t i o n Needs: R e g i s t e r e d N u r s e s ' A s s o c i a t i o n o f O n t a r i o , 1965. 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 Needs o f S u p e r v i s o r y P e r s o n n e l i n N u r s i n g S e r v i c e and N u r s i n g E d u c a t i o n : P e n n s y l v a n i a S t a t e U n i v e r s i t y , 1965. C o r r e s p o n d e n c e I n s t r u c t i o n as an E d u c a t i o n a l Method i n H o s p i t a l s ; P e n n s y l v a n i a S t a t e U n i v e r s i t y and t h e H o s p i t a l R e s e a r c h and E d u c a t i o n a l T r u s t o f t h e A m e r i c a n H o s p i t a l A s s o c i a t i o n , 1967 ( 3 7 ) . Management T r a i n i n g E f f e c t i v e n e s s : A Study o f Nurse Managers; Sponsored by t h e Texas League o f N u r s i n g ; 1965. What Do P r a c t i s i n g N u r s e s Want t o Know? A Study o f L e a r n i n g Needs. 207 As i s e v i d e n t , w e l l o v e r one h a l f o f t h e s t u d i e s r e p o r t e d a r e d e s c r i p t i v e o f n u r s e manpower r e s o u r c e s and t h e nurses;' p e r c e p t i o n s o f t h e i r l e a r n i n g n eeds. M o r e o v e r , most o f t h e r e p o r t e d r e s e a r c h on program e v a l u a t i o n s a r e , a t b e s t , e x p l o r a t o r y . I n 1971, t h e 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 was awarded a one y e a r f e d e r a l g r a n t t o c o n d u c t a n a t i o n a l s u r v e y of 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 . The p u r p o s e o f t h i s p r o j e c t w i l l be t o \" i d e n t i f y a l l t y p e s o f e x i s t i n g c o n t i n u i n g e d u c a t i o n programs and r e s o u r c e s \" ( 6 6 ) . I t i s hoped 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 w i l l p r o v i d e i n f o r m a t i o n w h i c h w i l l h e l p t o d e t e r m i n e t h e f u t u r e d i r e c t i o n f o r 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 . 208 CHAPTER X I I I PARTICIPATION IN CONTINUING EDUCATION A l t h o u g h t h e r e i s no d a t a a v a i l a b l e t o i n d i c a t e t h e e x t e n t of n u r s e 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 , u s i n g membership i n t h e 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 as a c r i t e r i a , C u r t i s s e t a l (51) p r o v i d e a n a t i o n a l e s t i m a t e o f l e s s t h a n 30 p e r c e n t . They s t r e s s t h a t t h e \"number of n u r s e s aware of t h e i r needs f o r f u r t h e r s t u d y a r e t o be f o u n d i n e n c o u r a g i n g numbers.\" CHARACTERISTICS OF PARTICIPANTS Through an a n a l y s i s o f d e s c r i p t i v e d a t a o b t a i n e d f r o m 314 n u r s e s who a t t e n d e d t h e U n i v e r s i t y o f W i s c o n s i n ' s E x t e n s i o n c o u r s e s between September 1, 1962, and August 31, 1963, Cooper and Hornback (28) a t t e m p t e d t o i d e n t i f y t h o s e p e r s o n a l - p r o f e s s i o n a l c h a r a c t e r i s t i c s o f n u r s e s who were more l i k e l y t o c o n t i n u e t h e i r p r o f e s s i o n a l e d u c a t i o n . The r e s u l t s o f t h i s s t u d y a r e summarized i n t h i s s e c t i o n , u s i n g o t h e r comparable d a t a where a p p r o p r i a t e . L o c a t i o n o f P r a c t i c e : N u r s e s a t t e n d i n g t h e U n i v e r s i t y of W i s c o n s i n e x t e n s i o n c o u r s e s d u r i n g t h e p e r i o d under s t u d y were a l m o s t e x c l u s i v e l y f r o m t h a t s t a t e . Those c o u n t i e s n o t r e p r e s e n t e d i n t h e p o p u l a t i o n tended t o be more r u r a l and employed f e w e r n u r s e s . A r e c e n t a n n u a l r e p o r t from 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 (100) d i s c l o s e d s i m i l a r f i n d i n g s i n w h i c h 90 p e r c e n t o f t h e c o u r s e r e g i s t r a n t s were from t h e p r o v i n c e , and 65 p e r c e n t f r o m t h e G r e a t e r V a n c o u v e r a r e a . 209 I n a WICHE s t u d y ( 9 6 ) , t h e g r e a t m a j o r i t y o f n u r s e r e s p o n d e n t s i n d i c a t e d t h a t \"because o f f a m i l y r e s p o n s i b i l i t i e s , t h e y w o u l d n o t a t t e n d s h o r t c o u r s e s o f f e r e d o u t s i d e t h e i r l o c a l c o m m u n i t i e s , even i f expenses were p a i d . \" P o s i t i o n i n N u r s i n g S e r v i c e : The m a j o r i t y o f n u r s e 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 e d u c a t i o n programs were f u l l - t i m e employees o f h o s p i t a l s . S u p e r v i s o r y p e r s o n n e l made up t h e l a r g e s t s i n g l e group o f p a r t i c i p a n t s , w i t h some 40 t o 50 p e r c e n t o f t h e p a r t i c i p a n t s i n t h i s g r o u p . S t a f f n u r s e s were n e x t i n f r e q u e n c y a t so m e t h i n g l i k e 40 p e r c e n t , w i t h a m i s c e l l a n e o u s c a t e g o r y a c c o u n t i n g f o r l e s s t h a n 15 p e r c e n t o f t h e p a r t i -c i p a n t s . T h i s d i s t r i b u t i o n by p o s i t i o n was fo u n d i n b o t h t h e W i s c o n s i n s t u d y , t h e UBC R e p o r t , and most o t h e r s i m i l a r s t u d i e s (28) (43) (89) (100) ( 1 0 2 ) . The g e n e r a l i z a t i o n t o be drawn f r o m t h e s e d a t a i s t h a t n u r s e s i n h i g h e r p o s i t i o n s a t t e n d more c o n t i n u i n g e d u c a t i o n programs. I n commenting on t h i s g e n e r a l i z a t i o n , Cooper and Hornback (28) a s k : A r e t h e l e a r n i n g needs o f s u p e r v i s o r y p e r s o n n e l g r e a t e r t h a n t h o s e o f n u r s e s on t h e s t a f f l e v e l ? Does t h i s s u g g e s t t h a t b a s i c n u r s i n g programs do n o t p r e p a r e n u r s e s a d e q u a t e l y f o r t h e s e r e s p o n s i b i l i t i e s ? Or does t h i s f i n d i n g s u g g e s t t h a t i t i s e a s i e r f o r s u p e r v i s o r y n u r s i n g p e r s o n n e l t o g e t away fr o m t h e i r j o b t o go t o m e e t i n g s ? M a r i t a l S t a t u s and Age: I n b o t h t h e W i s c o n s i n and UBC r e p o r t s , about one h a l f o f t h e p a r t i c i p a n t s were m a r r i e d o r d i v o r c e d . I n t h e W i s c o n s i n s t u d y , 45 p e r c e n t o f t h e p a r t i c i p a n t s had c h i l d r e n , and one f o u r t h o f t h e s e had c h i l d r e n under f i v e y e a r s o f age. I n c o n t r a s t , t h e UBC d a t a found t h a t o v e r one h a l f o f t h e p a r t i c i p a n t s had no c h i l d r e n . The W i s c o n s i n s t u d y found t h a t t h e l a r g e s t p e r c e n t a g e o f p a r t i c i p a n t s were those* i n t h e o l d e r age group (50 t o 54 y e a r s ) . S i m i l a r l y , t h e WICHE s t u d y f o u n d t h a t n u r s e s w i t h t e n t o tw e n t y y e a r s o r more o f a c t i v e p r a c t i c e e x p r e s s e d 210 t h e g r e a t e s t need f o r c o n t i n u i n g e d u c a t i o n . I n c o n t r a s t , t h e UBC d a t a r e v e a l s a d i s t r i b u t i o n t h a t i s somewhat e q u a l i n a l l age groups b u t w i t h a marked d e c r e a s e i n t h o s e o v e r 55 y e a r s o f age. E d u c a t i o n a l A c h i e v e m e n t : The W i s c o n s i n s t u d y r e p o r t e d t h a t 22 p e r c e n t o f t h e p a r t i c i p a n t s had a c o l l e g e d e g r e e i n c o n t r a s t t o 15 p e r c e n t o f t h e n u r s e p o p u l a t i o n o f W i s c o n s i n t h a t had d e g r e e s . I n t h e UBC r e p o r t , 18 p e r c e n t o f t h e p a r t i c i p a n t s had t h e b a c c a l a u r e a t e d e g r e e , 3 p e r c e n t had a M a s t e r ' s d e g r e e ; and 20 p e r c e n t a d i p l o m a o r c e r t i f i c a t e . These d a t a a r e c o n s i s t e n t w i t h p a r t i c i p a t i o n s t u d i e s i n a d u l t e d u c a t i o n w h i c h l e a d t o t h e g e n e r a l i z a t i o n t h a t 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 t e n d s t o i n c r e a s e w i t h f o r m a l e d u c a t i o n . A l b e i t b a s e d on a l i m i t e d sample (N=79), i n Shore's s t u d y (102) n u r s e s w i t h more e d u c a t i o n r e p o r t e d l e s s p a r t i c i p a t i o n i n programs o f c o n t i n u i n g e d u c a t i o n . She a t t r i b u t e d t h i s f i n d i n g i n p a r t t o t h e h i g h e r p r o p o r t i o n o f young g r a d u a t e s i n t h e sample, who \"perhaps f e l t l e s s o f a need f o r c o n t i n u i n g e d u c a t i o n . \" \u00E2\u0080\u00A2 F l e c k (44) f o u n d t h a t v a r i a b l e s s u c h as age, e d u c a t i o n a l b a c k g r o u n d , y e a r s o f e x p e r i e n c e , and m a r i t a l s t a t u s , d i d n o t c o r r e l a t e w i t h o p i n i o n s r e l a t i v e t o i n s e r v i c e e d u c a t i o n . She does n o t e , however, t h a t \" i n some i n s t a n c e s , t h e y e a r s o f p r o f e s s i o n a l e x p e r i e n c e d i d pro d u c e a g r e a t e r r e c o g n i t i o n o f t h e need f o r c o n t i n u i n g g r o w t h . \" Use o f O t h e r I n f o r m a t i o n S o u r c e s : I n t h e W i s c o n s i n s t u d y , o v e r one h a l f o f . t h e r e s p o n d e n t s i n d i c a t e d t h a t t h e y h e l d membership i n t h e 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 w h i c h c o n t r a s t e d w i t h t h e 32 p e r c e n t o f t h e n u r s i n g p o p u l a t i o n i n t h e s t a t e t h a t r e p o r t e d s u c h member-s h i p . Over one h a l f o f t h e r e s p o n d e n t s i n d i c a t e d t h a t t h e y r e a d two o r more 211 p r o f e s s i o n a l j o u r n a l s . F l a h e r t y (43) f o u n d t h a t o v e r one t h i r d o f t h e n u r s e s i n O n t a r i o f e l t t h a t t h e i r e d u c a t i o n a l needs were n o t b e i n g met y e t t w o - t h i r d s were e l i g i b l e f o r i n s e r v i c e e d u c a t i o n . F l a h e r t y o b s e r v e d t h a t p a r t - t i m e and p r i v a t e d u t y n u r s e s f a r e d b a d l y i n t h i s r e s p e c t . She a l s o f o u n d t h a t n u r s i n g l i b r a r y f a c i l i t i e s were po o r and a v a i l a b l e t o l e s s t h a n one h a l f of t h e r e s p o n d e n t s . She a l s o n o t e s t h a t \"what was a v a i l a b l e , was used i n f r e q u e n t l y by t h e n u r s e s . \" B u r t ' s s t u d y (16) o f 15 h o s p i t a l s t a f f e d u c a t i o n programs i n W ashington s t a t e d i s c l o s e d t h a t o n l y 13 p e r c e n t o f t h e r e s p o n d e n t s had done some r e a d i n g o r o t h e r p r e p a r a t o r y work i n c o n j u n c t i o n w i t h t h e i n s e r v i c e program a t t e n d e d (16) . P r o f e s s i o n a l j o u r n a l s and books r a n k e d f i r s t i n terms o f b o t h a v a i l a -b i l i t y and u s e , w h i l e c o n v e n t i o n s and m e e t i n g s r a n k e d second i n t h e WICHE s t u d y ( 9 6 ) . On t h e o t h e r hand, s h o r t term c o u r s e s were l e a s t a v a i l a b l e b u t t h e n u r s e s f e l t t h a t t h e s e were needed u r g e n t l y . A sample o f n u r s e s i n each o f f o u r m o u n t a i n s t a t e s were a s k e d t o i n d i c a t e w h e t h e r t h e y had r e c e i v e d a d d i t i o n a l f o r m a l e d u c a t i o n o r o n - t h e - j o b t r a i n i n g f o r work i n t h e c l i n i c a l a r e a i n w h i c h t h e y were t h e n employed. I n a l l f o u r r e g i o n s , o v e r 70 p e r c e n t o f t h e g r a d u a t e n u r s e s had r e c e i v e d i n s e r v i c e e d u c a t i o n o r o n - t h e - j o b t r a i n i n g . Of t h e t h r e e l e v e l s o f n u r s i n g e d u c a t i o n , 45 p e r c e n t o f t h e d i p l o m a g r a d u a t e s r e p o r t e d t h a t t h e y had r e c e i v e d a d d i t i o n a l f o r m a l e d u c a t i o n i n t h e c l i n i c a l a r e a compared t o 30 p e r c e n t o f b a c c a l a u r e a t e g r a d u a t e s and 9 p e r c e n t , o f a s s o c i a t e d e g r e e g r a d u a t e s . The c o u r s e s most l i k e l y t o g a i n s u p p o r t a r e t h o s e w h i c h a r e e i t h e r b a s e d on what t h e n u r s e b e l i e v e s t o be h e r own l e a r n i n g needs o r t h o s e w h i c h she f o u n d most h e l p f u l i n i n c r e a s i n g h e r j o b p r o f i c i e n c y (102) (16) (89) . 212 REASONS FOR PARTICIPATION OR NOT I n t h e W i s c o n s i n s t u d y (28) p a r t i c i p a n t s were found t o a t t e n d c o u r s e s f o r a v a r i e t y o f r e a s o n s , b u t none o f t h e r e s p o n d e n t s a t t e n d e d b e c a u s e i t was \"demanded\" by t h e employer o r f o r r e a s o n s o f p r o m o t i o n . The main r e a s o n s g i v e n f o r p a r t i c i p a t i o n were i n t e r e s t , d e s i r e t o improve t e a c h i n g o r n u r s i n g c a r e , and a d v i s e d t o do so by e m p l o y e r . F a m i l y r e s p o n s i b i l i t i e s was l i s t e d as t h e most i m p o r t a n t s i n g l e f a c t o r p r e v e n t i n g n u r s e s f r o m 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 (37) (28) (43) (122) ( 9 6 ) . O t h e r i m p o r t a n t b u t r e l a t e d d e t e r r e n t s i n c l u d e d t i m e , e x p e n s e , s t a f f c o v e r a g e (10) (96) (37) ( 2 5 ) , n o t h i n g a v a i l a b l e , and/or d i s t a n c e (96) (28) (43) ( 5 7 ) , i n s u f f i c i e n t advanced n o t i c e o f c o u r s e o f f e r i n g s , and/or i n a d e q u a t e p u b l i c i t y r e g a r d i n g t h e c o u r s e (25) ( 2 8 ) . I n t h e O n t a r i o S u r v e y o f Needs (25) empl o y e r s s t a t e d t h a t i t was d i f f i c u l t t o p l a n c o n t i n u i n g e d u c a t i o n programs f o r s t a f f development when l i t t l e advance n o t i c e o f c o u r s e o f f e r i n g s was g i v e n . N u r s e s were r e p o r t e d r e l u c t a n t t o t a k e advantage o f o p p o r t u n i t i e s a v a i l a b l e when c o s t s f o r a t t e n d i n g c o u r s e s on s h o r t n o t i c e p r o h i b i t e d i t s i n c l u s i o n i n t h e h o s p i t a l o r agency b u d g e t . I n h e r s t u d y , B u r t (16) f o u n d t h a t o f t h e f i f t e e n h o s p i t a l s p o l l e d , f o u r made a t t e n d a n c e c o m p u l s o r y a t i n s e r v i c e e d u c a t i o n p r o g r a m s , and one h o s p i t a l s p e c i f i e d t h a t \" a t t e n d a n c e was r e q u i r e d f o r some, b u t n o t a l l n u r s e s . \" I n t h e r e m a i n i n g t e n h o s p i t a l s a t t e n d a n c e was v o l u n t a r y . . Pa y s o n and S a l l o w a y (84) fo u n d t h a t one o f t h e ma j o r r e a s o n s s t a f f members d i d n o t l i k e t h e i n s e r v i c e programs was beca u s e t h e y were c o m p u l s o r y . On t h e o t h e r hand, some r e s p o n d e n t s i n d i c a t e d t h a t once t h e y g ot t h e r e t h e y f o u n d t h e programs e n j o y a b l e . F l e c k (44) c o n c l u d e d t h a t t h e ma j o r o b s t a c l e s t o p a r t i c i p a t i o n i n i n s e r v i c e e d u c a t i o n programs were: 1) t h e r o t a t i o n o f h o u r s and t h e heavy w o r k l o a d w h i c h l i m i t e d 213 a t t e n d a n c e ; 2) u n p l a n n e d , d u l l , p o o r l y p r e s e n t e d programs; 3) t h e g e n e r a l i n d i f f e r e n c e o f t h e m a j o r i t y o f s t a f f n u r s e s t o i n s e r v i c e e d u c a t i o n . These f i n d i n g s a r e n o t t o o d i f f e r e n t f r o m t h o s e r e p o r t e d i n t h e P e n n s y l v a n i a s t u d y (10) . S c h e d u l i n g : Most s u r v e y s d i s c l o s e t h a t n u r s e s want c o n t i n u i n g e d u c a t i o n p r e s e n t e d i n t h e i r l o c a l c o m m u n i t i e s (96) (57) (36) ( 1 2 2 ) . I n t h e two WICHE:MSRMP s u r v e y s o v e r 85 p e r c e n t o f t h e r e s p o n d e n t s i n d i c a t e d t h a t t h e y w o u l d a t t e n d s h o r t c o u r s e s . i f t h e s e were o f f e r e d i n t h e i r home c o m m u n i t i e s . The f r e q u e n c y w i t h w h i c h t h e y would be w i l l i n g t o a t t e n d s u c h c o u r s e s i s shown i n T a b l e V I I . A s u r v e y o f i n a c t i v e n u r s e s i n W i s c o n s i n (96) d i s c l o s e d t h a t o f t h e r e s p o n d e n t s who were i n t e r e s t e d i n r e t u r n i n g t o n u r s i n g , 73.12 p e r c e n t d e s i r e d r e f r e s h e r c o u r s e s s c h e d u l e d as p a r t t i m e c l a s s e s w i t h r o u g h l y one h a l f p r e f e r r i n g a day t i m e s c h e d u l e , and t h e o t h e r h a l f an e v e n i n g s c h e d u l e ; 67.65 p e r c e n t o f t h e i n a c t i v e n u r s e s e x p r e s s e d a w i l l i n g n e s s t o t r a v e l b u t one h a l f w o u l d n o t commute o v e r t e n m i l e s i n o r d e r t o a t t e n d r e f r e s h e r c o u r s e s . A s u r v e y (97) o f t e a c h e r s o f n u r s i n g i n O n t a r i o f o u n d t h a t t h e m a j o r i t y o f t e a c h e r s w o u l d l i k e c o u r s e s s c h e d u l e d i n t h e e v e n i n g s and t h e months most f a v o u r e d were F e b r u a r y and March. C o s t : I n F l a h e r t y ' s s t u d y i n O n t a r i o ( 4 3 ) , 40 p e r c e n t o f t h e r e s p o n d e n t s r e p o r t e d t h a t e m p l o y e r s g r a n t e d them t i m e o f f o r pay t o a t t e n d p r o g r a m s , m e e t i n g s , and c o n f e r e n c e s . The most f a v o u r e d groups i n t h i s r e g a r d were t h o s e i n a d m i n i s t r a t i o n , t e a c h i n g , and p u b l i c h e a l t h n u r s i n g . I n t h e W i s c o n s i n s t u d y ( 2 8 ) , t h r e e q u a r t e r s o f t h e r e s p o n d e n t s had t h e i r f e e s p a i d by t h e e m p l o y i n g agency. I n most c a s e s , t h i s was t h e e n t i r e f e e o r t h r o u g h t i m e TABLE V I I THE FREQUENCY WITH WHICH R.N.'S WOULD BE WILLING TO ATTEND SHORT TERM REGIONAL PROGRAMS F r e q u e n c y 1 R e g i o n a l Response Idaho Response Number P e r c e n t Number P e r c e n t Once a Month 219 54.88 54 52.42 E v e r y S i x Months 102 25.56 30 29.12 Once a Y e a r 47 11.77 11 10.67 O t h e r 31 7.76 8 7.76 T o t a l : 399 100.00 103 100.00 SOURCE: WICHE:MSRMP: I d a h o : A Program f o r C o n t i n u a t i o n N u r s i n g E d u c a t i o n ; An U n p u b l i s h e d R e p o r t . to 215 reimbursement i n t h e form o f \" g i v i n g on d u t y t i m e . \" Asked i f t h e y w o u l d be w i l l i n g t o pay t h e i r own f e e s , n e a r l y 62 p e r c e n t r e s p o n d e d i n t h e a f f i r m a t i v e w h i l e a p p r o x i m a t e l y 12 p e r c e n t responded n e g a t i v e l y and one q u a r t e r 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 . R e f e r r i n g t o t h e n o n - r e s p o n d e n t c a t e g o r y , Cooper and Hornback a s k : \"Does i t i m p l y i n d e c i s i o n o r can i t be assumed t h a t t h e m a j o r i t y o f t h e s e n u r s e s would n o t have a t t e n d e d t h e i n s t i t u t e had t h e y been e x p e c t e d t o pay t h e i r own f e e s ? \" ( 2 8 ) . A l t h o u g h i t i s i m p o s s i b l e t o draw f i r m c o n c l u s i o n s on t h e b a s i s o f t h e l i m i t e d d a t a a v a i l a b l e , a number o f r e p o r t s s u g g e s t t h a t many n u r s e s e x p e c t some t y p e o f reward f o r c o n t i n u i n g t h e i r own . e d u c a t i o n . As p r e v i o u s l y n o t e d , i n t h e O n t a r i o Survey (25) , e m p l o y e r s r e p o r t e d t h a t n u r s e s were o f t e n r e l u c t a n t t o f i n a n c e t h e i r own a t t e n d a n c e a t c o u r s e s . I n t h e WICHE:MSRMP s u r v e y s ( 9 6 ) , o n l y 24.2 p e r c e n t and 27.4 p e r c e n t o f t h e r e g i s t e r e d n u r s e s i n d i c a t e d t h a t t h e y would a t t e n d programs o u t s i d e t h e i r own c o m m u n i t i e s a t t h e i r own e x p e n s e , whereas 55.8 p e r c e n t and 63.3 p e r c e n t w o u l d a t t e n d i f t h e i r expenses were p a i d . S i m i l a r l y , G o l d f a r b (46) n o t e s t h a t \"most o f t h e n u r s e s who t a k e t h e c o u r s e e x p e c t compen-s a t i o n upon s u c c e s s f u l c o m p l e t i o n , \" however, \" t h e y were n o t s u r e where t h e c o m p e n s a t i o n was t o come fr o m o r what i t s h o u l d b e \" ( 4 6 ) . F e l t L e a r n i n g Needs: S u r v e y s w h i c h have used open ended t e c h n i q u e s t o i d e n t i f y t h e f e l t l e a r n i n g needs o f n u r s e s r e v e a l some s t r i k i n g s i m i l a r i t i e s i n r e s p o n s e s . R e g a r d -l e s s of p o s i t i o n o r t y p e o f agency, one o f t h e most p r o m i n e n t needs l i s t e d i s t h a t o f i m p r o v i n g c o m m u n i c a t i o n and m a n a g e m e n t - l e a d e r s h i p s k i l l s (36) (10) (43) (37) ( 2 5 ) . O t h e r l e a r n i n g needs r a t e d h i g h i n t h e l i s t o f p r i o r i t i e s i n c l u d e : newer d i m e n s i o n s i n n u r s i n g c a r e ; l e g a l a s p e c t s o f n u r s i n g ; and t h e c h a n g i n g r o l e of t h e n u r s e . I n t h e P e n n s y l v a n i a s t u d y ( 3 6 ) , many n u r s e s were b e i n g 216 promoted i n t o a d m i n i s t r a t i v e , s u p e r v i s o r y , and team l e a d i n g p o s i t i o n s w i t h l i t t l e p r e p a r a t i o n f o r t h e i r new r e s p o n s i b i l i t i e s , and hence were i n s e c u r e as managers. A c c o r d i n g l y , d i r e c t o r s o f n u r s i n g were i n f u l l agreement t h a t t h e r e was an u r g e n t need f o r c o u r s e s t o improve t h e s u p e r v i s o r y s k i l l s . I n t h e O n t a r i o Survey o f Needs (25) , e m p l o y e r s b o t h o f p u b l i c h e a l t h and o f h o s p i t a l n u r s e s e x p r e s s e d a s i m i l a r v i e w . D i r e c t o r s o f n u r s i n g a l s o i n d i c a t e d t h a t t h e y l o o k e d t o c o n t i n u i n g e d u c a t i o n c o u r s e s t o f i l l t h e gap c r e a t e d by t h e p h a s i n g o u t o f t h e one y e a r c e r t i f i c a t e programs on n u r s i n g s e r v i c e a d m i n i s t r a t i o n . O t h e r p r e s s i n g needs r e v e a l e d i n t h i s s u r v e y were: 1) c o u r s e s t o i n c r e a s e t h e t e a c h i n g s k i l l s o f n u r s e s i n d i f f e r e n t f i e l d s and l e v e l s o f n u r s i n g , i n c l u d i n g p u b l i c h e a l t h n u r s e s , i n s e r v i c e c o - o r d i n a t o r s and o c c u p a t i o n a l h e a l t h n u r s e s ; and 2) s p e c i a l i z a t i o n i n n u r s i n g , n o t a b l y i n t h e a r e a o f i n t e n s i v e c a r e n u r s i n g , c h r o n i c d i s e a s e , m e n t a l h e a l t h , and r e h a b i l i -t a t i o n . U t i l i z i n g a m o d i f i e d s u r v e y o r \" s l i p t e c h n i q u e , \" S k i n n e r and h e r c o l l e a g u e s i n t h e M i c h i g a n RMP (103) g a t h e r e d o p i n i o n s about t h e c u r r e n t l e a r n i n g needs o f s t a f f n u r s e s , team l e a d e r s , and head n u r s e s i n t h e c a r e o f p a t i e n t s w i t h h e a r t d i s e a s e , c a n c e r , s t r o k e , and r e l a t e d d i s e a s e s . F o r t y - e i g h t n u r s e s r e p r e s e n t i n g e ach l e v e l i d e n t i f i e d n o t o n l y t h e b r o a d l e a r n i n g needs r e f e r r e d t o i n t h e f o r e g o i n g s u r v e y s , b u t a l s o s p e c i f i c l e a r n i n g needs d i r e c t l y r e l a t e d t o p a t i e n t c a r e , i n c l u d i n g 1) how t o p o s i t i o n a c u t e l y - i l l p a t i e n t s t o p r e v e n t d e f o r m i t i e s and o t h e r c o m p l i c a t i o n s ; 2) how t o r e a d EKG's and r e c o g n i z e d e a t h p r o d u c i n g a r r h y t h m i a s ; _ 3) how t o be more e f f e c t i v e i n t e a c h i n g p a t i e n t s and f a m i l i e s ; 4) how t o c a r e f o r t e r m i n a l l y i l l p a t i e n t s ; 5) how t o c a r e f o r p a t i e n t s r e c e i v i n g chemotherapy and i r r a d i a t i o n . U s i n g a s c a l e d q u e s t i o n n a i r e and i n t e r v i e w s , T i f f n e y (109) sought t o 217 d e t e r m i n e t h e c o m p e t e n c i e s o f g e n e r a l s t a f f n u r s e s f u n c t i o n i n g i n t h e f i e l d o f r e h a b i l i t a t i o n . She c o n c l u d e d t h a t g e n e r a l d u t y n u r s e s l a c k e d the n e c e s s a r y c o m p e t e n c i e s f o r e f f e c t i v e work i n r e h a b i l i t a t i o n . A l t h o u g h t h e n u r s e s i n t e r -v i e w e d emphasized t h a t t h e i r r o l e was n o t u n d e r s t o o d o r a p p r e c i a t e d by t h e o t h e r d i s c i p l i n e s on t h e r e h a b i l i t a t i o n team, T i f f n e y a d d s , \" t h i s no doubt was a g g r a v a t e d by an a p p a r e n t l a c k o f u n d e r s t a n d i n g on t h e p a r t o f t h e n u r s e s them-s e l v e s as t o what t h e f u n c t i o n s o f t h e n u r s i n g s t a f f i n c l u d e . \" Among many recommendations, she u r g e d t h a t s h o r t term c o u r s e s i n r e h a b i l i t a t i o n be s e t up, o r g a n i z e d , and implemented by q u a l i f i e d p e r s o n n e l as a c r a s h program t o a l l e v i -a t e t h e volume- o f g r a d u a t e d u t y n u r s e s who r e q u i r e t h i s p r e p a r a t i o n t o f u n c t i o n as s k i l l e d p r a c t i t i o n e r s . I n t h e s t u d y of t e a c h e r s ' l e a r n i n g needs (97) o v e r 80 p e r c e n t o f t h e r e s p o n d e n t s r e q u e s t e d c o n t e n t r e l a t e d t o t h e b i o l o g i c a l and s o c i a l s c i e n c e s . The t e a c h e r s e x p r e s s e d t h e g r e a t e s t need f o r s u b j e c t m a t t e r s p e c i f i c a l l y r e l a t e d t o t h e i r own f i e l d o f p r a c t i c e . As a r e s u l t o f t h i s s u r v e y , s i x 3-week i n s t i t u t e s f o r t e a c h e r s of n u r s i n g were c o n d u c t e d . A l t h o u g h a r e l a t i v e l y u n s t r u c t e d program was p l a n n e d , i t soon became e v i d e n t t h a t t h e r e a l l e a r n i n g need o f t h e i n s t r u c t o r s was n o t c o u r s e c o n t e n t , b u t r a t h e r how t o a p p l y i t i n s i t u a t i o n - t y p e p r o b l e m s i n c l i n i c a l p r a c t i c e (94). P r i c e (89) a t t e m p t e d t o i d e n t i f y l e a r n i n g needs i n two ways: The f i r s t was a s e l f r e p o r t o f a c r i t i c a l i n c i d e n t e n c o u n t e r e d t h e p r e v i o u s y e a r w h i c h the n u r s e c o n s i d e r e d o f extreme s i g n i f i c a n c e and r e l a t e d t o h e r l a c k o f p r e p a r a -t i o n . The second was an i d e n t i f i c a t i o n o f t h e l e a r n i n g need w h i c h t h e n u r s e t h o u g h t would e n a b l e h e r t o b e s t improve t h e q u a l i t y o f c a r e she p r o v i d e d t o p a t i e n t s . U s i n g t h i s a p p r o a c h , P r i c e f ound t h a t w h i l e t h e n u r s e s r e p o r t e d t h e i r g r e a t e s t l e a r n i n g needs t o be i n d i r e c t p a t i e n t c a r e , most o f t h e c r i t i c a l i n c i d e n t s 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 . More s p e c i f i c a l l y , the g r e a t e s t 218 needs and/or p r o b l e m s r e l a t e d t o \" i n s e c u r i t y r e g a r d i n g n u r s i n g c a r e , new t e c h n i q u e s , methods r e l a t i n g t h e o r y t o p r a c t i c e . \" C o n c e r n i n g many o f t h e c r i t i c a l i n c i d e n t s r e p o r t e d , she s t a t e s : T h i s i n d i c a t e s a f a i l u r e o f t r a n s f e r o f l e a r n i n g f r o m p a s t e x p e r i e n c e s . I f t h i s does n o t t a k e p l a c e , p r e - s e r v i c e e d u c a t i o n must be c o n s i d e r e d i n a d e q u a t e . The p r e - s e r v i c e e d u c a t i o n o f t h e i n d i v i d u a l n u r s e s h o u l d e n a b l e h e r t o a n a l y z e h e r own a b i l i t i e s and r e c o g n i z e h e r needs f o r a d d i t i o n a l l e a r n i n g ( 8 9 ) . P r i c e i n d i c a t e d t h a t l e a r n i n g needs r e p o r t e d most f r e q u e n t l y i n t h e a r e a o f i n d i r e c t p a t i e n t c a r e were t h o s e r e l a t e d t o l e a d e r s h i p and management. I n t h i s a r e a , s k i l l i n h a n d l i n g p e o p l e was g i v e n p r i m a r y e m p h a s i s . I t was a l s o i n d i c a t e d t h a t c l a r i f i c a t i o n was needed w i t h r e g a r d t o c u r r e n t programs i n n u r s i n g e d u c a t i o n and r e g a r d i n g i n t e r p r e t a t i o n and i m p l e m e n t a t i o n o f h o s p i t a l p o l i c i e s . On t h e b a s i s o f h e r f i n d i n g s , P r i c e c o n c l u d e d t h a t t h e r e was no adva n t a g e i n t r y i n g t o group n u r s e s f o r i n s e r v i c e e d u c a t i o n a c c o r d i n g t o t h e amount o f p r o f e s s i o n a l t r a i n i n g r e c e i v e d , w h e t h e r t h e i r p r e s e r v i c e c l i n i c a l e x p e r i e n c e was i n t h e h o s p i t a l i n w h i c h t h e y were employed, o r on t h e b a s i s o f t h e number o f y e a r s away from h o s p i t a l n u r s i n g . She c o n c l u d e d t h a t t h e homo-g e n e i t y o f l e a r n i n g needs was p r o b a b l y most r e l a t e d t o f u n c t i o n a l r o l e , t y p e o f c a r e g i v e n , y e a r s i n n u r s i n g , and l e n g t h o f employment. Methods and T e c h n i q u e s : A r e c e n t s u r v e y (10) r e v e a l e d t h a t t h e i n s t r u c t i o n a l t e c h n i q u e s most p r e f e r r e d were: l e c t u r e , group d i s c u s s i o n s , f i l m s , h a n d o u t s , p a n e l , and r o l e p l a y i n g , i n t h a t o r d e r . F i f t y - e i g h t r e s p o n d e n t s e x p r e s s e d o p i n i o n s . One o f t h e most f r e q u e n t r e q u e s t s r e l a t i v e t o i m p r o v i n g i n s t r u c t i o n was more l e a r n e r p a r t i c i p a t i o n . S i m i l a r l y , B u r t (16) f o u n d t h a t many o f t h e n u r s e r e s p o n d e n t s w o u l d have l i k e d more o p p o r t u n i t i e s t o v o l u n t e e r comments and engage i n d i s c u s s i o n s w i t h c o l l e a g u e s . 219 On t h e o t h e r hand, n u r s i n g t e a c h e r s a d m i n i s t e r e d a p o s t - i n s t i t u t e q u e s t i o n n a i r e i n d i c a t e d t h a t t h e \" l e a s t h e l p f u l a s p e c t o f t h e programs were t h e s m a l l group d i s c u s s i o n s . \" The r e a s o n g i v e n was t h a t \" t h e group wandered f r o m t h e t o p i c . \" A t t h e same t i m e , o b s e r v a t i o n s by r e s o u r c e p e r s o n s d u r i n g t h e i n s t i t u t e s i n d i c a t e d t h a t t h e development of group d i s c u s s i o n and c o n f e r e n c e s k i l l s were a v e r y p r o m i n e n t need among t e a c h e r s o f n u r s i n g a t t e n d i n g t h e i n s t i t u t e . The r e f e r e n c e s found r e l a t i v e t o t h e p r e f e r e n c e s and o p i n i o n s o f n u r s e s a b o ut t h e newer mass media and s e l f i n s t r u c t i o n a l methods s u g g e s t t h a t n u r s e s a r e w i l l i n g t o u t i l i z e t h e s e where a v a i l a b l e (2) ( 1 4 ) . I n t h e WICHE s t u d y ( 9 6 ) , n u r s e s , p a r t i c u l a r l y younger n u r s e s , e x p r e s s e d an u r g e n t need f o r programmed i n s t r u c t i o n , t e l e v i s i o n , r a d i o and e d u c a t i o n a l f i l m s , more o r l e s s i n t h a t o r d e r . A r e c e n t s u r v e y (10) by t h e s c h o o l o f n u r s i n g a t P e n n s y l v a n i a S t a t e U n i v e r s i t y d i s c l o s e d t h a t 60 p e r c e n t o f t h e r e s p o n d i n g h o s p i t a l s would be w i l l i n g t o e x p e r i m e n t w i t h t e l e v i s i o n , w h i l e 21.42 p e r c e n t w o u l d n o t and 18.57 p e r c e n t were u n d e c i d e d . The m a j o r p r o b l e m s r e l a t i v e t o i t s use were: c o s t , l a c k o f f a c i l i t i e s o r equipment, and t h e q u a l i t y o f t h e program, i n t h a t o r d e r . 220 CHAPTER XIV PROGRAM, ORGANIZATION AND ADMINISTRATION A number o f d i f f e r e n t g r o u p s s p o n s o r programs o f c o n t i n u i n g n u r s i n g e d u c a t i o n i n c l u d i n g t h e u n i v e r s i t i e s and t h e i r s c h o o l s o f n u r s i n g , e m p l o y i n g i n s t i t u t i o n s \u00E2\u0080\u0094 n o t a b l y h o s p i t a l s and p u b l i c h e a l t h a g e n c i e s \u00E2\u0080\u0094 n u r s i n g and h o s p i t a l a s s o c i a t i o n s - , and v o l u n t a r y o r s p e c i a l t y h e a l t h g r o u p s . Of t h e s e , the u n i v e r -s i t i e s , h o s p i t a l s , and n u r s i n g a s s o c i a t i o n s a r e t h e p r i m a r y s p o n s o r s o f f o r m a l programs. SPONSORS AND PROGRAMS S i n c e t h e r e i s no n a t i o n a l l y s y s t e m a t i z e d method f o r r e p o r t i n g t h e numbers and t y p e s o f c u r r e n t c o u r s e o f f e r i n g s , t h e i n f o r m a t i o n p r o v i d e d i n t h i s s e c t i o n r e p r e s e n t s d a t a g l e a n e d f r o m a v a r i e t y o f s o u r c e s b u t w h i c h r e f l e c t s p r e s e n t p a t t e r n s and t r e n d s . N u r s i n g A s s o c i a t i o n s I n a r e c e n t a r t i c l e , S p e c t o r (105) w r o t e : C o n t i n u i n g e d u c a t i o n i n t h e A m e r i c a n NUrses A s s o c i a t i o n i s l i k e an i c e b e r g . That i s , i t s c l i n i c a l c o n f e r e n c e s and p u b l i c a t i o n s a r e c l e a r l y v i s i b l e . What i s l e s s e v i d e n t a r e t h e f o l l o w i n g : t h e e f f o r t s expended by t h e n a t i o n a l a s s o c i a t i o n t o encourage t h e development o f c o n t i n u i n g e d u c a t i o n programs and make i t p o s s i b l e f o r t h e p r o f e s s i o n t o d e t e r m i n e t h e s t a n d a r d o f i t s e d u c a t i o n and p r a c t i c e . More s p e c i f i c a l l y , t h e r o l e o f t h e n a t i o n a l n u r s i n g a s s o c i a t i o n s r e l a t i v e t o c o n t i n u i n g n u r s i n g e d u c a t i o n has been: 1) t o p r o c u r e f e d e r a l f u n d s f o r b o t h g r a d u a t e and c o n t i n u i n g e d u c a t i o n ; 2) t o en c o u r a g e t h e development o f e f f e c t i v e o r i e n t a t i o n and i n s e r v i c e e d u c a t i o n programs i n t h e e m p l o y i n g a g e n c i e s 3) t o promote t h e r e t u r n t o n u r s i n g o f i n a c t i v e n u r s e s ; and 4) t o p r o v i d e 221 i n f o r m a t i o n t o n u r s e s r e g a r d i n g v a r i o u s a l t e r n a t i v e s f o r p r o f e s s i o n a l advancement t h r o u g h f o r m a l e d u c a t i o n (95) (7) (105) ( 8 6 ) . I n a d d i t i o n t o t h e f o r e g o i n g , t h e C a n a d i a n N u r s e s A s s o c i a t i o n (CNA) p r o v i d e s a L i b r a r y Loan S e r v i c e on n u r s i n g p u b l i c a t i o n s , w h i l e t h e two m a j o r a s s o c i a t i o n s i n t h e U n i t e d S t a t e s o f f e r f o r r e n t o r p u r c h a s e v a r i o u s t e a c h i n g a i d e s and r e s o u r c e s . More r e c e n t l y , t h e N a t i o n a l League f o r N u r s i n g (NLN) i s r e p o r t e d d e v e l o p i n g programmed i n s t r u c t i o n on v a r i o u s a s p e c t s o f c l i n i c a l n u r s i n g ( 1 1 8 ) , I n 1967, t h e 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 (ANA) r e c e i v e d a $50,000 f e d e r a l g r a n t t o promote a n a t i o n - w i d e program o f r e f r e s h e r c o u r s e s t o e n c o u r a g e a t a r g e t o f 30,000 i n a c t i v e n u r s e s t o r e t u r n t o n u r s i n g w i t h i n one y e a r . The A s s o c i a t i o n ' s p r i m a r y r o l e i n t h i s v e n t u r e was t o i d e n t i f y t h e s o u r c e s o f i n a c t i v e n u r s e s and t o i n v o l v e a g e n c i e s , p a r t i c u l a r l y s t a t e n u r s i n g a s s o c i a t i o n s , i n t h e p r o v i s i o n o f t h e c o u r s e s . As p a r t o f i t s r e s p o n s i b i l i t y , t h e ANA d e s i g n e d a s e t o f g u i d e l i n e s and a model c o u r s e w h i c h was s u b s e q u e n t l y p u b l i s h e d ( 3 2 ) . S i n c e t h i s o r i g i n a l d r i v e , f u r t h e r g r a n t s have been made t o expand t h e ANA's p r o m o t i o n a l e f f o r t s ( 1 3 ) . F o r t h e p a s t decade the ANA has been s p o n s o r i n g t h r e e day r e g i o n a l c o n f e r e n c e s f o c u s s e d on c l i n i c a l p r a c t i c e . A l t h o u g h a t t e n d a n c e r e p o r t e d a t t h e s e c o n f e r e n c e s i s e s t i m a t e d a t some 950 p e r c o n f e r e n c e , one o f t h e p r i n c i p a l c o n c e r n s o f t h e a s s o c i a t i o n i s whether o r n o t t h e c o n f e r e n c e i s a c t u a l l y r e a c h i n g t h e d e s i r e d t a r g e t g r o u p , t h e c l i n i c a l p r a c t i t i o n e r s . A s t u d y i n 1967 r e v e a l e d t h a t t h e m a j o r i t y o f p a r t i c i p a n t s were t e a c h e r s and a d m i n i s t r a t o r s ( 1 0 5 ) . The m a j o r c o n t r i b u t i o n o f t h e CNA i s an e x t e n s i o n c o u r s e on N u r s i n g U n i t A d m i n i s t r a t i o n w h i c h i t has c o - s p o n s o r e d f o r a number o f y e a r s w i t h t h e C a n a d i a n H o s p i t a l A s s o c i a t i o n . D e s i g n e d t o combine c o r r e s p o n d e n c e s t u d y w i t h 222 a w orkshop, t h i s i s o f f e r e d n a t i o n w i d e t o n u r s e s employed i n s u p e r v i s o r y p o s i t i o n s . G e n e r a l l y c o n s i d e r e d a h i g h l y s u c c e s s f u l program, G o l d f a r b (46) r e p o r t e d t h a t i n t h e f i r s t f o u r y e a r s o f i t s e x i s t e n c e o v e r 1,500 head n u r s e s , s u p e r v i s o r s , and d i r e c t o r s o f n u r s i n g had c o m p l e t e d t h e c o u r s e . A l l t h r e e n a t i o n a l a s s o c i a t i o n s i n c o - o p e r a t i o n w i t h v a r i o u s s p e c i a l t y and l o c a l g r o u p s o f f e r c o n f e r e n c e s and workshops r e l a t i v e t o 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 (25) (118) ( 1 0 5 ) . A m a j o r c o n c e r n o f t h e n a t i o n a l n u r s i n g a s s o c i a t i o n a t p r e s e n t i s t h e e s t a b l i s h m e n t o f g u i d e l i n e s and p o l i c i e s g o v e r n i n g t h e e x p a n d i n g r o l e o f t h e n u r s e (20) ( 9 ) . As t h e h e a l t h p r o f e s s i o n s move towards \" r e l i c e n s u r e \" t h e development o f s t a n d a r d s f o r c o n t i n u i n g e d u c a t i o n and a g r e a t e r e f f o r t t o i n c r e a s e t h e number o f a v a i l a b l e l e a r n i n g o p p o r t u n i t i e s f o r p r a c t i s i n g n u r s e s (105) w i l l r e q u i r e n a t i o n a l a t t e n t i o n . T h i s s e a r c h o f t h e l i t e r a t u r e y i e l d e d l i t t l e on t h e a c t i v i t i e s i n c o n t i n u i n g e d u c a t i o n o f s t a t e , p r o v i n c i a l , and l o c a l n u r s i n g a s s o c i a t i o n s , R e cent a n n u a l r e p o r t s f r o m u n i v e r s i t y s c h o o l s o f n u r s i n g s u g g e s t t h a t n u r s i n g a s s o c i -a t i o n s a r e w o r k i n g more c l o s e l y w i t h t h e u n i v e r s i t y s c h o o l s o f n u r s i n g b o t h i n p l a n n i n g and i m p l e m e n t 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 a t t h e l o c a l l e v e l . T h e i r i n f l u e n c e i s a l s o e x p r e s s e d i n o t h e r ways, n o t a b l y t h r o u g h t h e p r o v i s i o n o f f u n d s f o r program d e v e l o p m e n t , s t u d i e s o f l e a r n i n g n e e d s , and t h e i r r o l e r e l a t i v e t o n u r s i n g s t a n d a r d s and p r a c t i c e s (100) (115) ( 2 5 ) . H o s p i t a l s : A l t h o u g h t h e r e a r e no d e t a i l e d s t u d i e s on i n s e r v i c e e d u c a t i o n , t h e e v i d e n c e a v a i l a b l e s u g g e s t s t h a t i t s development has been q u i t e l i m i t e d . One s u r v e y o f i n s e r v i c e e d u c a t i o n i n n i n e h o s p i t a l s r e p o r t e d as p a r t o f a n a t i o n a l s t u d y on t h e q u a l i t y o f n u r s i n g s e r v i c e i n Canada (95) r e v e a l e d t h a t i n a l l n i n e h o s p i t a l s s t u d i e d , o r i e n t a t i o n t o t h e ward s i t u 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 t h e head n u r s e and h e r s t a f f . I n a few i n s t a n c e s t h i s program was p l a n n e d t o 223 l a s t s e v e r a l days o r weeks w i t h c o n f e r e n c e s , c l a s s e s , and d e m o n s t r a t i o n s i n t h e a f t e r n o o n s . Three h o s p i t a l s had a d e s i g n a t e d i n s e r v i c e e d u c a t o r and t e n d e d t o o f f e r t h e more co m p r e h e n s i v e programs w i t h more c o n s i s t e n t f o l l o w - u p f o r each new employee. One m a j o r weakness o f most o r i e n t a t i o n programs was t h e l a c k o f p l a n n e d o r i e n t a t i o n t o e v e n i n g and n i g h t s h i f t s . On s e v e r a l o c c a s i o n s n u r s e s s t a t e d t h a t t h e y had been p l a c e d i n c h a r g e o f a ward on e v e n i n g o r n i g h t s w i t h o u t s u f f i c i e n t i n t r o d u c t i o n t o t h e a d m i n i s t r a t i v e f u n c t i o n s and p r o c e d u r e s , as w e l l as t o t h e p a t i e n t s and t h e i r n e eds. I n two i n s t a n c e s n u r s e s s a i d t h e y had t o depend on n u r s i n g a s s i s t a n t s and s t u d e n t s t o i n f o r m them o f t h e p o l i c i e s 5 r o u t i n e s , and r e s p o n s i b i l i t i e s o f v a r i o u s p e r s o n n e l . I n a l l b u t one of t h e h o s p i t a l s s u r v e y e d , p l a n n e d i n s e r v i c e e d u c a t i o n programs were p r o v i d e d . However, most o f t h e programs f o c u s s e d on d i s e a s e e n t i t i e s , t e c h n i c a l p r o c e d u r e s , and new e q u ipment, \"even though o b s e r v a t i o n s and d i s c u s s i o n s s u g g e s t e d a need f o r i n s e r v i c e e d u c a t i o n o r i e n t e d a r o u n d t h e k i n d s o f p a t i e n t s w h i c h n u r s i n g p e r s o n n e l i n d i c a t e d p r o v i d e d d i f f i c u l t n u r s i n g p r o b l e m s . \" C u r r e n t l i t e r a t u r e was a l m o s t n o n - e x i s t e n t on most n u r s i n g u n i t s ; however, one h o s p i t a l r e p o r t e d c i r c u l a t i n g s e l e c t p e r i o d i c a l s . Most o f t h e h o s p i t a l s i n d i c a t e d t h a t n u r s e s were a l l o w e d and i n f a c t , e n c o u r a g e d t o a t t e n d v a r i o u s s h o r t c o u r s e s , w o r k s h o p s , o r i n s t i t u t e s , c o n d u c t e d by n e a r b y u n i v e r s i t i e s . The two m a j o r a d m i n i s t r a t i v e p r o b l e m s emphasized by t h e n u r s e s were: 1) t h e d i f f i c u l t y o f r e l e a s i n g p e r s o n n e l t o a t t e n d t h e programs; and 2) t h e d i f f i c u l t y o f p l a n n i n g programs f o r e v e n i n g and n i g h t s t a f f . As s t a t e d by one r e s p o n d e n t , \" I t h i n k t h e a f t e r n o o n and n i g h t s t a f f s h o u l d have some fo r m o f i n s e r v i c e program, b u t you c a n ' t e x p e c t t h e n i g h t n u r s e t o g e t up f o r an a f t e r -noon m e e t i n g . \" Many o f t h e c r i t i c a l i n c i d e n t s p r o v i d e d by o v e r 1,000 r e g i s t e r e d 224 n u r s e s i n P r i c e ' s s t u d y (89) s u g g e s t t h a t comparable p r o b l e m s e x i s t i n many A m e r i c a n h o s p i t a l s . T h i s s t u d y emphasized t h a t a l l p e r s o n n e l , w h e t h e r f u l l o r p a r t t i m e , day, e v e n i n g , o r n i g h t s , s h o u l d p a r t i c i p a t e i n i n s e r v i c e e d u c a t i o n and i t recommended t h a t s c h e d u l i n g be i m p r o v e d by t h e p r o v i s i o n o f an ' e d u c a t i o n day' f o r e a c h n u r s e . \"When i n s e r v i c e e d u c a t i o n i s c o n s i d e r e d as e s s e n t i a l , improvement i n s c h e d u l i n g c a n and w i l l be made. T h i s i s r e c o g n i z e d t o be a t a s k t h a t i s d i f f i c u l t , b u t n o t i m p o s s i b l e . \" The r e p o r t a l s o recommended t h a t i n s e r v i c e p e r s o n n e l work w i t h n u r s i n g s e r v i c e t o e n s u r e t h a t n u r s e s n o t be a s s i g n e d t o a l e a d e r s h i p r o l e w i t h o u t p r e v i o u s o r i e n t a t i o n . I n t h e . I d a h o Study ( 5 7 ) , h o s p i t a l based i n s e r v i c e e d u c a t i o n programs were f o u n d t o be m i n i m a l , and much of what was b e i n g o f f e r e d c o n s i s t e d o f d i d a c t i c p r e s e n t a t i o n s . O n l y s i x f u l l t i m e e d u c a t i o n a l d i r e c t o r s were employed i n t h e f i f t y t h r e e h o s p i t a l s and f i f t y f o u r l o n g term c a r e f a c i l i t i e s i n t h a t s t a t e . None of t h e d i r e c t o r s had advanced e d u c a t i o n n o r any a d d i t i o n a l t r a i n i n g i n t h e e d u c a t i o n a l p r o c e s s . I n f a c t , t h i s s t u d y c o n c l u d e d t h a t t h e e d u c a t o r ' s needs f o r c o n t i n u i n g e d u c a t i o n were s i m i l a r t o t h o s e o f t h e n u r s i n g s t a f f . These f i n d i n g s a r e n o t t o o d i f f e r e n t t o t h o s e r e p o r t e d by T i f f n e y (109) , M u r r a y ( 7 5 ) , and o t h e r s (36) ( 9 2 ) . The N a t i o n a l Commission on N u r s i n g and N u r s i n g E d u c a t i o n (69) summarized i t s c o n c l u s i o n as f o l l o w s : The e n t i r e committment t o i n s e r v i c e e d u c a t i o n has been c h a r a c t e r i z e d by i n a d e q u a t e s u p p o r t and i n s u f f i c i e n t p e r s o n n e l . Of t h e more t h a n 7,000 h o s p i t a l s i n t h e U n i t e d S t a t e s , f o r example, no more t h a n 300 have a p r o f e s s i o n a l t r a i n i n g s p e c i a l i s t t o d i r e c t t h e i r i n s e r v i c e p r o g r a m s . A l l t o o f r e q u e n t l y r e s p o n s i b i l i t y has d e v o l v e d upon n u r s i n g s e r v i c e i n t h e absence o f any s p e c i f i c p l a n . D e s p i t e t h e d i s o r g a n i z e d s t a t e of t h e f i e l d , i t i s e x p e c t e d t h a t a number o f r e c e n t d e v e l o p m e n t s w i l l g r e a t l y i n f l u e n c e t h e f u t u r e o f i n s e r v i c e 225 e d u c a t i o n . One o f t h e s e i s t h e r e c e n t s t a t e m e n t by t h e J o i n t Commission on A c c r e d i t a t i o n w h i c h w o u l d r e q u i r e t h a t n u r s i n g d e p a r t m e n t s 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 f o r n u r s i n g p e r s o n n e l ( 8 2 ) . A l t h o u g h l i m i t i n g i n one s e n s e , t h i s r e q u i r e m e n t w o u l d p r o v i d e g r e a t e r s u p p o r t f o r i n s e r v i c e e d u c a t i o n . A n o t h e r development c o n c e r n s t h e e d u c a t i o n a l media w h i c h p r o m i s e a p a r t i a l s o l u t i o n t o some a s p e c t s o f t h e m u l t i - f a c e t e d p r o b l e m ( 1 7 ) . Even more i m p o r t a n t i s t h e i n c r e a s i n g t r e n d towards t h e r e g i o n a l 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 , w h i c h i n t u r n i s . f a c i l i t a t i n g c o o p e r a t i v e p l a n n i n g and i n d e e d , i n some a r e a s o f programming, i t i s becoming i n c r e a s i n g l y d i f f i c u l t t o d i s t i n g u i s h between \" i n s e r v i c e \" and \" c o n t i n u i n g \" e d u c a t i o n . U n i v e r s i t i e s and T h e i r S c h o o l s o f N u r s i n g : G w a l t n e y s u r v e y e d (49) a l l c o l l e g e s and u n i v e r s i t y s c h o o l s o f n u r s i n g i n t h e U n i t e d S t a t e s . T h i s s t u d y r e v e a l e d t h a t d u r i n g t h e academic y e a r T 9 6 8 \u00E2\u0080\u0094 flQ Al of\" t*Vl\u00C2\u00A3> r p c i n n n H l ncr c r l i n n l c r\-f-f a-rarl /IOD n-**rt / \u00C2\u00BB * 3 m c O T ^ i n r r c i o f f r o m \u00E2\u0080\u0094 - - i \u00E2\u0080\u0094 \u00E2\u0080\u0094 1 o - ~ -* ' \" \" \u00E2\u0080\u0094 1\u00E2\u0080\u0094 - ~\u00E2\u0080\u0094 \u00E2\u0080\u0094 \u00E2\u0080\u00A2 ~ ~ I o o 1 t o 69. I n a d d i t i o n , a l l 41 r e s p o n d e n t s i n d i c a t e d some d e g r e e o f p a r t i c i p a t i o n i n c o - s p o n s o r i n g c o u r s e s , n o t a b l y w i t h v o l u n t a r y h e a l t h a g e n c i e s , s t a t e n u r s i n g a s s o c i a t i o n s , RMPS, and o t h e r c o l l e g e s and u n i v e r s i t i e s . The l e n g t h o f t h e programs o f f e r e d v a r i e d f r o m one h a l f t o f o r t y d a y s . The O h l i g e r and B a r r a t t s u r v e y (81) o f 96 NLN a c c r e d i t e d s c h o o l s o f n u r s i n g o f f e r i n g a b a c c a l a u r e a t e b u t no h i g h e r d e g r e e s u g g e s t s even l e s s i n v o l v e m e n t o f c o l l e g i a t e 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 . Of t h e 62 s c h o o l s r e s p o n d i n g , o n l y 31 had o f f e r e d a c o n t i n u i n g e d u c a t i o n program d u r i n g t h e academic y e a r 1967-68. More s p e c i f i c a l l y , 15 s c h o o l s o f f e r e d 1 c o n t i n u i n g e d u c a t i o n program, 12 o f f e r e d 2 t o 5, and o n l y 4 o f f e r e d more t h a n 5. These programs v a r i e d i n l e n g t h f r o m one day t o two weeks w h i l e i n some c a s e s a program was o f f e r e d i n t e r m i t t e n t l y o v e r a s e m e s t e r . 226 The U n i v e r s i t y o f T o r o n t o Survey (25) r e v e a l e d t h a t between 1965 and 1968, f o u r o f t h e p r o v i n c e ' s u n i v e r s i t i e s p r o v i d e d 19 c o u r s e s f o r n u r s e s . Of t h e s e , o n l y 12 were s p o n s o r e d o r c o - s p o n s o r e d by s c h o o l s o f n u r s i n g . The o t h e r s were o f f e r e d by t h e f a c u l t y o f m e d i c i n e and t h e s c h o o l o f h y g i e n e . The l e n g t h o f the n u r s i n g s c h o o l programs ranged f r o m two days t o e i g h t weeks. I n t h e two n a t i o n a l s u r v e y s , g r o u p s f o r whom programs were most o f t e n p r o v i d e d were g e n e r a l s t a f f n u r s e s , head n u r s e s , s u p e r v i s o r s , i n s t r u c t o r s , p u b l i c h e a l t h n u r s e s , o c c u p a t i o n a l h e a l t h n u r s e s , and p r i v a t e d u t y n u r s e s , more o r l e s s i n t h a t o r d e r . I n G w a l t n e y ' s s u r v e y , t h e s c h o o l s i n d i c a t e d t h a t t h e most f r e q u e n t r e q u e s t was f o r management s k i l l s and t o a l e s s e r e x t e n t c l i n i c a l n u r s i n g . O h l i g e r and B a r r a t t r e p o r t e d t h e f o l l o w i n g c o n t e n t a r e a s : n u r s i n g i n p u b l i c h e a l t h , r e h a b i l i t a t i o n , m a t e r n a l - c h i l d , m e d i c a l - s u r g i c a l , and m e n t a l h e a l t h . More s p e c i f i c a l l y , t o p i c s i n c l u d e d : sex e d u c a t i o n and f a m i l y l i f e , p r i n c i p l e s o f management and s u p e r v i s i o n , s e n s i t i v i t y t r a i n i n g , head n u r s e r o l e s , l e g a l p r o b l e m s i n n u r s i n g , t e a c h i n g methods, p r o b l e m - s o l v i n g and n u r s i n g p r a c t i c e , and m e n t a l r e t a r d a t i o n . A r e v i e w o f r e c e n t program d e s c r i p t i o n s s u g g e s t s t h a t i n a d d i t i o n t o t h e f o r e g o i n g , u n i v e r s i t y s c h o o l s o f n u r s i n g a r e a l s o o f f e r i n g an a p p r e c i a b l e number o f r e f r e s h e r c o u r s e s f o r i n a c t i v e n u r s e s (22) (21) ( 1 1 4 ) . The l i t e r a -t u r e a l s o s u g g e s t s t h a t more c o n s i d e r a t i o n i s b e i n g g i v e n t o s e q u e n t i a l l y p l a n n e d c l i n i c a l l y o r i e n t e d c o u r s e s , p a r t i c u l a r l y t o t h e a r e a s o f i n t e n s i v e c a r e (17) and l e a d e r s h i p development (38) (39) ( 4 0 ) . I n a d d i t i o n , a few u n i v e r s i t i e s a r e r e p o r t e d o f f e r i n g c e r t i f i c a t e c o u r s e s d e s i g n e d to expand t h e r o l e o f t h e n u r s e i n t h e a r e a o f a m b u l a t o r y c a r e (114) (85) . On t h e w h o l e , c o m p r e h e n s i v e programs w i t h l o n g range g o a l s a p p e a r t o 227 be 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 . As i n a l l the h e a l t h p r o f e s s i o n s , t h e g r e a t m a j o r i t y o f programs i n c o n t i n u i n g n u r s i n g e d u c a t i o n a r e s h o r t c o u r s e s , d e s i g n e d t o meet the immediate needs o f n u r s e p r a c t i t i o n e r s and/or t h e e m p l o y i n g a g e n c i e s (18) (116) (48). ADMINISTRATION A l t h o u g h 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 v a r y , t h e m a j o r 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 a r e a d m i n i s t e r e d as p a r t o f t h e u n i v e r s i t i e s ' s c h o o l s o f n u r s i n g . A few,however, e x i s t as s e p a r a t e d i v i s i o n s but w i t h i n the h e a l t h s c i e n c e complex (49). At t h e U n i v e r s i t y o f W i s c o n s i n , c o n t i n u i n g n u r s i n g e d u c a t i o n i s o r g a n i z e d as a s e p a r a t e department w i t h i n t h e e x t e n s i o n d i v i s i o n . To e n s u r e c o - o r d i n a t i o n w i t h t h e s c h o o l o f n u r s i n g , t h e a d m i n i s t r a t o r s i n e x t e n s i o n a r e a l s o on t h e f a c u l t y o f t h e s c h o o l . I n k e e p i n g w i t h t h e e x t e n s i o n c o n c e p t , c o u r s e s i n n u r s i n g a r e o f f e r e d t h r o u g h o u t t h e s t a t e u s i n g a v a r i e t y o f 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 (26). The U n i v e r s i t y o f C o l o r a d o ' s c o n t i n u i n g e d u c a t i o n s e r v i c e s has a s t a t e a d v i s o r y committee made up o f r e p r e s e n t a t i v e s f r o m v a r i o u s f i e l d s o f n u r s i n g and a l l i e d h e a l t h p r o f e s s i o n s . The r o l e o f t h i s committee i s t o s e r v e as a means o f c o m m u n i c a t i o n r e l a t i v e t o c o n t i n u i n g e d u c a t i o n n e e d s , and as a l i a i s o n between t h e s c h o o l o f n u r s i n g and h e a l t h a g e n c i e s (115). G w e l t n e y (49) d i s c l o s e d t h a t t h e m a j o r i t y o f r e p o r t i n g s c h o o l s employed f u l l t i m e d i r e c t 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 n u r s e s . Of t h e s e , 27 d i r e c t o r s h e l d m a s t e r ' s d e g r e e s , 4 h e l d d o c t o r a l d e g r e e s , and one had a b a c c a l a u r e a t e . t A d d i t i o n a l n u r s e f a c u l t y engaged f u l l t i m e r a n g e d f r o m 3 t o 23. Most of t h e s e h e l d m a s t e r ' s d e g r e e s . O h l i g e r and B a r r a t t (81) r e p o r t e d t h a t 7 o f t h e 31 r e s p o n d i n g s c h o o l s r e p o r t e d t h a t p e r s o n s r e s p o n s i b l e f o r t h e program had some a d d i t i o n a l p r e p a r a t i o n i n a d u l t e d u c a t i o n . 228 I n s t r u c t o r s The n u r s i n g s c h o o l s r e p o r t e d t h e use o f b o t h r e g u l a r f a c u l t y and o u t s i d e p e o p l e t o t e a c h c o n t i n u i n g e d u c a t i o n p rograms. These l a t t e r i n c l u d e d : p u b l i c h e a l t h p e r s o n n e l , n u r s e c l i n i c i a n s , p h y s i c i a n s , p h y s i c a l t h e r a p i s t s , s o c i o l o g i s t s , p s y c h o l o g i s t s , s o c i a l w o r k e r s , p h a r m a c i s t s , a t t o r n e y s , and t e l e v i s i o n programmers (81) . Most s c h o o l s a l s o r e p o r t t h e use o f l o c a l n u r s e s as r e s o u r c e p e r s o n s and/or t e a c h e r s ( 9 2 ) . Some s c h o o l s r e p o r t t h e use o f p a t i e n t s and f a m i l i e s as i m p o r t a n t and e f f e c t i v e r e s o u r c e p e r s o n s (100) ( 7 9 ) . The r e c r u i t m e n t o f f a c u l t y , e x p e r t b o t h i n t h e f i e l d o f n u r s i n g and t h e p s y c h o l o g y o f a d u l t l e a r n i n g , has been i d e n t i f i e d as one o f t h e m a j o r p r o b l e m s i n s e l e c t i o n o f t e a c h e r s (100) ( 9 0 ) . A n o t h e r i s t h e heavy r e s p o n s i -b i l i t i e s w h i c h t h e r e g u l a r f a c u l t y c a r r y i n 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 programs. The p o l i c i e s o f some u n i v e r s i t i e s p r o h i b i t i n g payment t o f a c u l t y members 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 e d u c a t i o n programs i s s a i d t o f u r t h e r a g g r a v a t e t h e s i t u a t i o n ( 9 2 ) . R e c ent l i t e r a t u r e s u g g e s t s t h a t many u n i v e r s i t y s c h o o l s o f n u r s i n g a r e a t t e m p t i n g t o meet t h e a c u t e s h o r t a g e o f s k i l l e d a d u l t e d u c a t o r s t h r o u g h i n t e n s i v e t r a i n i n g c o u r s e s f o r n u r s e f a c u l t y , i n s e r v i c e c o o r d i n a t o r s , and p u b l i c h e a l t h n u r s e s (38) (39) (40) ( 4 1 ) . I n a d d i t i o n , a t l e a s t 2 RMPS have engaged f u l l t i m e p e r s o n n e l t o a s s i s t i n s e r v i c e e d u c a t o r s t o improve t h e i r programs and t o p r e p a r e l o c a l n u r s e s t o p l a n and implement programs o f i n s e r v i c e e d u c a t i o n ( 2 4 ) . F i n a n c e s : As i n t h e o t h e r h e a l t h p r o f e s s i o n s , 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 has been t h e r e c i p i e n t o f g r a n t s from t h e K e l l o g g F o u n d a t i o n (115) (100) ( 1 9 ) . 229 O t h e r s o u r c e s o f f u n d s i n c l u d e d o n a t i o n s , c o u r s e f e e 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 , e m p l o y i n g a g e n c i e s , and government g r a n t s (27) (115) ( 6 6 ) . U n i v e r s i t y s c h o o l s o f n u r s i n g i n t h e U n i t e d S t a t e s appear t o be i n a much more e n v i a b l e p o s i t i o n t h a n t h o s e i n Canada. I n f a c t t o d a t e , m e d i c i n e and n u r s i n g have r e c e i v e d t h e l i o n ' s s h a r e o f f u n d i n g f o r c o n t i n u i n g e d u c a t i o n t h r o u g h p u b l i c l a w 89-239 ( 2 3 ) . O t h e r l u c r a t i v e s o u r c e s o f r e v e n u e i n t h e U n i t e d S t a t e s have been t h e f e d e r a l s h o r t term t r a i n i n g g r a n t s t h r o u g h t h e Manpower T r a i n i n g A c t ( 6 6 ) , t h e NIMH ( N a t i o n a l I n s t i t u t e of M e n t a l H e a l t h ) g r a n t s ( 1 1 9 ) , and t h e t w e l v e month g r a n t s t h r o u g h t h e U.S. P u b l i c H e a l t h S e r v i c e , D i v i s i o n of N u r s i n g ( 8 3 ) . i D e s p i t e s u c h a d i v e r s i t y o f s o u r c e s , i n t h e U n i t e d S t a t e s as i n Canada f u n d i n g i s s a i d t o be i n a d e q u a t e (116) ( 9 0 ) . The main p r o b l e m seems t o be a s h o r t a g e o f 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 w h i c h r e q u i r e s ' a s e c u r e f i n a n c i a l b a s e . I n f a c t , t h e pace s e t t i n g s c h o o l s o f n u r s i n g appear t o be t h o s e w h i c h have had c o n s i d e r a b l e f i n a n c i a l s u p p o r t f r o m t h e u n i v e r s i t y (115) ( 2 6 ) . P u b l i c i t y and P r o m o t i o n : The p r o m o t i o n o f c o n t i n u i n g n u r s i n g e d u c a t i o n i s a c h i e v e d t h r o u g h t h e u s u a l b r o c h u r e s , n u r s i n g a s s o c i a t i o n n e w s l e t t e r s , n ewspapers, and n u r s i n g j o u r n a l s . Of t h e s e s t a n d a r d methods, t h e W i s c o n s i n s t u d y (28) f o u n d t h a t b r o c h u r e s arid f l i e r s s e n t t o h o s p i t a l s and o t h e r e m p l o y i n g a g e n c i e s were t h e most e f f e c t i v e means o f r e a c h i n g n u r s e p r a c t i t i o n e r s . I n o r d e r t o f a c i l i t a t e advanced p l a n n i n g by t h e e m p l o y i n g a g e n c i e s and . n u r s e p r a c t i t i o n e r s , some u n i v e r s i t i e s a r e p u b l i c i z i n g t h e i r program o f f e r i n g s once a y e a r i n t h e f o r m o f c a l e n d a r s (18) (114) ( 1 0 0 ) . S i n c e J a n u a r y 1971, t h e 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 has i n c l u d e d an \" E d u c a t i o n a l O p p o r t u n i t i e s \" s e c t i o n as a f u r t h e r a i d t o t h o s e n u r s e s i n t e r e s t e d i n a t t e n d i n g 230 programs b o t h w i t h i n and w i t h o u t t h e i r s t a t e . . As i n d e n t i s t r y , i t i s n o t u n u s u a l f o r c o u r s e s p o n s o r s t o o f f e r c r e d i t s o r c e r t i f i c a t e s f o r c o u r s e a t t e n d a n c e . I n G w a l t n e y ' s s u r v e y ( 4 9 ) , 7 s c h o o l s o f n u r s i n g r e p o r t e d o f f e r i n g c r e d i t s w h i l e 25 d i d n o t . C r e d i t was used most o f t e n by s c h o o l s o f f e r i n g e x t e n s i o n work i n some c o u r s e s u n r e l a t e d t o d e g r e e s . Program P l a n n i n g : Most of t h e u n i v e r s i t y s c h o o l s o f n u r s i n g u s e permanent o r r o t a t i n g c o m m i t t e e s t o a s s i s t w i t h t h e o v e r a l l p l a n n i n g . Committee members u s u a l l y c o n s i s t o f b o t h s c h o o l f a c u l t y and o u t s i d e r e s o u r c e p e r s o n s . I n a d d i t i o n , s p e c i a l c o m m i t t e e s a r e o r g a n i z e d t o . p l a n i n d i v i d u a l program o f f e r i n g s ( 1 1 5 ) . The p e r s o n n e l i n t h e s e p l a n n i n g groups a r e s e l e c t e d on t h e b a s i s o f t h e i r e x p e r t i s e and i n t e r e s t i n t h e p a r t i c u l a r program b e i n g p l a n n e d (100) (115) . R e p o r t s on i n s e r v i c e e d u c a t i o n s u g g e s t t h a t most programs u s e committees f o r p l a n n i n g (45) (42) ( 8 7 ) . I n t h e CNA s u r v e y (95) i t was fo u n d t h a t g e n e r a l s t a f f n u r s e s and n u r s i n g a s s i s t a n t s i n some h o s p i t a l s each a p p o i n t e d committees t o p l a n programs f o r t h e i r own g r o u p s . As i n m e d i c i n e and d e n t i s t r y , n u r s i n g a p p e a r s t o make e x t e n s i v e u s e o f p a r t i c i p a n t s ' o p i n i j n n a i r e s as a b a s i s f o r program p l a n n i n g . However, as i n most f i e l d s o f a d u l t e d u c a t i o n , t h e s e s u r v e y s do n o t i d e n t i f y t h e p a r t i c i p a n t s ' r e a l l e a r n i n g needs ( 9 2 ) . S t r a u b (107) fo u n d t h a t even when t h e n u r s e s s e l e c t e d t h e c o n t e n t , h e l p e d p l a n t h e program, and had t i m e p r o v i d e d so t h a t t h e y c o u l d a t t e n d , more t h a n one q u a r t e r o f t h e n u r s e s d i d n o t a t t e n d t h e m a j o r i t y o f t h e m e e t i n g s . She a l s o o b s e r v e d t h a t a t t e n d a n c e was much l o w e r f o r t h o s e m e e t i n g s d e v o t e d t o n u r s i n g c a r e and i n t e r d i s c i p l i n a r y m a t t e r s . S t r a u b a s k s : . S h o u l d t h e c o n t e n t f o r i n s e r v i c e e d u c a t i o n programs be d e t e r m i n e d by t h e n u r s e p r a c t i t i o n e r s ? Or s h o u l d a d d i t i o n a l t o p i c s be s u g g e s t e d 231 by p e o p l e i n l e a d e r s h i p p o s i t i o n s s u c h as the head n u r s e , s u p e r v i s o r , and d i r e c t o r o f n u r s i n g s e r v i c e ? P e r s o n s i n t h e s e p o s i t i o n s m i ght have a d i f f e r e n t c o n c e p t o f t h e needs o f n u r s i n g p e r s o n n e l b e c a u s e o f t h e i r p o s i t i o n s , e x p e r i e n c e , e d u c a t i o n and t h e l i k e ? G r o s i c k i (47) s u r v e y e d needs i n one 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 and f o u n d t h a t w h i l e many d i f f e r e n t v i e w p o i n t s had been i n c o r p o r a t e d i n t o t h e c a r e f u l l y p l a n n e d p r ograms, most of t h e a c t i v i t i e s met t h e immediate needs of t h e s i t u a t i o n , b u t were l a c k i n g i n c o n t i n u i t y and o v e r a l l program g o a l s . P r i m a r y emphasis had been p l a c e d on f u n c t i o n a l competence, p a r t i c u l a r l y t h e e f f i c i e n t management o f t h e u n i t , and \" t h i s a r e a showed t h e g r e a t e s t i n c r e m e n t o f a p p l i c a t i o n . I n o t h e r s u b j e c t a r e a s , v e r y l i t t l e o f what had s u p p o s e d l y been l e a r n e d had been put i n t o c l i n i c a l p r a c t i c e . The g r e a t e s t d e f i c i t a p p e a r e d i n c l i n i c a l competence.\" I n a s i m i l a r v e i n a t t h e W i l l i a m s b u r g c o n f e r e n c e (90) i t was a g r e e d t h a t t h e two most s e r i o u s d e f i c i e n c i e s i n c o n t i n u i n g e d u c a t i o n were: 1) t h e l a c k o f c o n t i n u i t y between knowledge and i t s u t i l i z a t i o n and, 2) t h e p r o b l e m o f unmet and u n i d e n t i f i e d l e a r n i n g needs. More r e c e n t l y , under t h e a u s p i c e s o f t h e WICHE:MSRMP, t h e Committee o f 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 i n Idaho (120) has drawn up a p r o p o s e d program b a s e d on t h e p h i l o s o p h y e x p r e s s e d by M i l l e r : I t w o u l d seem t h a t t h e t i m e has come t o t r y a d i f f e r e n t e d u c a t i o n a l model...one b u i l t upon s o l i d e v i d e n c e about t h e way a d u l t s l e a r n , r a t h e r t h a n upon t h e t i m e honored methods o f t e a c h i n g them. T h e r e i s ample e v i d e n c e t o s u p p o r t t h e v i e w t h a t a d u l t l e a r n i n g i s n o t most e f f i c i e n t l y a c h i e v e d t h r o u g h s y s t e m a t i c s u b j e c t i n s t r u c t i o n , i t i s a c c o m p l i s h e d by i n v o l v i n g l e a r n e r s i n i d e n t i f y i n g p r o b l e m s and s e e k i n g ways t o s o l v e them... I n k e e p i n g w i t h t h i s p h i l o s o p h y , t h i s program w i l l be i n t r o d u c e d i n p hases w i t h t h e m a j o r emphasis d u r i n g t h e f i r s t phase on the l e a r n i n g p r o c e s s . Group m e e t i n g s i n t h e c l i n i c a l a r e a s w i l l be u t i l i z e d w i t h a c t i v e i n v o l v e m e n t o f t h e p a r t i c i p a n t s i n a n a l y z i n g and d e t e r m i n i n g t h e i r own l e a r n i n g n e e d s , and 232 w i t h i n s t r u c t o r s a v a i l a b l e who w i l l be w o r k i n g w i t h s e v e r a l g r o u p s s i m u l t a n e o u s l y . C o n t e n t m a t e r i a l w i l l be p r o v i d e d as t h e groups a r e r e a d y f o r i t . E x i s t i n g r e s o u r c e s w i l l be used as r e q u i r e d . S e v e r a l i n s t r u c t i o n a l p r o c e s s e s w i l l be used i n r e s p o n s e t o t h e needs e x p r e s s e d by t h e p a r t i c i p a n t s . As t h e programs d e v e l o p t h e y w i l l be r e g i o n a l i z e d and u l t i m a t e l y i n t e g r a t e d w i t h c o n t i n u i n g e d u c a t i o n programs f o r p h y s i c i a n s and a l l i e d h e a l t h p r o f e s s i o n a l s . C o n t i n u o u s e v a l u a t i o n w i l l be b u i l t i n t o t h e s e programs t h r o u g h t h e use o f o b j e c t i v e s s t a t e d i n b e h a v i o u r a l t e r m s . P a r t i c i p a n t s , f a c u l t y , and t h e a g e n c i e s where n u r s e s a r e employed w i l l p a r t i c i p a t e i n t h e e v a l u a t i o n o f t h e p r o j e c t . More s p e c i f i c a l l y , t h e e v a l u a t i o n w i l l a t t e m p t t o : 1) a p p r a i s e t h e p a r t i c i p a n t s ' a b i l i t y t o i d e n t i f y t h e i r own e d u c a t i o n a l needs and t o e s t a b l i s h g o a l s f o r s u s t a i n e d ' s e l f e d u c a t i o n ' t h r o u g h t h e use o f a v a i l a b l e r e s o u r c e s ; 2) 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 t h e q u a l i t y o f p a t i e n t c a r e has improv e d and t o what e x t e n t t h e f a c i l i t i e s s u p p o r t c o n t i n u a t i o n o f the program, and 3) a g e n e r a l a n a l y s i s by t h e f a c u l t y o f t h e c o - o p e r a t i v e a p p r o a c h t o c o n t i n u i n g e d u c a t i o n and i t s v a l u e t o p a r t i c i p a n t s and t h e i r e m p l o y i n g a g e n c i e s . SOME SAMPLE PROGRAMS I t i s d i f f i c u l t t o g e n e r a l i z e about t h e i n s t r u c t i o n a l p r o c e s s e s c u r r e n t l y used i n c o n t i n u i n g n u r s i n g e d u c a t i o n . N e v e r t h e l e s s , a p e r u s a l o f r e c e n t program d e s c r i p t i o n s s u g g e s t s t h a t a h i g h premium i s p l a c e d on s m a l l group d i s c u s s i o n , hence i t i s n o t u n u s u a l f o r u n i v e r s i t y s c h o o l s o f n u r s i n g t o c o n t r o l e n r o l l m e n t , b o t h i n terms o f numbers and a c c o r d i n g t o s u c h v a r i a b l e s as a r e a o f s p e c i a l i z a t i o n , p o s i t i o n i n t h e e m p l o y i n g a g ency, and on o c c a s i o n , y e a r s o f e x p e r i e n c e (38) (39) (40) ( 4 1 ) . The most p r o m i s i n g a p p r o a c h e s appear t o be t h o s e w h i c h have managed t o combine t h e c l a s s r o o m i n s t r u c t i o n w i t h 233 c l i n i c a l p r a c t i c e . R e g i o n a l and S u b - R e g i o n a l Programs: I n 1957, t h e Western Commission on H i g h e r E d u c a t i o n i n N u r s i n g (WCHEN) l a u n c h e d a c e n t r a l l y p l a n n e d , r e g i o n a l l y implemented l e a d e r s h i p t r a i n i n g program f o r n u r s e s a l r e a d y employed i n key p o s i t i o n s . F i n a n c e d by t h e K e l l o g g F o u n d a t i o n , t h e p r i m a r y o b j e c t i v e was \" t o a i d t h e p a r t i c i p a n t s t o become more e f f e c t i v e l e a d e r s t h e r e b y i m p r o v i n g p a t i e n t c a r e . \" S e v e r a l f e a t u r e s d i s t i n g u i s h e d t h i s c o u r s e f r o m o t h e r p r e v i o u s e f f o r t s . I t was s c h e d u l e d on an i n t e r m i t t e n t b a s i s , c o n s i s t i n g o f one week c o n f e r e n c e s s e p a r a t e d by 3 t o 6 months i n t e r v a l s e x t e n d i n g o v e r t h r e e y e a r s . D u r i n g t h e i n t e r i m p e r i o d s t h e p a r t i c i p a n t s r e t u r n e d t o t h e i r work s e t t i n g s t o a p p l y what t h e y had l e a r n e d , w i t h c o n s u l t a t i o n s e r v i c e s a v a i l a b l e as r e q u e s t e d . I n t h i s way n u r s e s who o r d i n a r i l y would n o t have been a b l e t o engage i n f u r t h e r e d u c a t i o n were a b l e t o do -so. A n o t h e r a s p e c t o f t h i s program p a r t i c u l a r l y c o n d u c i v e t o l e a r n i n g was t h e i n - r e s i d e n c e c o n f e r e n c e w h i c h t o o k p a r t i c i p a n t s away f r o m t h e work s e t t i n g s where t h e y c o u l d f r e e l y exchange i d e a s and p r o g r e s s n o t e s on problems i n t h e i r home s i t u a t i o n s . E ncouraged by t h e f a v o u r a b l e r e s p o n s e t o t h i s e x p e r i m e n t , a g r a n t was r e c e i v e d f r o m t h e P u b l i c H e a l t h S e r v i c e , and t h e program c o n t i n u e d (29). S i n c e t h e i n i t i a l p r o j e c t , v a r i o u s a l t e r a t i o n s have been made i n t h e program w i t h t h e t i m e span r e d u c e d t o two y e a r s a n d , i n some c a s e s , one y e a r . T e c h n i q u e s o f i n s t r u c t i o n now i n c l u d e l e c t u r e s , p a n e l s , s m a l l group' d i s c u s s i o n s , and c l i n i c a l e x p e r i e n c e s . To f a c i l i t a t e t he a p p l i c a t i o n o f new l e a r n i n g s , each p a r t i c i p a n t s e l e c t s some a r e a o f work i n w h i c h she w i s h e s t o b r i n g about change w h i c h she u n d e r t a k e s as a take-home a s s i g n m e n t . These a r e d i s c u s s e d a t t h e i n i t i a l s e s s i o n and p r o g r e s s n o t e s r e v i e w e d a t subsequent s e s s i o n s , b o t h 234 i n d i v i d u a l l y and i n groups ( 6 8 ) . C o n t i n u i n g e v a l u a t i o n s have u t i l i z e d a v a r i e t y o f t e c h n i q u e s i n c l u d i n g o b s e r v a t i o n s o f s i m u l a t e d n u r s e - p a t i e n t s i t u -a t i o n s , a n a l y s i s o f p r o c e s s r e c o r d i n g s and d i a r i e s , r a t i n g a c h i e v e m e n t o f c o u r s e o b j e c t i v e s , s a t i s f a c t i o n r a t i n g s s u c h as t h e K r o p p - V e r n e r s c a l e , and F i r o - B , w h i c h i s a measure o f group c o m p a t a b i l i t y ( 3 1 ) . T h i s program d e s i g n i s w i d e l y used i n c o n t i n u i n g n u r s i n g e d u c a t i o n . Most o f t h e programs r e v i e w e d o r m e n t i o n e d i n t h i s s e c t i o n a r e r e p l i c a s o r m o d i f i c a t i o n s o f t h e o r i g i n a l WCHEN model-. D e s p i t e i t s s u c c e s s f u l a p p l i c a t i o n , and t h e h i g h r e g a r d w i t h w h i c h t h e WCHEN l e a d e r s h i p programs a r e v i e w e d , s u c c e s s has been d i f f i c u l t t o measure i n terms o f b e h a v i o r a l change. . Between 1962 and 1964, e i g h t WCHEN programs were o b j e c t i v e l y e v a l u a t e d u s i n g a v a r i e t y of p a p e r and p e n c i l t e s t s , s c a l e d r a t i n g s o f o b s e r v e d n u r s e - p a t i e n t s i t u a t i o n s , and employer-employee r a t i n g s on the j o b . F o u r hundred and t e n c o u r s e p a r t i c i p a n t s and 450 n o n - c o u r s e p a r t i c i -p a n t s were examined on t h e i r b e f o r e and a f t e r i n t e r p e r s o n a l r e l a t i o n s h i p s as w e l l as o t h e r changes i n b e h a v i o r . A l t h o u g h t h e e v a l u a t i o n f o u n d t h a t t h e c o u r s e s i g n i f i c a n t l y i n f l u e n c e d p a r t i c i p a n t a t t i t u d e s and b e l i e f s , no f i r m c o n c l u s i o n s c o u l d be drawn w i t h r e s p e c t t o a c t u a l changes i n b e h a v i o r ( 6 0 ) . An e a r l i e r , a l b e i t l e s s w e l l d e s i g n e d s t u d y by Todd (110) d i s c l o s e d s i m i l a r f i n d i n g s . U s i n g t h e WCHEN p a t t e r n , t h e Texas League o f N u r s i n g s p o n s o r e d a s i m i l a r s e r i e s o f r e g i o n a l c o n f e r e n c e s f o r management p e r s o n n e l between 1960 and 1964. An e v a l u a t i o n o f t h i s s e r i e s r e v e a l e d f i n d i n g s c o n s i s t e n t w i t h t h o s e o f t h e WCHEN s t u d i e s . I n b r i e f , a l t h o u g h t h e p a r t i c i p a n t s a p p e a r e d t o adopt a more d e m o c r a t i c and u n d e r s t a n d i n g a t t i t u d e , t h e r e was l i t t l e c o n c l u s i v e e v i d e n c e t o s u g g e s t a change i n j o b p e r f o r m a n c e ( 7 2 ) . Commenting on t h e WCHEN f i n d i n g s , I n g m i r e (60) r a i s e s a number o f c r u c i a l q u e s t i o n s : 235 How can t h e q u a l i t y o f n u r s i n g c a r e be measured? What o t h e r i n s t r u m e n t s c a n be d e v e l o p e d t o measure n u r s e b e h a v i o u r s i n t h e work s e t t i n g ? How can p a r t i c i p a n t s f o r f u t u r e programs be s e l e c t e d who have t h e g r e a t e s t p o t e n t i a l f o r p e r s o n a l growth? How can t h e p a r t i c i p a n t s ' l e a r n i n g s be e x t e n d e d i n t o i n s t i t u t i o n a l s ystems more e f f e c t i v e l y ? How can i n s t i t u t i o n a l a d m i n i s t r a t o r s and c o l l e a g u e s o f r e l a t e d d i s c i p l i n e s be more c l o s e l y i n v o l v e d i n t h i s o r s i m i l a r programs? I n an e f f o r t t o t a c k l e the m u l t i - f a c e t e d p r o b l e m o f t h e i n s t i t u t i o n a l c l i m a t e , I n g m i r e and h e r c o l l e a g u e s a t t h e U n i v e r s i t y o f C a l i f o r n i a have e x t e n d e d t h e WCHEN l e a d e r s h i p f o c u s t o many o f t h e i r c o n t i n u i n g e d u c a t i o n p rograms. I n g m i r e and B l a n s f i e l d (59) have r e c e n t l y d e s c r i b e d one s u c h program i n w h i c h h o s p i t a l a d m i n i s t r a t o r s , d i r e c t o r s o f n u r s i n g , and deans o f s c h o o l s o f n u r s i n g e n r o l l e d as teams \" t o l e a r n new and r e v i s e d t h e o r i e s o f team b u i l d i n g and t o c o n s i d e r ways i n w h i c h t h e s e t h e o r i e s c o u l d be a p p l i e d i n t h e back-home s e t t i n g . \" The program c o n s i s t e d o f t h r e e day c o n f e r e n c e s m e e t i n g t h r e e t i m e s o v e r a one y e a r p e r i o d , w h i c h p r o v i d e d t h e teams an o p p o r t u n i t y t o u t i l i z e and r e i n f o r c e c o n f e r e n c e l e a r n i n g s . The t r a i n i n g l a b o r a t o r y o r \"T\" group a p p r o a c h was u s e d w i t h t h e o r e t i c a l m a t e r i a l p r e s e n t e d as needed b u t m a i n l y t o p r o v i d e a f o c u s f o r d i s c u s s i o n and i n t e r a c t i o n among p a r t i c i p a n t s . An e v a l u a t i o n o f t h e program was c o n d u c t e d i n two ways: 1) p a r t i c i p a n t s ' p e r c e p t i o n s o f change i n t h e m s e l v e s and i n t h e i r r e l a t i o n s h i p s w i t h o t h e r s ; and 2) f a c u l t y ' s p e r c e p t i o n s o f change i n t h e p a r t i c i p a n t s ' method o f i n t e r a c t i n g d u r i n g t h e c o u r s e o f t h e s e s s i o n s . Of t h e 39 p a r t i c i p a n t s who c o m p l e t e d t h e f i r s t s e r i e s o f c o n f e r e n c e s , 27 r e s p o n d e d t o a q u e s t i o n n a i r e and t h e most f r e q u e n t l y r e p o r t e d b e h a v i o r a l changes were i n c r e a s e d u n d e r s t a n d i n g of them-s e l v e s and o t h e r s , and more open r e l a t i o n s h i p s . Of t h e r e p o r t e d changes i n o r g a n i z a t i o n and management p r o c e s s e s , i m p r o v e d m e e t i n g s was m e n t i o n e d most o f t e n . The most t a n g i b l e e v i d e n c e o f t h e s u c c e s s o f t h e c o u r s e was t h e p a r t i -c i p a n t s ' r e q u e s t f o r an advanced t r a i n i n g l a b o r a t o r y w h i c h has s u b s e q u e n t l y 236 been implemented w i t h h i g h e n r o l l m e n t r e p o r t e d . Brown (16) has r e p o r t e d a t h r e e y e a r p i l o t p r o j e c t i n w h i c h teams o f i n s t r u c t o r s and s u p e r v i s o r s were e n r o l l e d f o r a c o u r s e on c a n c e r n u r s i n g . C o - s p o n s o r e d by t h e S o u t h e r n R e g i o n a l E d u c a t i o n B o a r d (SREB) and t h e U n i v e r s i t y o f T e x a s , t h i s c o u r s e c o n s i s t e d o f t h r e e c o n f e r e n c e s e s s i o n s e x t e n d i n g o v e r a one y e a r p e r i o d . The major emphasis was on t h e n u r s i n g c a r e o f p a t i e n t s and f a m i l i e s . The s e s s i o n s a l s o s t r e s s e d and d e m o n s t r a t e d t h e m u l t i - d i s c i p l i n a r y a p p r o a c h . One o f t h e m a j o r t a k e home p r o j e c t s was t h e development o f a p l a n f o r e x t e n d i n g t h e knowledge and s k i l l s p a r t i c i p a n t s had a c q u i r e d t o o t h e r n u r s e s i n t h e back home s e t t i n g . A l t h o u g h w e l l c o n c e i v e d , Brown r e p o r t s t h a t many d i f f i c u l t i e s ensued i n t h e i m p l e m e n t a t i o n o f t h e program. Because t h i s t y p e o f an e d u c a t i o n a l e x p e r i e n c e was so new t o most o f t h e p a r t i c i p a n t s , and bec a u s e t h e y had such v a r i e d b a c k g r o u n d s , i n s t r u c t i o n had t o be p r o v i d e d on an i n d i v i d u a l b a s i s f r e q u e n t l y . The g r e a t e s t p r o b l e m r e l a t e d t o t h o s e a s s i g n m e n t s r e q u i r i n g p a r t i c i p a n t s t o engage i n d i r e c t n u r s i n g c a r e . B o t h t h e i n s t r u c t o r and s u p e r -v i s o r p a r t i c i p a n t s were found t o be p s y c h o l o g i c a l l y i n s e c u r e and r e l u c t a n t t o communicate w i t h p a t i e n t s and f a m i l i e s . T r u s c o t t and K e l l e r (112) have d e s c r i b e d an i n t e r d i s c i p l i n a r y program i n u s e i n t h e N o r t h C a r o l i n a RMP s t r o k e program. T h i s f o u r day c o u r s e i s o f f e r e d i n two day u n i t s w i t h a week i n between. C o n t e n t i d e n t i f i e d as p e r t i n e n t t o a l l p a r t i c i p a n t s , p h y s i c i a n s , n u r s e s , p h y s i c a l t h e r a p i s t s , s p e e ch t h e r a p i s t s , o c c u p a t i o n a l t h e r a p i s t s , and m e d i c a l s o c i a l w o r k e r s , i s p r e s e n t e d t h r o u g h j o i n t s e s s i o n . I n s t r u c t i o n i n c l u d e s l e c t u r e s and d i s c u s s i o n s s u pplemented by s l i d e s , f i l m s and f i l m s t r i p s . A l s o p r o v i d e d i s a l o o s e - l e a f n o t e b o o k w i t h r e v i e w n o t e s p e r t i n e n t t o each d i s c i p l i n e . F o u r su c h c o u r s e s have been c o m p l e t e d w i t h an a t t e n d a n c e o f 154 p r o f e s s i o n a l h e a l t h w o r k e r s . As a r e s u l t o f t h i s e x p e r i m e n t 237 i t i s f e l t t h a t t h e b a s i c c o r e c o n t e n t has been i d e n t i f i e d and t h a t t h e p a r t i -c i p a n t s a r e d e v e l o p i n g a b e t t e r u n d e r s t a n d i n g o f t h e meaning o f r e h a b i l i t a t i o n and t h e i r i n t e r r e l a t e d r o l e s i n t h e management o f t h e s t r o k e p a t i e n t . T r u s c o t t and K e l l e r (112) r e p o r t e d t h a t g r e a t gaps were f o u n d t o e x i s t i n t h e p a r t i c i p a n t s ' knowledge o f 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 w h i c h posed a r e a l p r o b l e m as d i d t h e a s s o c i a t e d u n l e a r n i n g w h i c h was n e c e s s a r y i n some i n s t a n c e s . A l t h o u g h p a r t i c i p a n t s were i d e n t i f i e d as a \" s t r o k e team,\" t h e team c o n c e p t as an a p p r o a c h t o c a r e was o f t e n n o t u n d e r s t o o d o r im p l e m e n t e d . I n j o i n t s e s s i o n s , p h y s i c i a n s were r e p o r t e d h e s i t a n t t o a s k q u e s t i o n s b e c a u s e n u r s e s were p r e s e n t , and n u r s e s were e q u a l l y r e l u c t a n t t o expose gaps i n t h e i r k n o w ledge. Some p a r t i c i p a n t s were f a c i l i t y r a t h e r t h a n d i s c i p l i n e o r i e n t e d i n t h a t t h e i r i n t e r e s t i n s t r o k e p a t i e n t c a r e was l i m i t e d t o i t s a p p l i c a t i o n i n t h e i r own p a r t i c u l a r t y p e o f f a c i l i t y . Thus p u b l i c h e a l t h n u r s e s were n o t i n t e r e s t e d i n a c u t e n u r s i n g c a r e and n u r s e s employed i n a c u t e h o s p i t a l s were n o t i n t e r e s t e d i n t h e community a s p e c t s . S i m i l a r l y , p a r t i c i p a n t s f r o m s m a l l r u r a l c o m m u n i t i e s were n o t i n t e r e s t e d i n h e a r i n g o r d i s c u s s i n g f a c i l i t i e s w h i c h were n o t a v a i l a b l e i n t h e i r own home s e t t i n g s . G e n e r a l l y s p e a k i n g , \" H e a l t h p r a c t i t i o n e r s were more i n t e r e s t e d i n t h e \"how t o \" r a t h e r t h a n t h e \"why\" o r t h e p h i l o s o p h y o f c a r e . \" I n a r e c e n t a r t i c l e , C o n l e y and L a r s o n (24) r e p o r t t h a t t h e C o l o r a d o RMP and t h e S c h o o l o f N u r s i n g a r e o f f e r i n g an i n d e r d i s c i p l i n a r y c o u r s e i n R e h a b i l i t a t i o n and M a i n t e n a n c e . T h i s program i s i n t e n d e d t o d e v e l o p s k i l l s needed f o r \" p o s t c r i s i s \" p a t i e n t s and i t i s o f f e r e d i n s m a l l r u r a l c o m m u n i t i e s t h r o u g h o u t t h e r e g i o n . . L o c a l p l a n n i n g c o m m i t t e e s composed o f r e p r e s e n t a t i v e s f r o m n u r s i n g and t h e a l l i e d h e a l t h p r o f e s s i o n s i d e n t i f y e d u c a t i o n a l needs and d e v e l o p t h e program w i t h t h e a s s i s t a n c e o f u n i v e r s i t y f a c u l t y . L o c a l h e a l t h p e r s o n n e l a r e u t i l i z e d as i n s t r u c t o r s w i t h t h e u n i v e r s i t y p r o v i d i n g a s s i s t a n c e 238 as n e c e s s a r y . The c o u r s e i s h i g h l y i n d i v i d u a l i z e d i n terms o f l o c a l needs and t h e needs o f p a r t i c i p a n t s as w e l l . S c h e d u l e d on an i n t e r m i t t e n t b a s i s , t h e program c o n s i s t s o f t h r e e 3-day c o n f e r e n c e s e s s i o n s . F o l l o w i n g t he i n i t i a l s e s s i o n , t h e p a r t i c i p a n t s e l e c t s a p a t i e n t f o r whom she d e v e l o p s a n u r s i n g c a r e p l a n . I n the p e r i o d between t h e second and t h i r d s e s s i o n s she i s as k e d t o d e v e l o p a t e a c h i n g program f o r h e r s e l e c t e d p a t i e n t . I n s t r u c t o r s p r o v i d e i n d i v i d u a l g u i d a n c e t o s t u d e n t s t h r o u g h o u t and each i s encouraged t o p r o c e e d a t he r own pace. C o n l e y and L a r s o n (24) a l s o r e p o r t t h a t t h e W e s t e r n P e n n s y l v a n i a RMP and t h e Gr a d u a t e S c h o o l o f P u b l i c H e a l t h a t t h e U n i v e r s i t y o f P i t t s b u r g h a r e c o n d u c t i n g a program f o r t h e l o n g term t r a i n i n g o f n u r s i n g home p e r s o n n e l , u s i n g b o t h u n i v e r s i t y and i n - p a t i e n t f a c i l i t i e s . The c o u r s e c o n s i s t s o f w e e k l y s e s s i o n s l a s t i n g one day f o r a n i n e month p e r i o d . F o r m a l p r e s e n t a t i o n s a r e m i n i m i z e d i n p r e f e r e n c e t o p r o b l e m - s o l v i n g . Where p o s s i b l e a d m i n i s t r a t o r s and ch a r g e n u r s e s have c l a s s e s t o g e t h e r . F o l l o w i n g t h e c o m p l e t i o n o f t h e program t h e p a r t i c i p a n t s a r e p r o v i d e d w i t h c o n s u l t a t i o n s e r v i c e s by t h e f a c u l t y f o r a two y e a r p e r i o d . A c c o r d i n g t o C o n l e y and L a r s o n , t h e e f f e c t i v e n e s s o f t h i s c o u r s e i s d e m o n s t r a t e d i n t h e p a t i e n t c a r e f a c i l i t i e s t o w h i c h t h e g r a d u a t e s have r e t u r n e d . They c i t e new and improv e d n u r s i n g p r o c e d u r e s t h a t have been i n s t i t u t e d i n t h e home f a c i l i t i e s , t h e e s t a b l i s h m e n t o f p o s i t i o n s f o r b o t h a d i r e c t o r and an i n s e r v i c e e d u c a t o r ; j o b d e s c r i p t i o n s and p e r f o r m a n c e e v a l u a t i o n s f o r n u r s e s have been d e v e l o p e d , and i n s e r v i c e programs have been implemented i n a number o f f a c i l i t i e s . The MSRMP (Nevada) i s u s i n g a C o n s u l t i n g Team a p p r o a c h t o c o n t i n u i n g e d u c a t i o n f o r h e a l t h s e r v i c e p e r s o n n e l i n r u r a l c o m m u n i t i e s i n Nevada. The c o r e o f t h e c o n s u l t i n g team c o n s i s t s o f p h y s i c i a n s and n u r s e s w i t h o t h e r h e a l t h 239 p r o f e s s i o n s s e r v i n g as r e s o u r c e s where t h e i r s k i l l s a r e r e q u i r e d . A b i - m o n t h l y s c h e d u l e o f v i s i t s p r o v i d e s c o n s u l t i n g s e r v i c e t o l o c a l c o m m u n i t i e s . The program f o r each v i s i t i s based upon the i d e n t i f i e d needs o f t h e community and i s d e v e l o p e d c o - o p e r a t i v e l y w i t h t h e h e a l t h p e r s o n n e l i n each a r e a t o be v i s i t e d . Thus t h e team may p r o v i d e e i t h e r s t r u c t u r e d c o u r s e s o r u n s t r u c t u r e d c o n s u l t a t i o n d e p e n d i n g on t h e need. The e v e r i n c r e a s i n g demand f o r n u r s e s w i t h s p e c i a l i z e d s k i l l s i n i n t e n -s i v e c a r e n u r s i n g , and more p a r t i c u l a r l y , c o r o n a r y c a r e , has r e s u l t e d i n a g r e a t p r o l i f e r a t i o n o f s h o r t c o u r s e s i n t h i s a r e a o f n u r s i n g . Of t h e many program d e s c r i p t i o n s r e v i e w e d , t h e one s p o n s o r e d by t h e Colorado-Wyoming RMP and t h e U n i v e r s i t y o f C o l o r a d o S c h o o l o f N u r s i n g (114) i s 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 w e l l i n t e g r a t e d . S c h e d u l e d on an i n t e r m i t t e n t b a s i s , the i n i t i a l two week s e s s i o n c o n s i s t s o f l e c t u r e s , s e l f s t u d y , and p r a c t i c a l e x p e r i e n c e f o l l o w e d by a s i x week i n t e r i m i n t h e p a r t i c i p a n t ' s own work s e t t i n g . D u r i n g t h i s p e r i o d t h e t r a i n e e c o m p l e t e s a s p e c i a l a s s i g n m e n t \"which i n v o l v e s i d e n t i f y i n g a p r o b l e m i n h e r c l i n i c a l s e t t i n g about w h i c h she d e v e l o p s a r e s e a r c h - t y p e p r o j e c t d i r e c t e d t o w a r d a s o l u t i o n . \" The second two week i n - t r a i n i n g s e s s i o n p l a c e s c o n s i d e r a b l e emphasis on c l i n i c a l e x p e r i e n c e w h i c h i s l a r g e l y i n d i v i d u a l i z e d t o meet t h e i n d i v i d u a l ' s own p a r t i c u l a r employment n e e d s . The l a s t two days a r e d e v o t e d t o management and c o - o p e r a t i o n between h e a l t h p e r s o n n e l i n c l i n i c a l s e t t i n g s . F o r t h i s l a s t s e s s i o n , p a r t i c i p a n t s a r e encouraged t o i n v i t e d i r e c t o r s o f n u r s e s , h o s p i t a l b o a r d members, h o s p i t a l a d m i n i s t r a t o r s , o r o t h e r s o f h e r c h o i c e f r o m t h e home h o s p i t a l . T h e r e a f t e r , a one week f o l l o w up s e s s i o n e ach y e a r i s a v a i l a b l e t o e n s u r e t h e n e c e s s a r y u p d a t i n g o f i n f o r m a t i o n and an e v a l u a t i o n o f t h e program's e f f e c t i v e n e s s . C o n c u r r e n t l y , t h e U n i v e r s i t y o f C o l o r a d o i s o f f e r i n g a c o u r s e on t h e i n t e n s i v e n u r s i n g c a r e o f c h i l d r e n as a companion t o t h e c o u r s e on i n t e n s i v e c a r e o f a d u l t s . The s e s s i o n s a r e c o n d u c t e d t o g e t h e r 240 where t h e two c o u r s e s have m a t e r i a l i n common. I n a d d i t i o n t o the b e h a v i o r a l and p h y s i o l o g i c a l a s p e c t s o f n u r s i n g c a r e , t h i s c o u r s e emphasizes t h e n u r s e ' s r o l e w i t h t h e t o t a l f a m i l y group and t h e team a p p r o a c h t o p a t i e n t c a r e i n t h e i n t e n s i v e c a r e u n i t . \u00E2\u0080\u00A2 I n s e r v i c e E d u c a t i o n : D e l Buerno e_t aJL (33) d e s c r i b e d a s p e c i a l o r i e n t a t i o n u n i t w i t h i t s own i n s t r u c t o r and a head n u r s e p a r t i c u l a r l y r e s p o n s i v e t o t h e needs o f s t a f f a t t h e P r e s b y t e r i a n H o s p i t a l i n New Y o r k . New s t a f f members a r e r o t a t e d t h r o u g h t h i s u n i t t o r e c e i v e n e c e s s a r y i n s t r u c t i o n and e x p e r i e n c e on a l l t h r e e s h i f t s under t h e g u i d a n c e o f an i n s t r u c t o r o r c h a r g e n u r s e . A l t h o u g h i t i s t o o e a r l y t o e v a l u a t e t h e o v e r a l l e f f e c t s o f t h i s p l a n , i t i s t h o u g h t t h a t t h i s program w i l l h e l p u l t i m a t e l y i n d e c r e a s i n g t h e h i g h t u r n o v e r r a t e o f n u r s i n g s t a f f . A t P e t e r Bigham H o s p i t a l i n B o s t o n ( 1 0 3 ) , n u r s e s w i t h l e s s t h a n s i x months e x p e r i e n c e a r e b e i n g r o t a t e d t h r o u g h two c l i n i c a l s p e c i a l t i e s f o l l o w i n g a s i x month p e r i o d i n m e d i c a l s u r g i c a l n u r s i n g . Programs o f i n s e r v i c e e d u c a t i o n a r e p r o v i d e d c o n c u r r e n t l y w i t h t h e s e new e x p e r i e n c e s . I n s p i t e o f t h e d i f f i c u l t i e s i n i m p l e m e n t i n g s u c h an a m b i t i o u s p l a n , t h e a d v a n t a g e s a r e f e l t t o be: 1) t h e n u r s e r e c e i v e d a y e a r o f p l a n n e d e x p e r i e n c e s d u r i n g w h i c h t i m e .she has t h e o p p o r t u n i t y t o c o n s o l i d a t e h e r m e d i c a l s u r g i c a l n u r s i n g s k i l l s and t o sample two k i n d s o f s p e c i a l i z e d n u r s i n g ; 2) t h e r e i s e v i d e n c e o f i n c r e a s e d m o r a l e among t h e n u r s e s ; and 3) n u r s e s a r e a v a i l a b l e t o r e l i e v e i n . s p e c i a l t i e s when n e c e s s a r y . A t t h e U n i v e r s i t y o f R o c h e s t e r ' s S t r o n g M e m o r i a l H o s p i t a l ( 7 0 ) , i n s t r u c t o r s have been a s s i g n e d t o each o f t h e m a j o r c l i n i c a l s e r v i c e s w h i c h has made p o s s i b l e u n i t based c l i n i c a l l y o r i e n t e d i n s e r v i c e e d u c a t i o n and more i n d i v i d u a l i z e d o r i e n t a t i o n programs. On t h e f i r s t day e a c h newcomer c o m p l e t e s 2 4 1 a q u e s t i o n n a i r e w h i c h a s k s about p a s t e x p e r i e n c e s and f e l t l e a r n i n g n e eds. Through an a n a l y s i s o f t h e i n f o r m a t i o n g l e a n e d f r o m t h e s u r v e y an i n d i v i d u a l -i z e d c l i n i c a l o r i e n t a t i o n i s t h e n p r o v i d e d as p a r t o f t h e o v e r a l l program. W i l k i n s o n (121) has r e p o r t e d an e x p e r i m e n t i n o r i e n t a t i o n a t t h e L a n g l e y P o r t e r N e u r o p s y c h i a t r i c I n s t i t u t e o f t h e U n i v e r s i t y o f C a l i f o r n i a i n w h i c h new p s y c h i a t r i c n u r s e s engage i n s e l f - o r i e n t a t i o n . I n t h i s e x p e r i m e n t a l p r o j e c t , t h e e n v i r o n m e n t was s t r u c t u r e d t o make a v a i l a b l e s e l e c t e d l e a r n i n g o p p o r t u n i t i e s and t h e n u r s e s were i n f o r m e d about them b u t no a t t e m p t was made f o r s t r u c t u r e d l e a r n i n g a c t i v i t i e s . The o n l y s p e c i f i c r e q u e s t s made o f t h e new s t a f f member was t h a t t h e y t a p e a r e p o r t a t t h e end o f each day w h i c h was a resume o f t h e day's a c t i v i t i e s , and t h e y were a s k e d t o i n f o r m t h e s c h o o l when t h e y t e r m i n a t e d t h i s s e l f o r i e n t a t i o n . F i n d i n g s r e v e a l e d t h a t t h e o r i e n t a t i o n was h i g h l y i n d i v i d u a l , w i t h no two n u r s e s p r o c e e d i n g i n t h e same manner y e t a l l o f them i n v o l v e d t h e m s e l v e s i n t h o s e a c t i v i t i e s w h i c h they c o n s i d e r e d s i g n i f i c a n t t o t h e i r o r i e n t a t i o n . From t h e t a p e r e c o r d i n g s i t was a p p a r e n t t h a t as t h e days p r o g r e s s e d , t h e n u r s e s became i n c r e a s i n g l y aware o f what t h e y must l e a r n i n o r d e r t o f u n c t i o n as w e l l as o t h e r s . T h i s p r o c e d u r e was i d e n t i f i e d as t h e \" s e l f i d e n t i f i c a t i o n o f c o n t i n u i n g l e a r n i n g n e e d s . \" A t t h e Loeb C e n t e r f o r N u r s i n g and R e h a b i l i t a t i o n i n M o n t e f i o r e , New Y o r k (3), t h e new n u r s e i s a s s i g n e d d i r e c t l y t o t h e u n i t t o work w i t h a s t a f f member who i s t h u s a v a i l a b l e t o h e r f o r h e l p as she i d e n t i f i e s a need o r e x p r e s s e s an i n t e r e s t . O p p o r t u n i t i e s f o r c o n f e r e n c e a r e a l s o a v a i l a b l e where she may r e c e i v e c l a r i f i c a t i o n on m a t t e r s o f p o l i c y and/or p r o c e d u r e s . Through t h i s program t h e newcomer i s encouraged t o i d e n t i f y h e r own need f o r h e l p and i s g i v e n t h e t i m e t o p l a n h e r own o r i e n t a t i o n . The i n s e r v i c e e d u c a t i o n program a t t h e Loeb C e n t e r i s p r o b a b l y one o f t h e b e s t examples o f how c o n t i n u i n g 242 n u r s i n g e d u c a t i o n can be b u i l t i n t o day t o day p r a c t i c e . S t a f f c o n f e r e n c e s s c h e d u l e d once a week f o r a l l n u r s e s i n v o l v e d i n t h e program p r o v i d e o p p o r t u n i t i e s f o r group d i s c u s s i o n s about ways t o f a c i l i t a t e c a r e and t o c l a r i f y v a r y i n g t y p e s o f pr o b l e m s w h i c h n u r s e s i d e n t i f y as i n t e r f e r i n g w i t h t h e i r work w i t h p a t i e n t s . U n i t c o n f e r e n c e s a r e h e l d as t h e need a r i s e s and n u r s e t o n u r s e r e p o r t s f r o m day t o e v e n i n g s h i f t s a r e d e s c r i b e d as \" c o n f e r r i n g , p l a n n i n g s e s s i o n s , \" r a t h e r t h a n t h e u s u a l r e c i t a t i o n o f a c t i v i t i e s . R e g u l a r l y p l a n n e d c o n f e r e n c e s and t e a c h i n g on t h e wards a l s o t y p i f y much o f t h e i n s e r v i c e e d u c a t i o n a t Rancho Los Amigos R e h a b i l i t a t i o n C e n t e r i n Los A n g e l e s ( 1 6 ) . I n a d d i t i o n , workshops on r e h a b i l i t a t i o n n u r s i n g a r e a l s o s c h e d u l e d r e g u l a r l y . These c o u r s e s a r e a v a i l a b l e t o n u r s e s f r o m g e n e r a l h o s p i t a l s , s p e c i a l l o n g term h o s p i t a l s , n u r s i n g homes, v i s i t i n g n u r s e s a s s o c i a t i o n s , and p u b l i c h e a l t h a g e n c i e s , as w e l l as t h e s t a f f a t Rancho Los Amigos. I n t e r d i s c i p -l i n a r y i n a p p r o a c h , some o f t h e s e s s i o n s i n c l u d e s e l e c t e d p a t i e n t s who p r e s e n t p e r t i n e n t a s p e c t s o f t h e i r c a s e h i s t o r i e s and d i s c u s s t h e i r p e r c e p t i o n s o f t h e t r e a t m e n t p r o c e s s . Of t h e g r o w i n g number o f programs p r e p a r i n g p e d i a t r i c n u r s e s , t h e one a t Bunker H i l l H e a l t h C e n t e r i n M a s s a c h u s e t t s (11) b e s t f i t s t h e d e f i n i 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 used i n t h i s r e p o r t , hence a d e s c r i p t i o n o f t h i s program i s p r o v i d e d as an example o f an i n n o v a t i v e program d e s i g n e d t o expand t h e r o l e o f t h e n u r s e . I n 1968 a s i x t e e n week program was s t a r t e d w h i c h a l l o w e d a n u r s e t o c o n t i n u e h e r r e g u l a r s c h e d u l e b u t w i t h a minimum o f one and a h a l f days p e r week r e l e a s e t i m e f o r t h e d u r a t i o n o f t h e c o u r s e . A d m i s s i o n r e q u i r e m e n t s were: 1) t h a t t h e n u r s e t r a i n e e a l r e a d y h o l d a j o b o r have p r o m i s e o f a j o b w i t h a p r a c t i t i o n e r who p r o v i d e d p e d i a t r i c c a r e f o r a l l c h i l d r e n i n t h e f a m i l y ; 2) each t r a i n e e be g u a r a n t e e d t h e o p p o r t u n i t y by h e r employee t o f u n c t i o n i n an expanded 243 r o l e i n h e r work s e t t i n g ; 3) on t h e j o b t r a i n i n g be p r o v i d e d by a q u a l i f i e d p e d i a t r i c i a n d u r i n g t h e c o u r s e ; and 4) o p p o r t u n i t y f o r on t h e j o b t r a i n i n g be a s s u r e d f o l l o w i n g c o m p l e t i o n o f t h e program. No s p e c i a l e d u c a t i o n a l q u a l i f i c a t i o n s were r e q u i r e d o t h e r t h a n s u c c e s s f u l g r a d u a t i o n f r o m an a c c r e d i t e d s c h o o l o f n u r s i n g . The c o u r s e was d i v i d e d i n t o 94 h o u r s o f c l a s s r o o m i n s t r u c t i o n , and 96 h o u r s o f c l i n i c a l p r a c t i c e i n a v a r i e t y o f i n - p a t i e n t and p e d i a t r i c a m b u l a t o r y s e t t i n g s . C l i n i c a l p r a c t i c e a l s o i n c l u d e d s p e c i a l l y a r r a n g e d e x p e r i e n c e s i n t h e n u r s e ' s own work s e t t i n g under t h e p r e c e p t o r s h i p o f t h e p e d i a t r i c i a n and t h e s u p e r v i s i o n o f t h e C e n t e r ' s n u r s i n g f a c u l t y . Through s e m i n a r s a n d ' i n d i v i d u a l s u p e r v i s i o n , t h e f o l l o w i n g f a c t o r s were e m p h a s i z e d : 1) t h e d e c i s i o n - m a k i n g p r o c e s s ; 2) c o n f l i c t and a n x i e t y i n r o l e r e - o r i e n t a t i o n ; 3) team work and i n t e r -p e r s o n a l r e l a t i o n s h i p s ; and 4) t h e p r o b l e m s o f d e l i v e r y o f h e a l t h s e r v i c e s t o c h i l d r e n and t h e i r f a m i l i e s . S i n c e t h e f i r s t two c o u r s e s were c o n s i d e r e d e x p e r i m e n t a l , no a t t e m p t \"was made t o make an o b j e c t i v e e v a l u a t i o n , however, c e r t a i n p e r s o n a l - p r o f e s s i o n a l c h a r a c t e r i s t i c s were t a b u l a t e d . T h i s d i s c l o s e d t h a t r o u g h l y one h a l f o f t h e p a r t i c i p a n t s had a d i p l o m a , a p p r o x i m a t e l y one t h i r d a b a c c a l a u r e a t e , and f i v e had a m a s t e r ' s d e g r e e . About one h a l f had had no p r i o r p e d i a t r i c o r p u b l i c h e a l t h n u r s i n g e x p e r i e n c e , and most o f t h e r e s t had l e s s t h a n f i v e y e a r s e x p e r i e n c e i n e i t h e r f i e l d . I n s h o r t , t h e y were a r e l a t i v e l y i n e x p e r i e n c e d and y o u t h f u l g r o u p . C o n c e r n i n g t h e s e d a t a , t h e a u t h o r s n o t e : \" I n o u r e x p e r i e n c e n u r s i n g e d u c a t i o n b a c k g r o u n d has had no r e l a t i o n s h i p w h a t s o e v e r t o s u c c e s s f u l and s a t i s f y i n g f u n c t i o n i n t h e r o l e o f p e d i a t r i c n u r s e p r a c t i t i o n e r . The same can be s a i d o f age, m a r i t a l s t a t u s , and number o f c h i l d r e n . \" They do p o i n t o u t t h a t c e r t a i n a r e a s o f c o n t e n t were weak, n o t a b l y c h i l d g r o w t h and development and knowledge 244 o f common p e d i a t r i c p r o b l e m s . They a l s o f e l t t h a t more t i m e was r e q u i r e d f o r the n u r s e s t o work t h r o u g h t h e p r o b l e m o f c o n f l i c t and a n x i e t y r e l a t e d t o r o l e r e - o r i e n t a t i o n . T h i s program has r e c e n t l y become a s s o c i a t e d w i t h N o r t h E a s t e r n U n i v e r s i t y , w h i c h , a c c o r d i n g t o Brown (16) \" s h o u l d p r o v i d e t h e d e p t h r e q u i r e d t o d e v e l o p t h e k i n d o f l e a d e r s h i p needed t o change t h e h e a l t h c a r e s y s t e m . \" Mass M e d i a and S e l f I n s t r u c t i o n a l Methods: S i n c e t h e c o m p l e t i o n o f t h e s t a t e w i d e e d u c a t i o n a l t e l e v i s i o n n e t w o r k i n K e n t u c k y , a l o n g w i t h t h e o t h e r h e a l t h p r o f e s s i o n s , n u r s i n g has been p r e s e n t i n g programs on PANMED, an i n t e r p r o f e s s i o n a l t e l e v i s i o n s e r i e s . From November 1969 t o November 1970, n u r s i n g p r e s e n t e d e i g h t programs i n t h i s s e r i e s . A s u r v e y -(14) b a s e d on 587 q u e s t i o n n a i r e r e s p o n s e s (66 p e r c e n t o f t h e r e g i s t e r e d n u r s e s i n K e n t u c k y ) d i s c l o s e d t h a t t h e m a j o r i t y o f n u r s e s w a t c h i n g t h e s e r i e s were young g r a d u a t e s f r o m d i p l o m a programs w o r k i n g g e n e r a l d u t y i n h o s p i t a l s . The o v e r a l l r e a c t i o n t o the programs was f a v o u r a b l e . ; w i t h many r e s p o n d e n t s i n d i c a t i n g t h a t t h e y f e l t PANMED programs c o u l d be used by n u r s e s t o c o n t i n u e t h e i r e d u c a t i o n . The m a j o r c r i t i c i s m o f t h e s e r i e s was a l a c k o f knowledge about t h e program. More s p e c i f i c a l l y , 174 o f t h o s e who d i d n o t w a t c h any o f t h e s e r i e s i n d i c a t e d t h a t t h e y d i d n o t know i t was t o be shown, and a n o t h e r 33 \" t h o u g h t i t was a r e f r e s h e r c o u r s e f o r n u r s e s . \" The second m a j o r c o m p l a i n t e x p r e s s e d by t h o s e who watched was t h a t t h e r e c e p t i o n was p o o r , w i t h 98 r e p o r t i n g t h a t t h e y were u n a b l e t o g e t t h e s e r i e s . On t h e b a s i s o f t h e s e f i n d i n g s , i t was recommended t h a t t h e s e r i e s be c o n t i n u e d , b u t t h a t some method f o r e v a l u a t i n g i t s e f f e c t i v e n e s s be i n s t i t u t e d . I t was a l s o recommended t h a t t h e s e r i e s be a d v e r t i s e d b e t t e r , and t h a t i t be shown a t an e a r l i e r t i m e . I t was f u r t h e r s u g g e s t e d t h a t t h e programs be made a v a i l a b l e t h r o u g h c l o s e d c i r c u i t t e l e v i s i o n i n t h e p u b l i c c o l l e g e s ; \"These c o u l d t h e n 245 s e r v e as c e n t e r s f o r f e e d b a c k and e v a l u a t i o n o f some o f t h e programs o f f e r e d . \" Abbey e_t a l _ (1) r e p o r t e d an e x p e r i m e n t u s i n g open c i r c u i t t e l e v i s i o n i n w h i c h t h e y sought t o d e t e r m i n e whether n u r s e s g a i n e d more f r o m a b r o a d c a s t v i e w e d i n d i v i d u a l l y a t home o r fr o m one v i e w e d w i t h a group o f c o l l e a g u e s i n a h o s p i t a l c o n f e r e n c e room. They a l s o a t t e m p t e d t o i d e n t i f y t h o s e c o n d i t i o n s w h i c h enhanced l e a r n i n g compared w i t h c o n v e n t i o n a l b r o a d c a s t s w h i c h r e q u i r e no a c t i v e p a r t i c i p a t i o n . I n t h i s e x p e r i m e n t , t h r e e r e s p o n s e c o n d i t i o n s were u s e d : 1) the. c o n t r o l c o n d i t i o n o r c o n v e n t i o n a l b r o a d c a s t p r e s e n t a t i o n ; 2) e x p e r i m e n t a l c o n d i t i o n s c o n s i s t i n g o f a \" c o v e r t \" p r e s e n t a t i o n i n w h i c h q u e s t i o n s were i n s e r t e d i n t o t h e b r o a d c a s t w i t h s t u d e n t s e n c o u r a g e d t o t h i n k o f t h e answers f o r t h e m s e l v e and 3) an \" o v e r t \" c o n d i t i o n i n w h i c h t h e s t u d e n t s were rewarded f o r making a w r i t t e n r e s p o n s e t o t h e q u e s t i o n s by b e i n g p r o v i d e d w i t h knowledge o f r e s u l t s by \u00E2\u0080\u00A2 r e t u r n m a i l . P a r t i c i p a n t s i n c l u d e d 120 g e n e r a l s t a f f n u r s e s drawn f r o m e a c h o f t h r e e g e o g r a p h i c a l l y s e p a r a t e d c i t i e s w h i c h p a r t i c i p a t e d i n t h e s t u d y . I n each c i t y , 20 r e s p o n d e n t s v i e w e d t h e o f f e r i n g s i n d i v i d u a l l y a t home, and 20 d i d so i n a group s e t t i n g . The program was s p o n s o r e d by t h e U n i v e r s i t y o f C a l i f o r n i a S c h o o l o f N u r s i n g as a t u i t i o n c o u r s e w h i c h c a r r i e d a c e r t i f i c a t e o f c o m p l e t i o n . L e a r n i n g a c h i e v e m e n t was measured by a s i x t y i t e m m u l t i p l e c h o i c e t e s t , w h i l e a t t e n d a n c e was measured i n two ways: 1) s u b j e c t s who c o m p l e t e d t h e c o u r s e i n d i c a t e d on a s p e c i a l form w h i c h programs t h e y had v i e w e d ; and 2) a c t u a l a t t e n d a n c e o f s u b j e c t s i n t h e h o s p i t a l s e t t i n g was r e c o r d e d f o r each b r o a d c a s t . The f i n d i n g s r e v e a l 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 r e g u l a r i t y o f v i e w i n g and c o m p l e t i o n o f t h e c o u r s e a c c o r d i n g t o p r e s e n t a t i o n r e s p o n s e c o n d i t i o n s . A l t h o u g h t h e r e s u l t s on t h e p r e s e n t a t i o n r e s p o n s e c o n d i t i o n s were s t a t i s t i c a l l y i n c o n c l u s i v e as measured by t e s t r e s u l t s , home v i e w i n g was f o u n d s u p e r i o r t o group v i e w i n g as measured 246 by learning achievement. The report concludes: If only group viewing at central location were effective, broadcast television would have limited instructional potential. The findings of this study indicate, however, that through home viewing, broadcast television has the potential to serve a l l health science professionals, including those in which members spend their working day separated from each other.\" For the past several years the University of California School of Nursing i n Los Angeles has been offering televized programs via the scrambled network system. The series i s presented on the Medical Television Network to , 70 member hospitals. Nurse co-ordinators in each of the hospitals are assigned responsibility for publicizing the programs, organizing the viewing f a c i l i t i e s and introducing and conducting a fifteen to twenty minute.discussion following the program. Approximately 13,000 nurses and members of other health disciplines are reported to have viewed the series. The programs are patient centered and frequently have used actual patients as well as health personnel with emphasis on demonstration. Squaires (106) identified the major problems.encountered in the f i r s t five years of the program: 1) poor selection of program chairman; 2) too much content; 3) not enough depth in content; 3) no permanent staff; 4) no money for implementing programs as part of the continuum of continuing education offerings. She also reports that portable equipment i s being taken into the f i e l d for li v e conferences and that this approach has been found effective in developing counselling inter-viewing techniques. The Ohio State University School of Nursing and the Department of Nursing Services of the-Ohio State University Hospitals (80) are broadcasting two-way radio telephone programs to 48 of the state hospitals to enable scattered audiences to participate in programs of continuing nursing education. Attendance 247 is reported to have increased from some 2,000 during the pi l o t project in 1966 to over 10,500 for the 1969-70 series. The programs consist of a lecture or panel presentation followed by questions and comments from the participating hospitals through their moderators. Each hospital is furnished a quantity of printed outlines and a set of 2 x 2 slides which are used in conjunction with the presentations. \"Interest and enthusiasm\" for the program i s said to be a motivating factor in the continu-ation and expansion of the series. In 1966 the University of Wisconsin (52) initiated the f i r s t statewide telephone conference for nurses. Fashioned after the telelectures developed for continuing medical education, this series was offered as a lecture followed by a question and answer period. The 12 classes presented weekly were received at 24 centers located in various c l i n i c s and hospitals throughout the state. Coordinators assumed responsibility for showing accompanying slides and serving as moderators. Since the original series, improvements in technology have made possible simultaneous transmission on FM radio. There are presently 56 telephone listening posts, and 27 radio listening posts,with about 1000 Wisconsin nurses participating in this weekly series. On the basis of a 20 percent return (N=209) of evaluations for the 1967-68 series, Hornback (92) reported: 1) the majority of the participants were currently employed in nursing; 2) for approximately one half of the res-pondents the telephone conferences comprised the f i r s t continuing education program attended; 3) most respondents f e l t satisfied with the programs but many thought that there were too many. Since 1969 a special radio-telephone series has been offered for inactive nurses in order to help them keep up to date on general nursing know-ledge. Funded by the Wisconsin RMP, this series is but one facet of the Wisconsin 248 Inactive Nurse Service (WINS). Another i s a project in which independent study guides are being developed on a number of topics requested by inactive nurses (2). Yet another innovation pioneered by medicine and which nursing now shares i s the dia l access library (77) . Nursing Dial Access was initiated in 1969 after a four month t r i a l period. It consists of a number of pre-recorded five to seven minute audio tapes on a variety of nursing subjects. The nurse dials a special telephone number and asks for the tape she is interested in hearing. The record is then played for her over the telephone. The service is available without charge to a l l Wisconsin nurses. A recently completed evaluation of the program found that more than one thousand calls are being received per month, with two-thirds of them between noon and midnight; nurses in more rural areas u t i l i z e the service more often than do their urban counter-parts; hospitals, nursing homes, and schools of nursing make the greatest use of the program (104) . In view of the many problems confronting inservice education, i t i s surprising that greater use has not been made of the newer educational media and, more particularly, self instructional methods. The only innovative program reported was that described by Lindeman and Aernam (67), which was conducted at Luther Hospital in Wisconsin. Using a portable slide/sound projector, the nursing staff at this hospital are developing their own self-study packages on various nursing procedures. Dubin, Marlow, and Alderman (37) surveyed the use of correspondence courses in hospitals. They found that hospital administrators and department heads in the United States generally lacked information about this method and that i t was rarely used for inservice education. On the other hand, hospital administrators in Canada were found to make f a i r l y extensive use of correspond dence courses for their employees. With the exception of the CNA-CHA Extension Course on U n i t A d m i n i s t r a t i o n , t h i s r e v i e w f o u n d no d e s c r i p t i v e s t u d i e s on i t s u s e i n e i t h e r c o u n t r y , and t h e same was t r u e f o r programmed i n s t r u c t i o n . RECURRING ISSUES AND TRENDS The i s s u e s c o n f r o n t i n g c o n t i n u i n g n u r s i n g e d u c a t i o n a r e n o t t o o d i f f e r e n t f r o m t h o s e f a c i n g m e d i c i n e and d e n t i s t r y ; hox^ever, c o n t i n u i n g n u r s i n g e d u c a t i o n i s f a c e d w i t h some u n i q u e p r o b l e m s r e l a t e d t o t h e a m b i g u i t y s u r r o u n d i n g n u r s i n g , as w e l l as the need t o \"upgrade t h e e d u c a t i o n o f n u r s e s who have g r a d u a t e d f r o m programs w h i c h d i f f e r w i d e l y \" ( 5 1 ) . A d d i n g t o t h e c o n f u s i o n has been t h e r e c e n t emphasis on t h e e x p a n d i n g r o l e o f t h e n u r s e . N u k o l l (78) r e p o r t e d an a n a l y s i s of a r e c e n t m a i l i n g from t h e A m e r i c a n Academy o f P e d i a t r i c s w h i c h f o u n d t h a t 24 o f t h e 34 t r a i n i n g programs l i s t e d f o r p e d i a t r i c p e r s o n n e l were d e s i g n e d t o a d m i t n u r s e s . Of t h e s e , o n l y 6 r e q u i r e d a B.S.N, degr e e f o r a d m i s s i o n . The d u r a t i o n o f t h e programs ra n g e d f r o m 16 weeks p a r t - t i m e t o 18 months f u l l - t i m e c u l m i n a t i n g i n a m a s t e r ' s d e g r e e . These d a t a s u g g e s t t h a t t h e r e i s as y e t no c o nsensus on t h e e d u c a t i o n a l p r e p a r a t i o n o f p e d i a t r i c n u r s e p r a c t i t i o n e r s . I n t h e meantime, H u t c h i s o n (56) has warned: There i s imminent t h r e a t o f c r a s h programs d e v e l o p i n g o u t s i d e t h e e d u c a t i o n a l m a i n s t r e a m . The p r e p a r a t i o n o f t h e p e d i a t r i c n u r s e a s s o c i a t e f a l l s s q u a r e l y w i t h i n t h e g e n e r a l l y a c c e p t e d scope o f c o n t i n u i n g e d u c a t i o n s i n c e t h e programs seek t o f u r t h e r p r e p a r e t h e p r a c t i t i o n e r n u r s e . She u r g e s t h a t c o n t i n u i n g e d u c a t i o n f a c u l t y e n s u r e t h a t t h e minimum s t a n d a r d s o u t l i n e d i n t h e g u i d e l i n e s f o r P e d i a t r i c N u r s e A s s o c i a t e s be f o l l o w e d and t h a t l e a d e r s h i p be e x e r t e d t o e n s u r e t h a t sound programs d e v e l o p under t h e s p o n s o r s h i p o f u n i v e r s i t y c o n t i n u i n g n u r s i n g and m e d i c a l e d u c a t i o n . As n o t e d e a r l i e r , Cooper (48) has e x p r e s s e d c o n c e r n f r o m a n o t h e r p o i n t o f v i e w . She q u e r i e s whether s h o r t t e r m c o u r s e s p r e p a r i n g p h y s i c i a n s ' a s s o c i a t e s \" w i l l p r e v e n t a r a p i d and n e c e s s a r y i n c r e a s e o f n u r s e s p e c i a l i s t s a t t h e 250 g r a d u a t e l e v e l . \" R e l a t e d t o t h i s p r o b l e m i s t h e q u e s t i o n as t o whether c o n t i n u i n g n u r s i n g e d u c a t i o n s h o u l d make s p e c i a l p r o v i s i o n f o r t h e g r a n t i n g o f c r e d i t s t o w a r d c o l l e g e d e g r e e s i n an e f f o r t t o e n a b l e t h e v a s t number o f e x p e r i e n c e d and c a p a b l e n u r s e s t o o b t a i n r e c o g n i t i o n f o r t h e i r c l i n i c a l c a p a b i l i t i e s . On t h i s i s s u e , S q u a i r e s (21) has advanced t h i s v i e w : C o n t i n u i n g e d u c a t i o n s h o u l d f a c i l i t a t e t h e pas s a g e f r o m one l e v e l t o a n o t h e r w i t h o u t l o w e r i n g s t a n d a r d s . T h i s c a n be done by c a r e f u l s t u d y and r e - d e s i g n i n g o f c u r r i c u l u m . K e e p i n g s t a n d a r d s a t t h e f o r e f r o n t b u t n o t a l l o w i n g t r a d i t i o n t o d o m i n a t e , c o n t i n u i n g e d u c a t i o n s h o u l d be i n v o l v e d i n t h e p l a n n i n g and p r o v i s i o n o f c o u r s e s t o move p e o p l e a l o n g t h e way. Even as t h e s e i s s u e s a r e b e g i n n i n g t o be s e r i o u s l y d i s c u s s e d by n u r s e l e a d e r s , n u r s i n g l i k e a l l t h e h e a l t h p r o f e s s i o n s i s moving i n t h e d i r e c t i o n o f mandatory c o n t i n u i n g e d u c a t i o n as a r e q u i s i t e f o r p r a c t i c e . I n 1970, t h e C a l i f o r n i a L e g i s l a t u r e p a s s e d a b i l l w h i c h s p e c i f i e s t h a t a f t e r J a n u a r y 1, 1975, n u r s e s and o t h e r h e a l t h p r o f e s s i o n a l s w i l l be r e q u i r e d t o s u b m i t p r o o f t h a t d u r i n g t h e p r e c e d i n g two y e a r s t h e y have i n f o r m e d t h e m s e l v e s o f d e v e l o p m e n t s i n t h e i r f i e l d s , e i t h e r by s u c c e s s f u l c o m p l e t i o n o f e x a m i n a t i o n s , o r by p u r s u i n g an a p p r o v e d c o u r s e o r c o u r s e s o f c o n t i n u i n g e d u c a t i o n ( 6 5 ) . A t t h e same t i m e , n u r s e e d u c a t o r s a r e unanimous i n agreement t h a t s h o u l d m a n d a t o r y c o n t i n u i n g e d u c a t i o n be i m p l e m e n t e d , c o l l e g e s and u n i v e r s i t i e s c o u l d n o t p r o d u c e t h e r e q u i r e d c o u r s e s a t p r e s e n t ( 5 1 ) . I n d e e d , w i t h t h e e x c e p -t i o n o f a few u n i v e r s i t i e s and r e g i o n a l e f f o r t s t o d e v e l o p c o n t i n u i n g e d u c a t i o n programs f r o m t h e p e r s p e c t i v e o f l o n g r a n g e c o - o r d i n a t e d p l a n n i n g , c o n t i n u i n g n u r s i n g e d u c a t i o n has been d e s c r i b e d as \" u n r e l a t e d , ad hoc measures, l a c k i n g c o n t i n u i t y and f o l l o w up\" ( 9 2 ) . 251 CHAPTER XV SUMMARY R e g i s t e r e d n u r s e s a r e t h e l a r g e s t s i n g l e group o f h e a l t h p r o f e s s i o n a l s . T h i s group i s made up l a r g e l y o f women, o f whom w e l l o v e r o n e - h a l f a r e m a r r i e d , and a p p r o x i m a t e l y one f o u r t h o f t h e group i s employed p a r t - t i m e . There i s a l a r g e i n a c t i v e group o f n u r s e s , many o f whom would be w i l l i n g t o r e - e n t e r t h e work f o r c e . E n t r y i n t o t h e p r o f e s s i o n i s a c h i e v e d t h r o u g h e i t h e r a d i p l o m a o r a d e g r e e program b u t t h e v a s t m a j o r i t y o f n u r s e s have no academic d e g r e e . Where p r i v a t e d u t y n u r s i n g was once t h e maj o r f i e l d o f employment, o v e r 83 p e r c e n t o f t h e employed n u r s e s a r e now w o r k i n g i n h o s p i t a l s and n u r s i n g s c h o o l s . The r o l e o f t h e n u r s e i n p a t i e n t \" c a r e i s i n a s t a t e o f f l u x w i t h t h e new r o l e n o t y e t c l e a r l y d e f i n e d . As i t emerges, t h e t r e n d i s toward expanded r e s p o n s i b i l i t i e s b o t h i n g e n e r a l n u r s i n g d u t y and i n s p e c i a l i z a t i o n . T h i s i s c r e a t i n g new d i m e n s i o n s t o t h e knowledge r e q u i r e d t o p e r f o r m new o r m o d i f i e d t a s k s i n p a t i e n t c a r e t h a t r e s u l t s i n t h e need f o r s y s t e m a t i c l e a r n i n g a t a l l l e v e l s w i t h i n t h e p r o f e s s i o n . T h e r e have been f o u r m a j o r developments i n n u r s i n g o v e r t h e p a s t decade. These a r e : 1) a r e - o r i e n t a t i o n o f g r a d u a t e n u r s e s back t o t h e b e d s i d e ; 2) a t r e n d toward c l i n i c a l s p e c i a l i z a t i o n ; 3) an i n c r e a s e d e f f o r t t o d e f i n e n u r s i n g p r a c t i c e t h r o u g h r e s e a r c h i n t o p a t i e n t c a r e ; and 4) changes i n t h e r e c i p r o c a l r o l e s o f p h y s i c i a n s and n u r s e s . I n s e r v i c e and c o n t i n u i n g e d u c a t i o n have been i d e n t i f i e d as i m p o r t a n t v e h i c l e s f o r f a c i l i t a t i n g t h e s e t r e n d s , and i n d e e d , f o r s o l v i n g many o f the pro b l e m s i n n u r s i n g . W h i l e t h e i d e n t i f i e d l e a r n i n g needs r e l a t i v e t o the b r o a d e r a r e a s o f 252 nursing are not at a l l surprising, a number of studies indicate that nurses at a l l levels are insecure in their present positions and that they are concerned regarding their future in nursing. Furthermore, the few studies which have attempted to determine not only what nurses believe they need, but also their real learning deficiencies, suggest that the learning needs of registered nurses are numerous and diverse. While inservice education offers the greatest potential for the develop-ment of c l i n i c a l competence, i t s potential has hardly been touched. On the other hand, although continuing nursing education at the university level i s in i t s infancy, i t i s faced with some extraordinary demands, which the majority of schools cannot cope with at present, neither in terms of faculty, f a c i l i t i e s , nor finances. What is required, therefore, i s a clearer delineation of respec-tive roles of the university schools, the employing agencies, and the professional associations who are the three major sponsors of continuing education in nursing. More specifically, in view of the evolving trends in nursing, i t would seem that the university schools should focus on the develop-ment of leadership and consultant services to the employing agencies rather than investing scarce resources in short course offerings which at best only serve to meet the pressing needs of the moment. Continuing nursing education should exert leadership in the development of new instructional materials and program designs. As noted by Conley and Larsen (24), most of the innovative programs in nursing funded through public law 89-239 have been innovations in organization and administration rather than in educational design. This i s equally true with respect to most of the other innovative programs described above. Joint planning and the co-ordination of resources at a l l levels are i 253 a l s o i n d i c a t e d . I n a d d i t i o n , t h e h e a l t h p r o f e s s i o n s m i g h t p r o f i t a b l y p o o l r e s o u r c e s and work t o g e t h e r i n d e v e l o p i n g c l i n i c a l p r o g r a m s , f o r as amply d e m o n s t r a t e d i n t h i s r e v i e w , some o f t h e most \" s u c c e s s f u l \" programs i n n u r s i n g have been t h o s e w h i c h have been d e v e l o p e d w i t h i n t h e framework o f a h e a l t h team a p p r o a c h . I n o r d e r 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 n u r s i n g can a c h i e v e t h e l e a r n i n g and changes i n b e h a v i o r t h a t a r e r e q u i r e d by t h e e x p a n d i n g r o l e o f t h e n u r s e i n p a t i e n t c a r e , i t i s n e c e s s a r y t h a t e d u c a t i o n a l programs be d e v e l o p e d t h a t a r e f u n c t i o n a l l y e f f i c i e n t as i n s t r u m e n t s f o r change. T h i s c a n o n l y be a c c o m p l i s h e d t h r o u g h t h e d e s i g n and management o f programs t h a t a r e g e a r e d t o a d u l t l e a r n i n g . Among t h e s e v e r a l h e a l t h p r o f e s s i o n s , n u r s i n g has been t h e f i r s t t o a c c e p t t h e need f o r s p e c i a l i z e d s k i l l and knowledge i n a d u l t e d u c a t i o n as a p r e - r e q u i s i t e f o r e d u c a t i o n a l p l a n n i n g . 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Ingmire, A . , et a l . , Abstract: The Effectiveness of a Leadership Program in Nursing, Western Interstate Commmssion on Higher Education, Boulder, Colorado, 1967. 61. Juzwiak, M . , \"How A Good Inservice Program Can Benefit you\", R . N . , (December, 1967), pp. 37-45. 62. Kohn, R . , Emerging Patterns in Health Care, Royal Commission on Health Services, Queen's Printer, Ottawa, 1966. 63. Kuehn, R . , \"Continuing Education in Nursing\", Journal of the American Medical Association, 190:544-546, (November 9, 1964). 259 64. \"Landmark Statement: The American Nurses' Association on Inservice Education\", Journal of Continuing Education in Nursing, 1:23-25, (May, 1970). 65. \"Landmark Statement From California Assembly Bill #449\", Journal of Continuing Nursing Education, 2:28-31, (September-October, 1971). 66. Lee, B . , \"Financial Support For Continuing Education\", Journal of Continuing Nursing Education, 2:7-12, (September-October, 1971). 67. Lindeman, C . , Aernam, A . , \"Staff Develops Inservice Program to Teach Itself\", Modern Hospital, (October, 1970), pp. 98-100 68. Lynch, L . , \"Leadership Training in the West\", Nursing Outlook, (February, 1970), pp. 38-39. 69. Lysaught, J . , (Director), Abstract for Action: National Commission for the Study of Nursing and Nursing Education, McGraw Hill Books C o . , New York, 1970. 70. McCle l lan .M. , \"Staff Development in Action\", American Journal of Nursing, 68:288-300, (February, 1968). . 71. McKinley, J . , \"Inservice Education for Leadership\", Nursing Outlook, (September, 1968), pp. 47-49. 72. McLenmore, S. , Hil l , R . , Management Training Effectiveness: A Study of Nurse Managers, Bureau of Business Research, The University of Texas, 1965. 73. Metcalf, M . , \"Clinical Rotation for New Graduate Nurses\", Nursing Outlook, (September, 1968), pp. 44-46. 74. Mil ler , M . , Inservice Education for Hospital Nursing Personnel, National League for Nursing, New York, 1958. 75. Murray, V . , Nursing in Ontario, Study for the Committee on the Healing Arts, Queen's Printer, Ottawa, 1970. 76. Mussallem, H . , \"Manpower Problems in the Nursing Profession\", Medical Care Insurance and Health Manpower; Proceedings. The Canadian Medical Association, Quebec, June 19-23, 1967. 260 77. Niles, A . , Definitive Dialing, Nursing Dial Access: A Report of the Planning Year and the First Eighteen Months in Operation, University Extension, Department of Nursing, University of Wisconsin, 1970. 78. Nuckolls, K . , \"Continuing Education and the Extended Role of the Nurse\", Journal of Continuing Nursing Education, 2:29-35, (July-August, 1971). 79. \"Nurses Learn from Patients in Coronary Care Training\", Hospitals, 42:13, (March, 16, 1968). 80. Ohio State University College of Medicine-- School of Nursing: Continuing Education for Nurses, brochure, 1970-1971. 81. Ohliger, J . , Barritt, E . , \"Continuing Education\", American Journal of Nursing, 69:2170-2171, (October, 1969). 82. Orlan, D . , A Survey of Selected Hospitals in New Jersey: The Use of Many Tools in Evaluating and Improving the Quality of Nursing Care. In League Exchange, Volume 91, Number 92, 1969. 83. Osgood, G . , \"Funding Sources and Rationale for Such Sources\", Proceedings Book of the National Conference on Continuing Education for Nurses, Sponsored by the School of Nursing of the Medical College of Virginia, Health Sciences Division of the Virginia Commonwealth University, Williamsburg, Virginia, November 10-14, 1969, pp. 76-79. 84. 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Wolfe, E . , \"Nurse Clinician in a Specialty Hospital\", Nursing Outlook, (June, 1968), pp. 41-43. PART FIVE CONTINUING EDUCATION IN PHARMACY 264 265 CHAPTER XVI THE PROFESSION AND CONTINUING EDUCATION With the transfer of drug production from the local pharmacy to a highly specialized pharmaceutical industry, the traditional combining and compounding s k i l l s of the pharmacist are fast becoming obsolete. At the same time, i n the wake of the so-called \"drug revolution,\" pharmacists have a major role to play in ensuring \"adequate controls in the handling and dispen-sing of today's potent drugs\" (30). Accordingly, the profession of pharmacy i s presently seeking to define and interpret this mainstream professional function within the context of the changing health care system. COMPOSITION AND DISTRIBUTION Ross (33) surveyed the f i e l d of pharmacy in 1964 and found that the distribution of pharmacists i n Canada followed a pattern somewhat similar to that reported for dentists and physicians. In short, British Columbia, Ontario, and Manitoba, reported the most optimum pharmacist/population ratios, while Newfoundland and the Yukon Territories reported the least favourable situation. In a l l regions the large urban centers were found to attract the greatest numbers and the younger pharmacists. A great majority of pharmacists in this country were engaged in r e t a i l pharmacy in 1962. Although more recent figures were not available for Canada as a whole, pharmacist manpower st a t i s t i c s in the United States (11) and the 1968 Survey of Pharmacy in Ontario (22) suggest that the manufacturing and r e t a i l branches of pharmacy are s t i l l absorbing the greatest number of pharmacists. In the TABLE VIII PERCENTAGE DISTRIBUTION OF PHARMACISTS BY FIRST AND CURRENT EMPLOYMENT, 1962 Category of Percentage in Percentage i n Employment Firs t Employment Current Employment Retail 90.64 79.60 Hospital 4.25 6.80 University 0.56 1.06 Government 0.07 0.44 Armed Forces 0.76 0.88 Manufacturing 2.89 7.17 Organizations 0.18 0.25 Retired 0.95 Outside Profession 0.65 1.81 Total: 100.00 100.00 SOURCE: Ross, T., Pharmacist Manpower in Canada; Royal Commission on Health Services; Ottawa, Queen's Printer, 1967, p.124. 267 meantime, there i s evidence to suggest that hospital pharmacy i s on the ascendancy and predictions are that as medical care becomes more hospital based i t w i l l become necessary to increase the number of hospital pharmacists and specialized training programs related to institutional pharmacy practice (10). The proportion of women in pharmacy is reported to be increasing sharply (33). The Ontario study (30) revealed that in the 1967 graduating class of the Faculty of Pharmacy at the University of Toronto, 40.1 percent of graduates were women as compared to an average of 5.5 percent in the years 1926 to 1939. Hospital employment appears to attract a far greater number of female pharma-cists that i t does males (33). If these trends continue, they w i l l have an important influence on the future nature of the profession. It can be expected that as the proportion of female graduates increases, a larger number of pharmacists w i l l leave the profession at least temporarily after relatively few years of practice, and that an equally large number of pharmacists employed in hospital pharmacy w i l l be part time workers. From the point of view of continuing education, this w i l l mean that the profession w i l l have to include in i t s long range plans an appreciable increase in the number of ongoing flexibly scheduled refresher courses. As might be expected, faculties of pharmacy and research divisions in manufacturing establishments attract those few pharmacists with advanced degrees, while those with the minimum basic educational requirement are found primarily in hospitals and r e t a i l work (33). Brodie (10) notes, \"that the future of pharmacy might well have been cast i n a different mold had pharmacy chosen the model of medicine establishing the minimum educational requirement for practice as a professional doctor's degree.\" He believes that the 268 development of a sound professionally oriented program of pharmaceutical education at the time medicine established i t s basic educational program would have kept the practice of pharmacy free of the commercialism which is said to have clouded the profession. The Changing Nature of Practice: Whatever i t s past may have been, the practice of pharmacy is changing rapidly. The pharmacist is no longer simply a fabricator and dispenser of drugs. This traditional function has passed from the practitioner to the manu-facturer and, more recently, pharmacy educators have been advocating a new role variously defined in the literature as \" c l i n i c a l pharmacist,\" \"therapeutic adviser,\" or even \" c l i n i c a l pharmacologist\" (16) (29) (2) (18). Whatever the name used,.and in spite of the minor differences i n the functions proposed, in a l l definitions i t i s emphasized that the pharmacist must be available to provide precise information on medicaLioiis Lo enquiring healLli personnel and patients (30). In short, this new role would establish the pharmacist as a \"drug information specialist.\" The implementation of this new role i s a major concern of the profession for while some hospitals have successfully placed pharmacists on nursing units and on ward rounds with physicians (23), the process of change has been slow. Moreover, studies have shown that health professionals tend to seek drug information from sources other than pharmacists (30) (23). A number of studies have revealed that pharmacists are able to provide the factual drug information, but lack consulting s k i l l s although several studies suggest that knowledge deficiencies may exist (23) (24). Since most of these studies are defective with respect to research procedures, no firm conclusions can be drawn. Most writers agree that an important vehicle for 269 h e l p i n g p h a r m a c i s t s t o assume t h i s new r o l e i s c o n t i n u i n g e d u c a t i o n . NEED FOR CONTINUING EDUCATION I n pharmacy, c o n t i n u i n g e d u c a t i o n r e f e r s t o t h a t phase o f p r o f e s s i o n a l e d u c a t i o n w h i c h b e g i n s \" a f t e r t h e p r a c t i t i o n e r has r e c e i v e d h i s b a s i c e d u c a t i o n , u s u a l l y a B a c h e l o r o f S c i e n c e o r a D o c t o r Pharmacy d e g r e e , o r a f t e r he has c o m p l e t e d a program d e v o t e d t o advancement i n a p a r t i c u l a r a r e a o f h i s base e d u c a t i o n , u s u a l l y a M a s t e r o f S c i e n c e o r , more r a r e l y , a D o c t o r o f P h i l o s o p h y d e g r e e a n d / o r a h o s p i t a l pharmacy r e s i d e n c e . \" I t ' s p u r p o s e , \" i s t o p r o v i d e a p r a c t i t i o n e r l e a r n e r w i t h knowledge, s k i l l s , a t t i t u d e s , and i n s i g h t s , t h a t w i l l c o n t i n u e t o i n c r e a s e h i s c a p a c i t i e s and i m p r o v e h i s p r o f e s s i o n a l c o n f i d e n c e i n r e n d e r i n g p a t i e n t c a r e \" ( 1 2 ) . As i n t h e o t h e r h e a l t h p r o f e s s i o n s , t h e development o f c o n t i n u i n g e d u c a t i o n i s r e l a t i v e l y r e c e n t i n pharmacy. B l o c k s t e i n (7) and o t h e r s (14) ( 9 ) , t r a c e i t s b e g i n n i n g s t o t h e P h a r m a c e u t i c a l S u r v e y o f 1948 (7) w h i c h b r o u g h t t h e u n i v e r s i t y pharmacy s c h o o l s i n t o t h e m a i n s t r e a m o f c o n t i n u i n g e d u c a t i o n a c t i v i t i e s . I t s recommendations r e l a t i v e t o i n s t i t u t i o n s o f h i g h e r l e a r n i n g w e r e: 1. I t i s recommended t h a t e a c h o f t h e a c c r e d i t e d c o l l e g e s and s c h o o l s o f pharmacy r e c o g n i z e and assume r e s p o n s i b i l i t y f o r p r o v i d i n g o r g a n i z e d programs o f i n - s e r v i c e p r o f e s s i o n a l i n s t r u c t i o n o f t h e p r a c t i s i n g p h a r m a c i s t s w i t h i n t h e a r e a n o r m a l l y s e r v e d by t h e i n s t i t u t i o n , and t o t h i s end s e t up, under competent, p r o f e s s i o n a l d i r e c t i o n , an o p e r a t i o n u n i t t o be known as t h e \" d i v i s i o n o f p h a r m a c e u t i c a l e x t e n s i o n . \" 2. I t i s recommended t h a t t h e d u t i e s o f s u c h d i v i s i o n s o f p h a r m a c e u t i c a l e x t e n s i o n i n c l u d e t h e development o f r e f r e s h e r c o u r s e s c o n d u c t e d a t t h e i n s t i t u t i o n s , programs o f r e a d i n g c o r r e s p o n d e n c e s t u d y c o u r s e s , and the s y s t e m a t i c v i s i t a t i o n and p e r s o n a l c o u n s e l l i n g of p h a r m a c i s t s . 3. I t i s recommended, i n o r d e r t o i n s u r e t h e maximum c o o p e r a t i v e e f f o r t , t h a t t h e s t a t e b o a r d s of pharmacy o f each s t a t e t a k e t h e i n i t i a t i v e f o r the c r e a t i o n i n t h e s t a t e o f a P h a r m a c e u t i c a l E x t e n s i o n C o u n c i l c o n s i s t i n g of t h e dean o f t h e c o l l e g e ( s ) o r s c h o o l ( s ) o f pharmacy, t h e d i r e c t o r ( s ) o f t h e d i v i s i o n ( s ) o f p h a r m a c e u t i c a l e x t e n s i o n and r e p r e s e n t a t i v e s o f t h e s t a t e p h a r m a c e u t i c a l a s s o c i a t i o n and t h e s t a t e department o f p u b l i c i n s t r u c t i o n . 270 In response to these recommendations a number of pharmacy schools are reported to have established continuing education programs, and the concept of continuing education as a responsibility of the pharmacy schools gained i n popularity, albeit slowly. In 1955, the American Association of the College of Pharmacy (hereinafter referred to as the AACP), established a Committee on Continuation Studies. Its purpose was to \"study the problems of continuing education, make recommenda-tions to the AACP, and to serve as a communication media among the member schools\" (9). The annual reports issued between 1957 and 1967 have consisted largely of brief quantitative summaries of educational a c t i v i t i e s reported by member schools and comments with regards to reported problems. As early as 1957, the Committee recommended that a study be undertaken to determine the nature and scope of continuing education i n pharmacy, yet i t was not u n t i l 1967 that such a survey was actually undertaken (22). The findings of this study reflect some progress where comparative data are available. Nevertheless, a more recent report by the Committee (37) concludes: It i s d i f f i c u l t to find anyone who is satisfied with the present state of continuing education for pharmacists. Without impugning the fine efforts of some individuals, colleges, and associations, i t i s f a i r to state that more significant and successful continuing education programs are needed to help the practising pharmacists who are confronted by an ever increasing body of knowledge and by constantly changing conditions affecting their professional practice...it should be appreciated that the folleges must sponsor and direct the efforts needed to find solutions to the ever-present problems of continuing education, a low level of p a r t i c i -pation, inadequate or unsuitable programs, and insufficient financial support. This review of the literature from 1960 to 1970 proved equally unrewarding. Only thirty three references were found which related to continuing education in pharmacy, and of these, only seven were of a research, 271 or more correctly, survey nature. Of the reports located, probably the most useful source of information for those developing continuing education programs, are the proceedings of national conferences held by the Teachers' Section on Continuing Education of the AACP. These have been published in the American Journal of Pharmaceutical Education since 1964. 272 CHAPTER XVII PARTICIPATION IN CONTINUING EDUCATION Pharmacy has been the last of the major health professions to engage in the continuing education of i t s members. This involvement i s of such recent origin that i t Is not generally recognized or accepted by either practising pharmacists or by universities. Consequently, there is a paucity of literature describing the extent of opportunities for continuing education or the acceptance of these opportunities by the profession. Braucher (9) surveyed f i f t y - f i v e colleges of pharmacy in the United States and gathered data about their programs in continuing education which gives some indication of participation by pharmacists. In presenting his data, Braucher indicates the number of pharmacists who were \"promoLed\" or suliciLed to participate i n courses and the number who actually attended. From these data he computes a participation index that i s an interesting and curious s t a t i s t i c . In one respect this index i s a measure of the percentage of the potential population that actually participated and, i n another sense, i t i s an index of interest in continuing education and assessment of the effectiveness of the promotional a c t i v i t i e s of the sponsoring agencies (TablelX). Braucher's data covers two years and while there is generally an increase in 1968 over 1967, this i s too short a period of time to indicate any trend toward increasing participation in continuing education by pharmacists. Between 1967 and 1968 there was an increase of 30.57 percent in the total number of participants in a l l courses reported. Furthermore, there was an increase from 5.64 percent to 7.31 percent in the percentage of the target TABLE ' ix A COMPARISON OF PARTICIPANTS IN AND THE PROMOTION OF COURSES OFFERED BY PHARMACY SCHOOLS IN 1967 AND 1968 BY SPECIALTY OF THE PARTICIPANTS Specialty of the Participants Total Courses Sponsored by Schools Courses Co-sponsored 1967 1968 % Change 1967 1968 % Change 1967 1968 % Change Community Pharmacy No. Participants No. Promoted Participation Index Hospital Pharmacy No. Participants No. Promoted Participation Index Industrial Pharmacy No. Participants No. Promoted Participation Index Mixed (Pharmacists and other Health Groups) No. Participants No. Promoted Participation Index Total No. Participants No. Promoted Participation Index 3,649 50,436 7.23 597 18,610 3.20 1,195 >7,044 4.41 4,071 58,429 6.96 749 20,350 3.68 911 12,069 7.54 9,710 14,052 172,275 179,637 5.63 7.82 15,151 19,783 268,365 270,485 5.64 7.31 11.56 15.84 25.46 9.34 -23.76 -55.37 803 27,077 2.97 144 16,560 0.87 708 10,294 7.67 1,237 36,800 3.36 171 16,650 1.03 730 9,519 6.88 44.71 5,991 6,403 4.27 127,240 113,449 4.71 5.64 30.57 7,646 8,541 0.78 181,171 176,418 4.84 4.22 54.04 35.90 18.75 0.54 3.10 7.52 6.87 10.83 11.70 2.62 2,846 23,359 12.18 453 2,050 22.10 487 16,750 2.91 3,719 45,035 8.26 7,505 87,194 8.61 2,834 21,629 13.10 578 3,700 15.62 181 2,550 7.10 7,649 66.188 11.56 11,242 94,067 11.95 0.42 0.74 27.59 80.48 -62.83 -84.77 105.67 46.97 49.79 7.88 SOURCE: Braucher, C , \"A Comparative Analysis of Three Years of Continuing Education Activity\"; American Journal of Pharmaceutical Education; 34:237 (May, 1970). 274 population that participated. When employment i s considered, community pharmacists showed an increase in participation of 11.56 percent, hospital pharmacists increased 25.46 percent, and those pharmacists classified as mixed increased participation by 44.71 percent. On the other hand, industrial pharmacists showed a decline of 23.76 percent. In 1967, the courses sponsored by pharmacy schools alone attracted 1.87 percent more participants than courses co-sponsored with associations but in 1968 the co-sponsored courses exceeded the school courses by 31.6 percent. This suggests that the associations were a force in promoting courses. This i s born out by the participation index computed by Braucher which shows 11.95 percent in 1968 compared with the schools index of 4.22 percent in the same year. The participation index shows a decline in participation by community pharmacists but an increase in a l l other classes between 1967 and 1968. Indust-r i a l pharmacists had a greater increase in the participation index than did any other class. When Braucher's data for 1967 i s compared with that reported by Jobe (22) for 1966, there is a decrease of 7.8 percent but an increase of 20.38 percent in 1968. The concern is expressed by some in the profession that continuing education may be reaching the same group and that those most in need of continuing education may not be participating (8) (32). REASONS FOR ATTENDING OR NOT The three major obstacles to participation identified by respondents in the Purdue study (32) were: the d i f f i c u l t y of finding registered personnel to relieve the pharmacist during his absence; loss of income relative to time away from work; and geographical distance from the location of programs, in that 275 order. While distance was cited as an important obstacle by almost one quarter of the respondents, the school of pharmacy at Purdue conducts programs in local communities; furthermore, four of the eight respondents l i v i n g in the v i c i n i t y of the campus admitted to not having attended a program on campus. This study also found that while 80 percent of the owners of pharmacies expressed a willingness to defray expenses for employees, only 5 percent of the employee respondents had had their expenses paid to attend. Deficiencies in the program were also rated as an important deterrent to attendance. The most frequently cited weakness of programs was their similarity. Subject matter was the most important reason for attending while a well known speaker was rated second, and conference location third. The inclusion of social events in continuing education sessions was not found to be a major factor influencing the decision to attend. Polls indicate that pharmacists prefer one day sessions (19) (32), however, studies disclose that longer courses scheduled intermittently in the evenings are also favoured by a relatively large percentage of respondents (17) (19). In an earlier survey in the state of Mississippi, two to three day courses were rated highly, despite the obstacles to attendance (17). Fees: According to the respondents in the Purdue survey, a reasonable fee for a single session was considered to be between $5.00 and $14.00, but fees were not seen as a major deterrent to attendance. Felt Learning Needs: A number of surveys and reports suggest that despite a wide variety of topics requested, pharmacists tend to rate business management subjects 276 r e l a t i v e l y high (13) (32) (19) (17). At l e a s t two surveys reveal that i n the science area the greatest learning needs r e l a t e to pharmaceutical advances and pharmacology (19) (32). Bernardi (5) reports that i n Connecticut pharmacists are in c r e a s i n g l y requesting courses on physiology. Other topics which have been asked for frequently are i n t e r p r o f e s s i o n a l r e l a t i o n s h i p s and the e f f e c t of l e g i s l a t i o n on pharmacists (8) (19). When respondents were asked to o f f e r further suggestions i n the Purdue study, p r o f e s s i o n a l topics were requested f a r more often than business matters but with s c i e n t i f i c subjects almost completely ignored. I n s t r u c t i o n a l Processes: The M i s s i s s i p p i survey (17) found that 64 percent preferred the l e c t u r e technique. Less than 10 percent wanted p a r t i c i p a t i v e laboratory courses, but 43.7 percent of the respondents did express an i n t e r e s t i n demonstrations,which may i n d i c a t e that pharmacists desir e to l e a r n and observe new techniques. In t h i s study, 18.4 percent selected correspondence as the preferred means of keeping up to date. Other studies provide evidence that pharmacists would l i k e opportunities to engage i n independent study (13) (4). Tape recordings on pertinent topics have been c i t e d as a method which would obviate the need to leave work i n order to keep up to date. A recent evaluation of a correspondence course reported by Barnes (3) revealed that pharmacists rated correspondence study highly, with older pharmacists most responsive. 277 C H A P T E R X V I I I P R O G R A M O R G A N I Z A T I O N A N D A D M I N I S T R A T I O N A n u m b e r o f i n s t i t u t i o n s a n d o r g a n i z a t i o n s a r e p r e s e n t l y i n v o l v e d 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 h a r m a c i s t s . T h e s e i n c l u d e : T h e A m e r i c a n S o c i e t y o f H o s p i t a l P h a r m a c i s t s , t h e C a n a d i a n a n d A m e r i c a n H o s p i t a l A s s o c i a t i o n s , u n i v e r s i t y s c h o o l s o r c o l l e g e s o f p h a r m a c y a n d m e d i c i n e , a n d p h a r m a c e u t i c a l a s s o c i a t i o n s a t a l l l e v e l s \u00E2\u0080\u0094 n a t i o n a l , s t a t e o r p r o v i n c i a l , a n d l o c a l . H o w e v e r , t h e p r i m a r y s p o n s o i s o f f o r m a l p r o g r a m s a r e t h e u n i v e r s i t y s c h o o l s o f p h a r m a c y . C U R R E N T C O U R S E O F F E R I N G S T h e r e i s v e r y l i t t l e d e s c r i p t i v e d a t a a v a i l a b l e a b o u t t h e e x t e n t o f c o n t i n u i n g e d u c a t i o n i n p h a r m a c y s c t h a t i t i s n o t p o s s i b l e t o s h e w c h a n g e s o v e r t i m e w i t h a n y v a l i d i t y . B r a u c h e r ( 9 ) h a s s u p p l i e d v i r t u a l l y t h e o n l y s u b s t a n t i v e d a t a a v a i l a b l e a n d t h i s c o v e r s t h e p e r i o d o f 1 9 6 6 t o 1 9 6 8 s o i t i s n o t s u f f i c i e n t t o s h o w p o s i t i v e t r e n d s . C o u r s e s c o n d u c t e d b y S c h o o l s o f P h a r m a c y d u r i n g t h i s t h r e e y e a r p e r i o d s h o w a s l i g h t i n c r e a s e f r o m 1 0 9 i n 1 9 6 6 t o 1 4 5 i n 1 9 6 8 . W h i l e m o s t o f t h e s e c o u r s e s w e r e o f f e r e d o n c a m p u s , t h e t r e n d t o m o r e o f f c a m p u s c o u r s e s i s e v i d e n t . I n 1 9 6 6 , 6 8 . 8 0 p e r c e n t o f t h e c o u r s e s o f f e r e d w e r e o n c a m p u s b u t t h i s d e c l i n e d t o 4 6 . 8 9 p e r c e n t i n 1 9 6 8 . I n 1 9 6 7 , t h e u s e o f t e l e v i s i o n w a s i n t r o d u c e d w i t h 1 3 . 0 4 p e r c e n t o f t h e c o u r s e s i n 1 9 6 7 a n d 1 7 . 9 3 p e r c e n t i n 1 9 6 8 o f f e r e d t h r o u g h t h a t m e d i a . A s t h e n u m b e r o f c o u r s e s i n c r e a s e t h e a v e r a g e l e n g t h o f t h e c o u r s e d e c l i n e d f r o m 9 . 5 1 c o n t a c t h o u r s i n 1 9 6 6 t o 8 . 9 2 c o n t a c t h o u r s i n 1 9 6 8 . ( T a b l e X . ) T A B L E X C O U R S E S S P O N S O R E D B Y S C H O O L S O F P H A R M A C Y 1 9 6 6 - 1 9 6 8 C L A S S I F I E D B Y L O C A T I O N A N D C O N T A C T H O U R S 1 C o u r s e Y e a r 1 9 6 6 - 1 9 6 7 1 9 6 8 N u m b e r P e r c e n t N u m b e r P e r c e n t 1 N u m b e r ; P e r c e n t L O C A T I O N O n C a m p u s O f f C a m p u s O t h e r * T o t a l C o u r s e s : C O N T A C T H O U R S O n C a m p u s O f f C a m p u s O t h e r * T o t a l H o u r s : A v e r a g e h o u r s p e r c o u r s e : 7 5 3 4 6 8 . 8 0 5 9 3 1 . 1 9 4 1 1 5 5 1 . 3 0 3 5 . 6 0 1 3 . 0 4 6 8 ! 4 6 . 8 9 5 1 ' 3 5 . 1 7 2 6 j 1 7 . 9 3 1 0 9 ' 1 0 0 . 0 0 1 1 5 i j - 1 - 6 1 9 - ; - 4 0 4 i - 3 6 l 1 0 0 . 0 0 ! 1 4 5 ; 1 0 0 . 0 0 j j 5 8 . 4 5 | 8 2 2 \ 6 3 . 5 2 3 8 . 1 4 j 3 8 9 1 / 2 j 3 0 . 0 6 3 . 3 9 8 3 6 . 4 1 1 , 0 3 7 1 , 0 5 9 1 0 0 . 0 0 1 , 2 9 4 1 / 2 ; 1 0 0 . 0 0 1 ; \u00C2\u00BB 1 9 . 5 1 j 9 . 2 0 | j 8 . 9 2 * T h i s i n c l u d e s t e l e v i s i o n , t e l e l e c t u r e , e t c . S O U R C E : B r a u c h e r , C , \" T h r e e Y e a r A n a l y s i s o f C o n t i n u i n g E d u c a t i o n . \" A m e r i c a n J o u r n a l o f P h a r m a c e u t i c a l E d u c a t i o n 3 4 : 2 3 5 ( M a y , 1 9 7 0 ) . TABLE XI COURSES SPONSORED JOINTLY BY SCHOOLS OF PHARMACY AND PROFESSIONAL ASSOCIATIONS 1966-1968 BY LOCATION AND CONTACT HOURS Course Year 1966 \u00E2\u0080\u0094 i 1967 1968 Number Percent Number Percent Number Percent LOCATION On Campus Off Campus Other Total Courses: CONTACT HOURS On Campus Off Campus Other Total Hours: Average hours per course: 22 124 145 784 5.40 15.17 85.51 100.00 42 73 2 35.89 62.39 1.70 40 96 2 28.98 69.56 1.44 117 455 1/2 393 1/2 30 1/2 100.00 51.76 44.70 3.41 138 351 1/2 542 59 100.00 36.86 56.93 6.19 879 1/2 , 100.00 7.51 952 1/2 100.00 6.90 SOURCE: Braucher, C. \"Three Year Analysis of Continuing Education.\" American Journal of Pharmaceutical Education, 34:235 (May, 1970). TABLE XII NUMBER OF COURSES OFFERED BY SUBJECTS IN 1967 AND 1968 1967 Percent 1968 Percent Pharmacology Community Pharmacy Institutional Pharmacy Management Medicare Pharmaceutics Law and Ethics Industrial Technology Pharmaceutical Chemistry Disaster Preparedness Pharmacognosy Medical Detailing Communications and New Drugs Radioisotopes History Career Orientation Teaching Science Librarianship Cancer Control and Detection Toxicology Public Health Dental Health Miscellaneous TOTAL: 32 31 31 34 5 26 13 14 3 1 8 1 3 1 1 20 227 14.09 13.65 13.65 14.97 2.20 11.45 5.72 6.16 1.32 0.44 3.52 1.32 0.44 1.32 0.44 0.44 8.81 100.00 48 36 31 34 4 26 14 15 16 1 6 3 4 4 3 3 6 262 18.32 13.74 11.83 12.97 1.52 9.92 5.34 5.72 6.10 0.38 2.29 1.14 1.52 1.52 1.14 1.14 2.29 3.05 100.00 SOURCE: Braucher, C , \"Three Year Analysis of Continuing Education\"; American Journal of Pharmaceutical Education; 34:236 (May, 1970). 2 8 2 A D M I N I S T R A T I O N T h e 1 9 6 2 - 6 3 R e p o r t o f t h e A m e r i c a n C o l l e g e o f P h a r m a c e u t i c a l E d u c a t i o n d i s c l o s e d t h a t i n 1 9 6 2 , t h i r t e e n c o l l e g e s o f p h a r m a c y h a d E x t e n s i o n d e p a r t -m e n t s . O f t h i s n u m b e r , t h r e e r e p o r t e d a f u l l t i m e p e r s o n i n c h a r g e , w h i l e n i n e h a d a p a r t t i m e d i r e c t o r , w i t h t w o c o l l e g e s r e p o r t i n g a n a d d i t i o n a l p a r t t i m e p e r s o n , a n d t h r e e r e p o r t i n g f u l l t i m e c l e r i c a l s t a f f ( 2 7 ) . A m o r e r e c e n t r e p o r t c o v e r i n g t h e a c a d e m i c y e a r 1 9 6 7 - 6 8 r e v e a l e d l i t t l e c h a n g e , w i t h o n l y e i g h t o f t h e 7 4 c o l l e g e s r e p o r t i n g a f u l l t i m e d i r e c t o r i n c o n t i n u i n g e d u c a t i o n o r e x t e n s i o n a n d o n l y n i n e t e e n a p a r t t i m e p e r s o n . T h e m a j o r i t y o f c o n t i n u i n g e d u c a t i o n p r o g r a m s s p o n s o r e d b y t h e c o l l e g e s a r e m a n a g e d b y f a c u l t y w h o h a v e r e s p o n s i b i l i t i e s e l s e w h e r e ( 1 ) w h i c h m a y a c c o u n t f o r t h e r e l a t i v e l y f e w c o u r s e s a v a i l a b l e . F i n a n c e s a n d F a c u l t y : A s i n t h e o t h e r h e a l t h p r o f e s s i o n s , f u n d s a r e o f p r i m e c o n c e r n i n c o n t i n u i n g p h a r m a c e u t i c a l e d u c a t i o n . I n 1 9 6 6 , r e g i s t r a t i o n f e e s m a d e u p a b o u t 4 5 p e r c e n t o f t h e t o t a l r e v e n u e , a n d i n 1 9 6 8 , s o m e 5 0 p e r c e n t . T h e s e c o n d m a j o r s o u r c e o f f u n d s i n 1 9 6 8 w a s g r a n t m o n e y u s e d t o s u b s i d i z e c o u r s e s ( 9 ) . A l t h o u g h d e p a r t m e n t s o f c o n t i n u i n g p h a r m a c e u t i c a l e d u c a t i o n w h i c h a r e p a r t o f s t a t e u n i v e r s i t i e s a r e i n a m o r e s t a b l e p o s i t i o n f i n a n c i a l l y , g e n e r a l l y s p e a k i n g u n i v e r s i t i e s h a v e n o t a l l o c a t e d m u c h m o n e y t o c o n t i n u i n g e d u c a t i o n . S i n c e r e g u l a r f a c u l t y m e m b e r s w h o p a r t i c i p a t e i n c o n t i n u i n g e d u c a t i o n p r o g r a m s a r e u s u a l l y n o t p a i d , t h i s l i m i t s t h e c h o i c e o f i n s t r u c t o r s ( 3 4 ) . A l t h o u g h p h a r m a c e u t i c a l f i r m s h a v e p r o v i d e d l a r g e s u m s f o r t h e d e v e l o p -m e n t o f e x p e r i m e n t a l p r o j e c t 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 , t h e y h a v e n o t b e e n a s i g n i f i c a n t s o u r c e o f f u n d s f o r c o n t i n u i n g p h a r m a c e u t i c a l e d u c a t i o n . 283 Furthermore, government grants to support continuing education have been minimal. A number of writers express the view that pharmacy has lacked an organized approach in i t s efforts to obtain additional funding, and they recommend 1) establishment of central statewide continuing education offices to co-ordinate programs, pool resources, and to seek funds; 2) implementation of programs within the RMPS; and 3) inclusion of a research component in the program proposal, thereby ensuring potential sponsors some tangible results from the funds granted (21) (34). Promotion and Publicity: Promotion and publicity for continuing education in pharmacy have uti l i z e d the well established methods of direct mailing, professional associ-ation bulletins, calendars, newspapers, and professional journals (27). The University of Wisconsin department i s one exception as i t publishes a special periodical which includes, i n addition to current course offerings, papers from university programs as well as articles and reports from journals which are not always available to practitioners (36). An interesting technique that combines promotion with program planning i s reported in use at the University of Colorado. White (38) noted: 1. A l i s t of \"proposed seminar topics\" is sent to the students through their association. The participants indicate in which topics they are interested. They also indicate which night and what time schedule they prefer. 2. These are returned to the school of pharmacy, and a seminar schedule is made up. 3. Students are registered for the seminar by the Bureau, and fees are collected...The Bureau also makes expense payments to the school and to individuals. 4. Outlines for each session are prepared by the faculty member in charge of the evening class and these are made available to the students. 5. At the last session the students make an evaluation of the seminar, and attendance certificates are presented to the students (38). 284 SOME SAMPLE PROGRAMS While continuing education in pharmacy i s reported using a wide variety of methods and techniques, the typical program is said to be a conference, institute, or short course, a l l three of which consist of a series of lectures either on a wide variety of subjects or focussing on several aspects of a single theme (32) (14) (6). Of the few programs mentioned i n the literature, the following examples i l l u s t r a t e the more innovative approaches currently in use in continuing pharmaceutical education. Regional Programs: The Kansas School of Pharmacy has been conducting statewide c i r c u i t type courses for many years. At present, four such programs are being offered in four places throughout the state, with the specific location varying for each c i r c u i t . In this way more rural pharmacists are able to participate i n planned programs of continuing education (38). For the past several years the American Society of Hospital Pharmacists (ASHP) has been sponsoring a centrally planned, regionally implemented eight to ten week preceptorship program,designed to orientate community pharmacists to institutional practice. Organized on an intermittent basis one half to one day weekly, this course combines classroom study with c l i n i c a l practice. In 1969 McConnell (25) reported that more than 2,000 community pharmacists had participated in the program. Mass Media: As part of the university's extension service, the pharmacy program at the University of Wisconsin is using telelectures. The f i r s t series of such lectures was offered i n March and April 1966, and attracted 180 viewers for 2 8 5 e a c h p r o g r a m . A n e v a l u a t i o n o f t h i s s e r i e s r e v e a l e d a n o v e r w h e l m i n g l y f a v o u r -a b l e r e s p o n s e ; c o n s e q u e n t l y , i n M a y 1 9 6 6 a s e c o n d s e r i e s w a s o f f e r e d o n I n s t i t u t i o n a l P h a r m a c y , u t i l i z i n g a w i d e v a r i e t y o f s p e a k e r s , i n c l u d i n g a n u r s e w h o d i s c u s s e d t h e n u r s e ' s r o l e i n t h e a d m i n i s t r a t i o n o f m e d i c a t i o n s . A q u e s t i o n n a i r e s u r v e y r e v e a l e d t h a t t h i s p r o g r a m w a s r e g a r d e d a s e x c e l l e n t b y t h e m a j o r i t y o f r e s p o n d e n t s . T e l e l e c t u r e s r e a c h 4 7 l o c a t i o n s t h r o u g h o u t t h e S t a t e o f W i s c o n s i n a n d h a v e a t t r a c t e d a n e n t h u s i a s t i c r e s p o n s e . T h e . c o l l e g e o f p h a r m a c y a t t h e U n i v e r s i t y o f M i n n e s o t a h a s b e e n u s i n g c l o s e d c i r c u i t t e l e v i s i o n w i t h d i r e c t f e e d b a c k b y t e l e p h o n e s i n c e 1 9 6 7 . T h e i n i t i a l p r o g r a m , p r e s e n t e d t o t h r e e a r e a s o n t h r e e s u c c e s s i v e M o n d a y e v e n i n g s , a t t r a c t e d a n i n t e r e s t e d a u d i e n c e s o t h e p r o j e c t w a s e x t e n d e d . S u b s e q u e n t p r o g r a m s h a v e u s e d p r e - t a p e d l e c t u r e s b u t w i t h t h e l e c t u r e r p r e s e n t i n t h e s t u d i o f o r t h e q u e s t i o n a n d a n s w e r p e r i o d . I n 1 9 6 8 , H o d a p p ( 2 0 ) r e p o r t e d t h a t t h e a u d i e n c e w a s m a d e u p o f p h y s i c i a n s , p h a r m a c i s t s , d r u g c o m p a n y r e p r e -s e n t a t i v e s , a n d n u r s e s . C o m m e n t s f r o m p a r t i c i p a n t s d i s c l o s e d t h a t t h e i n t e r -d i s c i p l i n a r y m i x w a s f e l t t o b e a v a l u a b l e l e a r n i n g e x p e r i e n c e . O n e q u e s t i o n n a i r e e v a l u a t i o n r e v e a l e d t h a t w h i l e 5 2 p e r c e n t o f t h e p h a r m a c i s t r e s p o n d e n t s t h o u g h t t h e s u b j e c t w a s c o v e r e d i n p r o p e r d e p t h , 7 5 p e r c e n t o f t h e n u r s e s f e l t i t w a s c o v e r e d i n t o o m u c h d e p t h . O t h e r s t a t e s r e p o r t e d u s i n g t e l e v i s i o n i n c l u d e N e w Y o r k , N o r t h a n d S o u t h D a k o t a , I n d i a n a , a n d O k l a h o m a ( 7 ) . H o m e S t u d y : T h e h i g h l y s u c c e s s f u l c o r r e s p o n d e n c e c o u r s e s d e s i g n e d b y B a r n e s a t t h e S t . L o u i s C o l l e g e o f P h a r m a c y a r e s a i d t o h a v e p i o n e e r e d t h e u s e o f c o r r e s p o n -d e n c e a s a n i n s t r u c t i o n a l m e t h o d i n c o n t i n u i n g p h a r m a c e u t i c a l e d u c a t i o n ( 2 7 ) . A n u m b e r o f c o l l e g e s a r e r e p o r t e d o f f e r i n g c o r r e s p o n d e n c e c o u r s e s ( 9 ) , a n d 286 these appear to be widely used both by course sponsors as adjuncts to short courses and by practitioners as a method of independent study (A). More recently, programmed instruction i s making i t s way into pharma-ceutical continuing education. North Eastern University in Boston, Massachusetts, i s reported developing self-contained units and experimental courses (28) . ISSUES AND TRENDS A recurring theme in the literature on continuing pharmaceutical education is the reported apathy or lack of motivation of practising pharmacists to continue their professional education. The question of how to reach the great number of practitioners who are presently not being reached has been widely discussed from many points of view. A national survey conducted in 1965 of State pharmacy boards investi-gated their authority to make continuing education a condition for practice. Of the responding boards 36 f e l t that they were not so empowered, 9 f e l t they were, and 7 were uncertain (11). Since that study, at least two states have made participation in continuing education mandatory (8), and i n 1968, the Committee on Continuation Studies recommended that a study be undertaken to determine the f e a s i b i l i t y of making continuing education mandatory on a national basis (37). Because there are as many valid arguments for as against such a proposal, pharmacy remains divided on the issue (26). At the same time, paralleling the increased pressure.from governments to make periodic re-licensure of health professionals compulsory, most of the pharmacy colleges and professional associations are presently re-assessing their continuing education role and activities in the f i e l d . 287 CHAPTER XIX SUMMARY The most significant development in the pharmacy profession in the past decade has been a change in the role of the pharmacist. With the transfer of drug production from the local pharmacy to an industrial establishment, the traditional role of the pharmacist as a compounder of drugs is rapidly disappearing. In its place is emerging a new role that places the pharmacist as the drug expert on the health care team. This emerging role is not completely recognized or accepted by the profession because i t demands know-ledge and skills of a different sort than that with which the pharmacist has been equipped in his pre-professional education. To assume a new role, then, pharmacists must acquire new and different knowledge through continuing education. Neither individual pharmacists nor their institutions or associations have long considered continuing education to be a matter of importance. Con-sequently, there has been l i t t l e done to provide programs for the further education of the profession. The lack of interest and concern in continuing education is amply illustrated by the paucity of literature on the subject as well as the almost total absence of any relevant research about continuing education in pharmacy. The scanty literature that has been produced is too nebulous and inconsistent to allow for any very reliable description of programs, administration, or participation in continuing education. Only a very small percentage of the members of the profession parti-cipate regularly in planned programs of continuing education. This results 288 from both individual and professional factors. Individuals are deterred from participation by the loss in salary entailed as a result of being away from work and those who are entrepreneurs face the problem of securing a legally qualified person to substitute for them in their pharmacy. The profession, through i t s associations and the schools of pharmacy, has failed to provide adequate opportunities for continuing education. This failure stems largely from a lack of interest in and concern for the continuing education of the profession. Add to these a lack of knowledge about how to provide educational opportunities and a lack of fundamental knowledge derived from research about the profession and i t s need for or acceptance of continuing education. As this review has shown, when the associations and the schools work together to provide educational opportunities, the response i s enhanced so they need to become more deeply committed and involved. The drug industry has provided support for research and experimentation in continuing education for other of the health professions but there is l i t t l e evidence that i t has done so for i t s own professional group. This may well be due to their not having been pressed to do so by the pharmacy profession. University schools of pharmacy have the greatest stake in continuing education for the profession since education i n pharmacy i s their sole raison d'etre. Although they have been involved to some extent in continuing education this appears to have occurred with some reluctance and certainly without creative leadership. The university schools of pharmacy have done vi r t u a l l y no research to provide a basis for programs and such that has been done suggests that continuing education has made but a minimal impact upon the practice of pharmacy because the knowledge essential to functional program planning has not been acquired through research. As the role of the 289 pharmacist changes, so must the form, content, and duration of education i n pharmacy. In the l i t e r a t u r e reviewed there was no evidence to i n d i c a t e an awareness of t h i s i n the schools. Of the several health professions, pharmacy i s the most backward with respect to continuing education. The profession must be aroused to the need fo r i t to ensure the s u r v i v a l of pharmacy as a profession. REFERENCES 290 1. \"Annual Progress Report From the College of Pharmacy\", American J ournal of Pharmaceutical Education, 33:556-557, (February, 1969)\"! 2. Archambult, A . , \"Continuing Education for the Practising Pharmacist\", Canadian Pharmaceutical Journal, (February, 1963), pp. 20-22, 28. 3. Barnes, B . , \"Practical Approach to Continuing Education: Correspondence\", Journal of the American Pharmaceutical Association, NS7:18-22, (January, 1967) 4. Barnes, B. , \"Cont inuing Educat i on by Correspondence\", American J ournal of Pharmaceutical Education, 23:826-831, (December, 1969). 5. Bernardi, V . , \"Panel: Identifi cation of Specif i c Content Needs\", American Journal of Pharmaceutical Educat ion, 33:742-744, (December, 1969). 6. Blockstein, W . , \"Myths and Realities - - Continuing Pharmaceutical Education\", Journal of the American Pharmaceutical Association, NS7:10-12, (January, 1967). 7. Blockstein, W . , \"Developing A Program for Continuing Education for a College of Pharmacy\", American Journal of Hospital Pharmacy, 33:767-773, (December, 1969). 8. Bowles, G . , \"Continuing Education May be Required for Pharmacist License\", Modern Hospital, 113:130, (October, 1969). 9. Braucher, C , \"A Comparative Analysis of Three Years of Continuing Education Activity\", American Journal of Pharmaceutical Education, 34:234-240, (May, 1970). 10. Brodie, D . , Commission on Pharmaceutical Services to Ambulant Patients by Hospitals and Related Facilities: The Challenge to Pharmacy in Times of Change, Washington, D . C , 1968. 11. \"Can Pharmacy Boards Make Continuing Education a Prerequisite for Licensure Renewal?' American Professional Pharmacist, October, 1965, pp.28-33. 12. Carlin, H . , \"Continuing Education Requirements for Institutional Pharmacy Practice\", American Journal of Hospital Pharmacy, 24:188-191, (April, 1967). 13. \"Continuing Education: Voluntary or Compulsory7', Pharmacy Times, (May, 1970), pp. 38-43. 291 14. Daniels, W. , \"Variations in Needs of Pharmacists for Continuing Education\", American Journal of Pharmaceutical Education, 33:729-734, (December, 1969). 15. Dubin, S. et a l . , Correspondence Instruction as an Educational Method in Hospitals, Pennsylvania State University and the Hospital Research and Educational Trust of the American Hospital Association, 1967. 16. Gallina, J . , Jeffrey, L . , \"Clinical Pharmacists in To-day's Health Care Delivery System\", Hospital Pharmacy, (August, 1970), pp. 23-25. 17. Hartman, C . , Watkins, E . , \"Opinions on Continuing Education\", American Journal of Pharmaceutical Education\", 27:426-431, 1963. 18. Hartshorn, E . , \"In Continuing Education The Pharmacist Must be Both Teacher and Student\", Hospitals, 42:105,108,109, (January, 16, 1968). 19. Huyck, C , \"Topics Practising Pharmacists Prefer on Refresher Programs\", American Journal of Pharmaceutical Education, 24:185-190, 1960. 20. Hodapp, W., Walker, A . , \"An Experiment in Continuing Education Utilizing Closed Circuit Television\", American Journal of Pharmaceutical Eduaction\", 32:625-633, (November, 1968y 21. Hodapp, W., \"Panel: Funding Continuing Education Programs\", American Journal of Pharmaceutical Education\", 33:782-785, (December, 1969). 22. Jobe, B. , \"A Survey of Continuing Pharmaceutical Education\", American Journal of Fnarmaceutical Education\", 32:611-615, (November, 1968). 23. Knapp, D . , Knapp, D . , \"An Appraisal of the Contemporary Practice of Pharmacy, \" American Journal of Pharmaceutical Education\", 32:747-758, (November, 1968). 24. Libby, G . , Hepler, C , \"Situational Factors and Pharmaceutical Knowledge\", American Journal of Hospital Pharmacy, 27:375-383, (May, 1970). 25. McConnell, W . , \"Panel: Identification of Specific Content Needs\", American Journal of Pharmaceutical Education, 33:750-753, (December, 1969). 26. McGowan, M . , \"Legal Aspect of Requiring Continuing Education For Licensure Renewal\", American Journal of Pharmaceutical Education, 30:486-490, 1966. 292 27. Mahaffrey, F . , \"Annual Progress Report\", American Journal of Pharmaceutical Education, 26:303-306, 1962. 28. Northeastern University Investigates Programmed Instruction\", Journal of the American Pharmaceutical Association, NS7:17, (January, 1967) 29. Piecoro, J . , e t a l . , \"A Pharmacist on Hospital Ward Rounds\", Journal of the American Pharmaceutical Association, NS7:630-633, (December, 1967) 30. Report of the Committee on the Healing Ar ts , volume 2, Queen's Printer, Toronto, 1970. 31. Rising, L . , \"Summary of the Activities of the Workshop on Needs of Pharmacists\", American Journal of Pharmaceutical Education, 33:735-741, (December, 1969^ 32. Rodowskas, C . , Evanson, R . , \"Continuing Education in Pharmacy: Motivation and Content\", American Journal of Pharmaceutical Education, 29:393-403,1965. 33. Ross, T . , Pharmacist Manpower in Canada, Queen's Printer, Ottawa, 1967. 34. Schwartz, M . , \"Panel: Funding Continuing Education Programs\", American Journal of Pharmaceutical Education, 33:786-788, (December, 1969). 35. Smolek, R . , \"Program Prepares Pharmacists for Service in E C F ' s \" , Hospital Topics, 47:57-63, (July, 1969). 36. Strommen, R . , \"Education by Coercion: Effective Methods of Increasing Attendance at Adult Education Programs Through Increased Services and Expanded Promotional Effort\", American Journal of Pharmaceutical Education, 24:180-184, 1960. 37. White, A . , \"Report of the Committee on Continuation Studies\", American Journal of Pharmaceutical Education, 32:447-448, (October, 1968). 38. White, T . , \"Continuing Education Programs and Techniques\", American Journal of Pharmaceutical Education, 30:679-689, 1966. 39. White, T . , \"Improving Instruction in Continuing Education\", American Journal of Pharmaceutical Education, 30:690-697, 1966. PART SIX CONTINUING EDUCATION IN THE HEALTH PROFESSIONS: MAJOR CONCLUSIONS 293 294 CHAPTER XX MAJOR CONCLUSIONS The development of continuing education in medicine, nursing, dentistry, and pharmacy, has followed the struggle of the professions to keep abreast of the rapidly expanding knowledge and practice i n the health care f i e l d . Medicine is far in the lead in the development of this facet of education, both with respect to the extensiveness of i t s course offerings, and i t s resources. It has also accumulated through research and experimentation a wealth of information concerning the f i e l d . Yet paradoxically, on a national basis, the problems of continuing medical education are not too different from those confronting the other three health professions surveyed in this report. COMMON FINDINGS AND IMPLICATIONS The existing pattern of continuing education for health practitioners i s evolving without the benefit of any overall planning or administration. While this in i t s e l f i s not a bad thing as i t permits f l e x i b i l i t y and experi-mentation, i t does account for many of the problems that arise. For convenience, these problems are discussed under the following headings: 1) educational planning; 2) organization and administration; 3) methods and techniques; and 4) evaluation. EDUCATIONAL PLANNING The most striking characteristic of continuing education for the health professions i s the overabundance of short courses designed to meet the pressing needs of the moment. While many individuals benefit from these programs, i t 295 i s q u e s t i o n a b l e w h e t h e r such a p i e c e m e a l , e p i s o d i c a p p r o a c h c a n e v e r hope t o surmount t h e p r o b l e m s o f p r o f e s s i o n a l o b s o l e s c e n c e . I n m e d i c i n e i t has been s a i d t h a t the body o f m e d i c a l and s c i e n t i f i c knowledge d o u b l e s e v e r y t e n y e a r s . I f t h i s i s t r u e o f m e d i c i n e , i t i s e q u a l l y t r u e o f t h e o t h e r h e a l t h p r o f e s s i o n s . A c c o r d i n g l y , h e a l t h p r a c t i t i o n e r s c annot a f f o r d t o i n v e s t t h e i r time i n f r u i t l e s s e f f o r t s , however much t h e s e may be e n t e r t a i n i n g o r i n t e r e s t i n g . Nor i s i t n e c e s s a r y o r p o s s i b l e i n t h i s age o f s p e c i a l i z a t i o n f o r e v e r y h e a l t h p r a c t i t i o n e r t o know a l l about e v e r y a s p e c t o f t h e a r t and s c i e n c e o f h i s p r o f e s s i o n . Thus i t i s n e c e s s a r y t o i d e n t i f y t h e new knowledge, s k i l l s , and a t t i t u d e s w h i c h h e a l t h p r o f e s s i o n a l s must a c q u i r e c o n t i n u o u s l y i n o r d e r t o p r o v i d e a h i g h e r q u a l i t y o f p a t i e n t c a r e . The t e n d e n c y has been f o r program p l a n n e r s t o d e s i g n programs based on what p r a c t i t i o n e r s s a y t h e y want o r need. M e e t i n g p r a c t i t i o n e r s ' e x p r e s s e d needs f o r c o n t i n u i n g e d u c a t i o n i s c e r t a i n l y a v e r y i m p o r t a n t a s p e c t o f program p l a n n i n g b u t as d e m o n s t r a t e d i n t h i s r e v i e w , e x p r e s s e d needs may n o t be t h e r e a l l e a r n i n g n e eds. M o r e o v e r , as s t r e s s e d by M i l l e r (8) and o t h e r s ( 1 7 ) , w h i l e i t i s d i f f i c u l t t o a c c e p t t h a t r e s o u r c e s a r e n o t u n l i m i t e d , t h e s e t t i n g o f p r i o r i t i e s i s e s s e n t i a l . R e l e v a n t P r o g r a m s : The l e a r n i n g needs o f h e a l t h p r o f e s s i o n a l s must be i d e n t i f i e d i n terms o f t h e p r i o r i t y h e a l t h c a r e needs o f t h e a r e a w h i c h t h e y s e r v e . T h i s may r e q u i r e a c a r e f u l a n a l y s i s o f l o c a l h e a l t h needs and s i n c e t h i s i s a complex and o f t e n e x p e n s i v e a c t i v i t y , t h e s e v e r a l h e a l t h p r o f e s s i o n s m i g h t p r o f i t a b l y combine t h e i r r e s o u r c e s t o t h a t end. When h e a l t h needs a r e i d e n t i f i e d , i t i s t h e n n e c e s s a r y t o t r a n s l a t e t h e s e i n t o l e a r n i n g n e eds. On a day t o day b a s i s , t h e most u s e f u l method o f d e t e r m i n i n g t h e l e a r n i n g 296 needs of i n d i v i d u a l s and g r o u p s o f p r o f e s s i o n a l s i s by s m a l l s c a l e s t u d i e s d e s i g n e d t o h e l p p r a c t i t i o n e r s i d e n t i f y t h e i r own l e a r n i n g needs. T h i s r e q u i r e s s p e c i f i c s k i l l s i n s o c i a l s c i e n c e r e s e a r c h p r o c e d u r e s so t h e p r o f e s s i o n s a r e b e t t e r a d v i s e d t o seek a s s i s t a n c e . Some such p r o c e d u r e s have been d e v e l o p e d and used i n m e d i c i n e , p a r t i c u l a r l y t h e m e d i c a l a u d i t and i n d i v i d u a l s e l f a ssessment t e s t s . W h i l e t h e s e have some i n h e r e n t w e a k n e s s e s , t h e y do have m e r i t and m i g h t w e l l be a d a p t e d f o r t h e o t h e r h e a l t h p r o f e s s i o n s . I n s p i t e o f t h e c a r e f u l d e t e r m i n a t i o n o f n e e d s , t h e r e s u l t a n t e d u c a -t i o n a l programs o f t e n f a i l b e c a u s e o f a f a i l u r e t o t r a n s l a t e needs i n t o l e a r n i n g o b j e c t i v e s t h a t a r e o b t a i n a b l e . E x i s t i n g p r o g r a m s , as n o t e d i n t h i s r e v i e w , t e n d t o t r a n s l a t e needs i n t o o b j e c t i v e s t h a t i n v o l v e i n f o r m a t i o n o n l y . T h i s r e s u l t s i n programs t h a t a r e n o t s p e c i f i c a l l y p r a c t i c a l f o r t h e p a r t i c i -p a n t s . As q uoted by A x f o r d ( 2 ) , P e a r l Buck has s u c c i n c t l y summed up t h e a t t r i b u t e s o f t h e competent program p l a n n e r : The program p l a n n e r must l e a r n t h e s k i l f u l a r t o f g i v i n g p e o p l e what t h e y need t o know, and i n d e e d must know, w h i l e he i s g i v i n g them what t h e y want. I t t a k e s a h i g h i n t e g r i t y , a p r o f o u n d knowledge o f p e o p l e , and where t h e y a r e , as w e l l as t h e t e c h n i q u e s o f p o p u l a r e d u c a t i o n , t o be a good program p l a n n e r . A H e a l t h Team A p p r o a c h : I n a d d i t i o n t o t h e need f o r a more s y s t e m a t i c a p p r o a c h t o programming w i t h i n p r o f e s s i o n s , g r e a t e r a t t e n t i o n must a l s o be g i v e n t o t h e development o f i n t e r - p r o f e s s i o n a l programs. T h i s r e v i e w 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 f i e l d s u g g e s t s t h a t w h i l e p r o g r e s s has been made i n t h i s d i r e c t i o n , i t has been s l o w . One r e a s o n f o r t h i s i s t h a t l i t t l e t i m e has been s p e n t on t h e d i f f i c u l t t a s k o f c l a r i f y i n g common p u r p o s e s and a r e a s o f common l e a r n i n g . A n o t h e r has been t h e r e l u c t a n c e o f t h e s e n i o r h e a l t h p r o f e s s i o n s t o a c c e p t t h e 297 concept of the health team* approach, even though this i s the kind of health service expected by society today. One other common finding in this regard is the apparent neglect of the preventive and social aspects of health care. This in turn i s related to the lack of substantial knowledge concerning the effectiveness of various alternative methods for organizing health services in a way which would f a c i l i t a t e combining preventive and curative functions. Accordingly, in a l l health professions, this i l l defined but important area is the major responsibility of a small nucleus of health workers in a separate specialty called \"public health.\" Clearly, there i s a need for change in the organization of health services and clearer delineation of roles in the light of the changing health care needs of society. The continuing education of physicians, nurses, dentists, pharmacists, and other health workers, should place greater emphasis on the social and preventive aspects of their work, and as well should engage in experi-mental programs jointly planned and conducted by interdisciplinary teams. In their study of continuing dental education, O'Shea and Black comment, \"Perhaps continuing dental education too often follows the market rather than leads i t \" (10). This remark i s equally applicable to the other health professions reviewed in this report. ORGANIZATION AND ADMINISTRATION In the f i e l d of the health sciences, continuing education i s provided under many different auspices with the major locus of responsibility in the *Health Team\u00E2\u0080\u0094\"a group of health professionals with their respective associated technicians and other essential personnel whose overall goals are the promotion of health, the prevention of disease, the diagnosis and treatment of illness and the alleviation of suffering, who by co-operation, co-ordination, and integration of effort provide health and patient care\"... Adapted from D. William's paper, Continuing Education For the Health Team. 298 u n i v e r s i t y p r o f e s s i o n a l s c h o o l s . A t t h e s a m e t i m e , t h e p l a c i n g o f t h i s r e s p o n -s i b i l i t y i n t h e u n i v e r s i t i e s h a s n o t n e c e s s a r i l y b e e n a c c o m p a n i e d b y t h e r e s o u r c e s n e c e s s a r y t o o p e r a t e a d e q u a t e p r o g r a m s . A c c o r d i n g l y , u n i v e r s i t y s c h o o l s d o n o t c o n s i d e r c o n t i n u i n g e d u c a t i o n t o b e a p r i m a r y f u n c t i o n . A g r e a t s t e p f o r w a r d w o u l d b e t h e e s t a b l i s h m e n t o f s e p a r a t e c o n t i n u i n g e d u c a t i o n d i v i s i o n s , w i t h a f u l l t i m e d i r e c t o r a n d a d e q u a t e f i n a n c i a l b a c k i n g i n a l l s c h o o l s . T h i s w o u l d h e l p e l i m i n a t e t h e m a r g i n a l s t a t u s o f 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 . T h e R o l e o f t h e U n i v e r s i t y ; P r o f e s s i o n a l e d u c a t i o n i n t h e h e a l t h f i e l d i s c h a r a c t e r i z e d b y d i s t i n c t p h a s e s : p r e - p r o f e s s i o n a l , u n d e r g r a d u a t e , a n d g r a d u a t e e d u c a t i o n , a n d w i t h c o n t i n u i n g e d u c a t i o n t a c k e d o n a s a n a f t e r t h o u g h t . C u r r i c u l u m c h a n g e i n f o r m a l e d u c a t i o n i s p a i n f u l l y s l o w , o f t e n l a g g i n g f a r b e h i n d s o c i a l a n d t e c h n o l o g i c a l c h a n g e , w h i l e c o n t i n u i n g e d u c a t i o n , b e c a u s e i t i s u n b u r d e n e d b y f o r m a l s t r u c t u r e s o r c r e d i t r e q u i r e m e n t s , i s o n e o f t h e p r i m e m e a n s o f b r i n g i n g a b o u t c h a n g e c o n s i s t e n t w i t h t h e r a p i d l y c h a n g i n g h e a l t h n e e d s o f s o c i e t y . I f c o n t i n u i n g e d u c a t i o n w e r e m o r e e f f e c t i v e l y o r g a n i z e d a n d a c c e p t e d a s a n i n t e g r a l p a r t o f p r o f e s s i o n a l e d u c a t i o n i t w o u l d b e e a s i e r t o e n c o u r a g e t h e a c c e p t a n c e o f t h e c o n c e p t o f \" c o n t i n u i n g \" l e a r n i n g a t a l l l e v e l s o f e d u c a t i o n . F u r t h e r m o r e , i t w o u l d e n c o u r a g e t h e d e v e l o p m e n t o f m o r e s u s t a i n e d c o m p r e h e n s i v e p r o g r a m s . F l e x i b l y o r g a n i z e d s p e c i a l d e g r e e p r o g r a m s p e r m i t t i n g l a t i t u d e t o e x p e r i e n c e d p r a c t i t i o n e r s , w o u l d f a c i l i t a t e t h e a t t a i n m e n t o f a d d i t i o n a l d e g r e e s a n d c e r t i f i -c a t e s a s e v i d e n c e o f o r g a n i z e d s t u d y b e y o n d t h e i n i t i a l p r o f e s s i o n a l p r e p a r a t i o n . T h i s d e v e l o p m e n t w o u l d s e e m p a r t i c u l a r l y u r g e n t i n t h e p a r a m e d i c a l p r o f e s s i o n s a s n e w r o l e s e v o l v e , a n d t h e p r e s s u r e f o r d e g r e e s c o n t i n u e s t o m o u n t . T h e R o l e o f H o s p i t a l S e r v i c e s : C o n t i n u i n g e d u c a t i o n s h o u l d a l s o b e p a r t o f t h e d a i l y l i f e o f h e a l t h 299 p r a c t i t i o n e r s a s a n i n t e g r a l p a r t o f d a y t o d a y p r a c t i c e . S i n c e h o s p i t a l s a r e t h e d a i l y w o r k p l a c e o f m a n y h e a l t h p r o f e s s i o n a l s , t h e s e i n s t i t u t i o n s s h o u l d b e t h e m a j o r f o c i o f o n g o i n g c o n t i n u i n g e d u c a t i o n . I n m o s t h o s p i t a l s , c o n t i n u i n g e d u c a t i o n i s p r e s e n t l y e p i s o d i c a n d i s t h e r e s p o n s i b i l i t y o f i n d i v i d u a l s w i t h o t h e r r e s p o n s i b i l i t i e s o f t e n c o n s i d e r e d m o r e i m p o r t a n t . A s o n e p r a c t i c a l s o l u t i o n t o t h e p r o b l e m , R i s i n g ( 1 3 ) h a s s u g g e s t e d t h a t t h o s e h o s p i t a l s w h o d o n o t h a v e t h e p e r s o n n e l a n d r e s o u r c e s n e c e s s a r y t o c a r r y a c o m p l e t e c o n t i n u i n g e d u c a t i o n p r o g r a m s h o u l d \" a s s o c i a t e t h e m s e l v e s w i t h o t h e r a g e n c i e s w i t h s i m i l a r e d u c a t i o n a l r e q u i r e m e n t s , i n o r d e r t o e n s u r e t h e s e r v i c e s o f a c o m p e t e n t e d u c a t o r t o f u n c t i o n f o r t h e w h o l e g r o u p . \" T h e i n c r e a s i n g t r e n d o n t h e p a r t o f u n i v e r s i t y p r o f e s s i o n a l s c h o o l s t o s e r v e a s c o n s u l t a n t s i n r e g i o n a l p r o g r a m s i s a n o t h e r a p p r o a c h w h i c h s h o u l d b e f u r t h e r d e v e l o p e d . T h e p r a c t i c e o f c a r r y i n g p r e - p a c k a g e d c o u r s e s i n t o l o c a l c o m m u n i t i e s i s b o t h e c o n o m i c a l l y a n d e d u c a t i o n a l l y u n s o u n d . I n t h e p r o f e s s i o n s , i t w o u l d s e e m a d v i s a b l e f o r t h e p r o f e s s i o n a l s c h o o l s t o p r e p a r e s k i l l e d c l i n i c i a n s a s a d u l t e d u c a t o r s s o t h a t t h e y c a n s e r v e b o t h a s c o n s u l t a n t s a n d r o l e m o d e l s i n t h e c l i n i c a l s e t t i n g s , t h e r e b y f a c i l i t a t i n g t h e m o v e m e n t o f c o n t i n u i n g e d u c a t i o n 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 . C o o r d i n a t i o n o f P r o g r a m s : O r g a n i z a t i o n s o t h e r t h a n u n i v e r s i t i e s a n d h o s p i t a l s m u s t s h a r e g r e a t e r r e s p o n s i b i l i t y f o r s u p p o r t i n g p r o g r a m s n e c e s s a r y f o r t h e h e a l t h p r a c t i t i o n e r s . J o i n t a n d i n t e r - r e l a t e d p l a n n i n g a m o n g a n d b e t w e e n t h e v a r i o u s g r o u p s c o n c e r n e d h a s b e e n m i n i m a l . T h i s a c c o u n t s f o r t h e l a c k o f i n t e r - r e l a t e d n e s s o f c o u r s e s , a s w e l l a s f o r t h e g r e a t g a p s i n s o m e a r e a s a n d d u p l i c a t i o n s i n o t h e r s . T h e r e 3 0 0 i s a n e e d f o r c e n t r a l c l e a r i n g h o u s e s a n d i n f o r m a t i o n c e n t e r s , w h i c h w o u l d c o l l e c t d a t a o n p r o g r a m s o n a r e g i o n a l , s t a t e o r c o m m u n i t y b a s i s . T h r o u g h s u c h s e r v i c e s , c o n f l i c t s a n d o v e r l a p s w o u l d b e f u r t h e r a v o i d e d . P e r h a p s t o o , t h e t i m e i s r i p e f o r a n o t h e r a t t e m p t t o e s t a b l i s h a n a t i o n a l p l a n . T h e c o n d i t i o n s o f t h e 7 0 ' s a r e a p p r e c i a b l y d i f f e r e n t t o t h o s e e x i s t i n g a t t h e t i m e o f t h e p u b l i c a t i o n o f t h e D r y e r R e p o r t ( 5 ) . S i n c e 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 a r e n o w f a c e d w i t h s i m i l a r a n d i n t e r - r e l a t e d p r o b l e m s a n d n e e d s , t h e y s h o u l d b e i n c l u d e d i n s u c h a p l a n . F i n a n c i n g a n d P r o m o t i n g C o n t i n u i n g E d u c a t i o n : T h e c o s t 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 p r o f e s s i o n s h a s b e e n m e t l a r g e l y t h r o u g h f e e s a n d o r g a n i z a t i o n a l b u d g e t s p r o v i d e d b y t h e s p o n s o r i n g a g e n c i e s . T h i s h a s f r e q u e n t l y m e a n t i n a d e q u a t e f u n d s a n d c o n s e q u e n t l y , p r o g r a m s a r e g e a r e d t o o l o w . O n t h e o t h e r h a n d , w h e r e f u n d s h a v e b e e n a d e q u a t e a n d s u s t a i n i n g , p r o g r a m s h a v e t e n d e d t o e x p a n d a n d g r e w . S o m e o f t h e R M T S a n d N I l i G s u p p o r t e d p r o j e c t s i l l u s t r a t e t h i s ( 3 ) ( 1 5 ) . I n t e r m s o f f e d e r a l f u n d i n g , i n t e r p r o f e s s i o n a l p r o g r a m s s e e m p a r t i c u l a r l y p r o m i s i n g . E v e n m o r e i m p o r t a n t l y , t h o s e p r o g r a m s w h i c h p r o m i s e s o m e t a n g i b l e r e s u l t s a r e m o r e l i k e l y t o s e c u r e f i n a n c i a l a s s i s t a n c e , n o t o n l y f r o m g o v e r n -m e n t s , b u t f r o m t h e m a n y o t h e r s o u r c e s o f f u n d i n g ( 6 ) . I t i s r e c o m m e n d e d t h a t t h e r e b e a s o u n d r e s e a r c h c o m p o n e n t i n p r o g r a m p r o p o s a l s a l o n g w i t h a b e t t e r o r g a n i z e d a n d m o r e c e n t r a l i z e d a p p r o a c h t o f u n d s e e k i n g . A c o m p a r a t i v e r e v i e w o f m o s t m a j o r s t u d i e s s u g g e s t s t h a t o t h e r f i e l d s o f a d u l t e d u c a t i o n a r e f a c i n g s i m i l a r p r o b l e m s ( 3 ) c o n c e r n e d w i t h t h e m a r g i n a l s t a t u s o f c o n t i n u i n g e d u c a t i o n . I t w o u l d b e m u t u a l l y b e n e f i c i a l f o r 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 o r e l a t e m o r e c l o s e l y w i t h t h e b r o a d e r a d u l t e d u c a t i o n c o m m u n i t y . S u c h a s s o c i a t i o n s w o u l d h e l p t o g a i n g r e a t e r n a t i o n a l 301 r e c o g n i t i o n f o r a d u l t l e a r n i n g , a n d w o u l d f a c i l i t a t e t h e e x c h a n g e o f i d e a s . W h e r e a p p r o p r i a t e , s u c h i n t e r - r e l a t i o n s h i p s a m o n g a l l a s p e c t s o f a d u l t e d u c a t i o n w o u l d e n c o u r a g e m u l t i d i s c i p l i n a r y r e s e a r c h a n d p r o g r a m p l a n n i n g . T h e E d u c a t o r i n C o n t i n u i n g E d u c a t i o n ; T o b e r e a l l y 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 i n t h e h e a l t h f i e l d s n e e d s t o b e t t e r p r e p a r e m o r e i n d i v i d u a l s a s i n s t r u c t o r s . T h e p r e s e n t p r a c t i c e o f d e p e n d e n c e o n t h e u n i v e r s i t i e s f o r i n s t r u c t o r s i s u n w i s e , n o t o n l y b e c a u s e f a c u l t y a r e a l r e a d y o v e r b u r d e n e d , b u t a l s o b e c a u s e f a c u l t y o f u n d e r g r a d u a t e p r o g r a m s m a y n o t n e c e s s a r i l y b e c o m p e t e n t t o m e e t t h e n e e d s o f 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 . T h e a s s u m p t i o n t h a t o n l y o n e w i t h s p e c i a l i z e d k n o w l e d g e a n d s k i l l c a n a l s o t e a c h a d u l t s i s i n v a l i d . A n i n s t r u c t o r f o r b u s y h e a l t h p r a c t i t i o n e r s m u s t b e a s p e c i a l i s t i n h i s f i e l d o f p r a c t i c e a n d e q u a l l y c o m p e t e n t i n a d u l t l e a r n i n g a n d i n s t r u c t i o n . M i l l e r (8) h a s c r i t i c i z e d t h e o v e r - d e p e n d enc.p. upon t h e s o - c a l l e d k n o w l e d g e e x p e r t , a n d l i k e K n o w l e s ( 7 ) , h a s a d v o c a t e d t h e u s e o f a n a d u l t l e a r n i n g a p p r o a c h . I n t h i s , t h e c o n t e n t o f c o n t i n u i n g e d u c a t i o n p r o g r a m s e v o l v e s f r o m t h e p r o c e s s o f p r o b l e m s o l v i n g , w h i c h i n t h e h e a l t h p r o f e s s i o n s r e l a t e s t o t h e p r o b l e m s o f c l i n i c a l p r a c t i c e . U s i n g t h i s m o d e l , a n i n s t r u c t o r m a y a t a n y o n e t i m e f u n c t i o n a s t e a c h e r , l e a r n e r , c o n s u l t a n t , o r r e s o u r c e p e r s o n , d e p e n d i n g o n t h e n e e d s o f t h e g r o u p a n d t h e n a t u r e o f t h e l e a r n i n g p r o b l e m s . T h e a b i l i t y o f a n e d u c a t o r t o u s e e f f e c t i v e l y h i s o w n r e s o u r c e s a s w e l l a s t h o s e o f t h e p a r t i c i p a n t s i s a s k i l l w h i c h c a n b e a c q u i r e d t h r o u g h s p e c i a l t r a i n i n g i n t h e t h e o r y a n d p r a c t i c e o f a d u l t e d u c a t i o n . S i n c e a d v a n c e d p r o f e s s i o n a l a c a d e m i c t r a i n i n g i n a d u l t e d u c a t i o n c a n n o t p r o d u c e a s u f f i c i e n t n u m b e r o f s u c h s p e c i a l i s t s , t h i s c a n b e d o n e f o r a l l t h e h e a l t h p r o f e s s i o n s t h r o u g h c o u r s e s o n a d u l t l e a r n i n g . I t w o u l d a l s o b e 302 a d v a n t a g e o u s f o r t h e h e a l t h p r o f e s s i o n s t o e s t a b l i s h r e l a t i o n s h i p s w i t h u n i v e r s i t y a c a d e m i c d e p a r t m e n t s o f a d u l t e d u c a t i o n f o r h e l p a n d a d v i c e i n e d u c a t i o n a l m a t t e r s . O n l y a f e w s u c h r e l a t i o n s h i p s e x i s t a t p r e s e n t . T h i s i s u n f o r t u n a t e s i n c e t h e i r p o t e n t i a l f o r a d v i c e , c o u n s e l , a n d t r a i n i n g , o n m a t t e r s p e r t a i n i n g t o t h e e d u c a t i o n o f a d u l t s i s v e r y r e a l i n d e e d a n d t h e y a r e t h e p r i m a r y r e s o u r c e f o r s u c h h e l p a v a i l a b l e . M E T H O D A N D T E C H N I Q U E S T h e f i n d i n g s o f t h i s s u r v e y h a v e b e e n d i s c u s s e d l a r g e l y w i t h i n t h e f r a m e w o r k o f f o r m a l c o u r s e s p r o v i d e d w i t h i n t h e i n s t i t u t i o n a l s e t t i n g , s i n c e t h a t i s t h e p r i n c i p a l m o d e l u s e d i n 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 f i e l d s . A s d i s c l o s e d i n t h i s r e v i e w , t h e r e a r e m a n y w a y s h e a l t h p r a c t i t i o n e r s s e e k t o m a i n t a i n t h e i r p r o f e s s i o n a l c o m p e t e n c e , a n d t h e t i m e h a s c o m e t o i n c l u d e a l l o f t h e s e v a r y i n g m o d a l i t i e s u n d e r t h e t e r m \" c o n t i n u i n g e d u c a t i o n . \" l u u e e u , I I i t i s t r u e t h a t c o n t i n u i n g e d u c a t i o n s h o u l d a s s i s t t h e h e a l t h p r a c t i t i o n e r t o l e a r n w h a t h e n e e d s , w h e r e , a n d w h e n h e n e e d s i t , t h e n c o n t i n u i n g e d u c a t i o n i n i t s i n s t i t u t i o n a l f o r m m a y n o t b e t h e m o s t e f f e c t i v e w a y o f p r o m o t i n g c o n t i n u i n g l e a r n i n g . N o m a t t e r h o w f l e x i b l y s u c h p r o g r a m s m a y b e o r g a n i z e d , t h e p r o b l e m s o f t i m e , c o s t , a n d d i s t a n c e , w i l l a l w a y s b e l i m i t i n g f a c t o r s f o r s o m e p r a c t i t i o n e r s . O n t h e o t h e r h a n d , t h e e d u c a t i o n a l m e d i a d o h a v e p o t e n t i a l u t i l i t y i n r e d u c i n g s o m e o f t h e s e p r o b l e m s . M o r e o v e r , i t i s a l s o a p p a r e n t t h a t t h e n e w e r e d u c a t i o n a l t e c h n o l o g i e s o f f e r a m e a n s w h e r e b y c o n t i n u i n g s e l f e d u c a t i o n a n d s e l f e v a l u a t i o n m a y b e e n c o u r a g e d . W h i l e t h e i m p a c t o f t h e m e d i a h a s b e e n d i f f i c u l t t o d e t e r m i n e b y r e s e a r c h , f u r t h e r e x p e r i m e n t a t i o n w i t h a n d e v a l u a t i o n o f t h e i r e f f e c t i v e n e s s i s i n d i c a t e d . I n a d d i t i o n , m o r e i n f o r m a t i o n i s n e e d e d o n t h e u s e a n d e f f e c t i v e n e s s o f p r o f e s s i o n a l l i t e r a t u r e , i n f o r m a l c o n s u l t a t i o n s , 303 a n d o t h e r i n f o r m a t i o n s o u r c e s w h i c h h e a l t h p r a c t i t i o n e r s i n d i c a t e a r e i m p o r t a n t s o u r c e s o f t h e i r l e a r n i n g . T h e t e c h n i q u e s o f i n s t r u c t i o n u s e d i n c o n t i n u i n g e d u c a t i o n p r o g r a m s m u s t b e e q u a l l y v a r i e d . T h e r e i s n o o n e r o y a l r o a d t o l e a r n i n g e v e n t h o u g h m a n y s e e m t o t h i n k t h e r e i s . T h e l e c t u r e h a s b e e n j u s t l y c r i t i c i z e d b u t r e s e a r c h d i s c l o s e s t h a t t h e l e c t u r e c a n b e a s e f f e c t i v e a s a n y o t h e r t e c h n i q u e w h e n i t i s u s e d c o r r e c t l y ( 1 4 a ) . T h e e f f e c t i v e u s e o f t h e l e c t u r e d e p e n d s o n t h e n a t u r e o f t h e l e a r n i n g t a s k a s w e l l a s o n t h e a b i l i t y o f t h e p a r t i c i p a n t t o l e a r n f r o m a l e c t u r e , a n d t h i s i n t u r n d e p e n d s o n h o w w e l l a p e r s o n i s a c q u a i n t e d w i t h t h e f i e l d ( 1 6 ) . O n t h e o t h e r h a n d , a l t h o u g h g r o u p d i s c u s s i o n h a s b e e n h i g h l y r e c o m -m e n d e d a s a p a r t i c i p a t i v e t e c h n i q u e a s d i s c l o s e d i n t h i s r e v i e w ( 1 1 ) ( 1 4 ) , u n l e s s i t i s u s e d w i s e l y f o r t h e a p p r o p r i a t e l e a r n i n g t a s k a n d u n l e s s t h e r e i s a n o p e n f e e d b a c k s y s t e m , g r o u p d i s c u s s i o n i s o f l i m i t e d v a l u e . F u r t h e r m o r e , i t w o u l d s e e m t h a t a p r a c t i t i o n e r ' s p r e f e r e n c e f o r a n y s p e c i f i c m e t h o d o r t e c h n i q u e i s r e l a t e d t o m a n y f a c t o r s , i n c l u d i n g h i s f a m i l i a r i t y w i t h t h e d i f f e r e n t t e c h n i q u e s , h i s a g e , a n d e v e n m o r e s i g n i f i c a n t l y , h i s o w n u n i q u e s t y l e o f l e a r n i n g . I n c o n c l u s i o n t h e n , i t c a n b e s a i d t h a t t h e r e i s n o o n e m e t h o d o r t e c h n i q u e w h i c h i s s u p e r i o r t o a l l o t h e r s . M o r e i m p o r t a n t l y , t h e r e s h o u l d b e a v a i l a b l e m a n y d i f f e r e n t c o m b i n a t i o n s o f s y s t e m a t i c a l l y 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 s , u s i n g a w i d e v a r i e t y o f m e t h o d s a n d t e c h n i q u e s , a n d r e i n f o r c e d b y i n t e r - r e l a t e d s e l f i n s t r u c t i o n a l d e v i c e s , b o t h t r a d i t i o n a l a n d m o d e r n . E V A L U A T I O N A s i n m o s t k i n d s o f a d u l t e d u c a t i o n , t h e p r o b l e m o f e v a l u a t i o n r e m a i n s u n s o l v e d . T h e r e s e a r c h o n t h e e v a l u a 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 d o e s s u g g e s t t h a t a t t h e m o m e n t p e r h a p s t h e p r a c t i c a l p r o b l e m s i n t h e h e a l t h c a r e 304 f i e l d l i m i t the extent to which s o c i a l science research techniques f o r evaluation can be ri g o r o u s l y a pplied. It i s very d i f f i c u l t to determine whether health care improves because p r a c t i t i o n e r s r e g u l a r l y p a r t i c i p a t e i n continuing education, or, stated another way, \"whether a b i l i t y to perform the work expected of them i s m a t e r i a l l y diminished i n i t s absence.\" Such being the case, i t would seem unwise f o r the health professions to comply with the increasing pressures to make course attendance a condition f o r p r a c t i c e . Far more v a l i d as a method of re - a p p r a i s a l f o r p e r i o d i c r e l i c e n s u r e would be a separate system f o r evaluating c l i n i c a l competencies. Although the establishment of such a system i s a d i f f i c u l t task, i t i s not impossible as demonstrated by M i l l e r ' s study (9). Furthermore, through the establishment of such a system, continuing education would be kept free from regulation and hence could further develop f l e x i b l e programs using a wide v a r i e t y of methodologies. Copeland (4) provides thp. most appropriate raHnnalp i n support of t h i s s o l u t i o n to the much debated problem of mandatory continuing education. He reminds us that: ...continuing education (and adult education) i s a process whereby men and women improve themselves i n terms of knowledge, s k i l l s , and a t t i t u d e s . In t h i s d e f i n i t i o n , continuing education i s not the work of i n s t i t u t i o n s ; i t i s something that happens i n (not \"to\") the learner (4). SUMMARY As i s apparent, t h i s review of the l i t e r a t u r e i s l a r g e l y i m p r e s s i o n i s t i c and based on data that are rather tenuous i n nature. Nevertheless, the generalized implications derived from proceedings of conferences, research (loosely defined), program brochures, and many other d e s c r i p t i v e sources, have helped to i d e n t i f y some of the broad problem areas to which continuing education i n the four senior health professions must address i t s e l f . 305 To summarize, these problems are: l ) l a c k of c l a r i t y i n d e f i n i t i o n of terms, 2) the secondary place afforded continuing education, 3) the lack of q u a l i f i e d adult educators; 4)the need f o r more and bet t e r adult education research, and 5) the l i m i t a t i o n s of course objectives and lac k of i n t e r -relatedness i n terms of o v e r a l l program goals. Although e f f o r t s to resolve these problems have been l a r g e l y u n i -professional and i n s t i t u t i o n a l , the fin d i n g s of t h i s survey i n d i c a t e that much more could be accomplished through j o i n t e f f o r t s , both i n t r a 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 . Furthermore, present trends suggest that as health care becomes inc r e a s i n g l y complex, the present p r a c t i c e of a s i n g l e health profession functioning independently i s r a p i d l y becoming obsolete. Accordingly, continuing education i n the health sciences must seek to e s t a b l i s h program models, which w i l l f a c i l i t a t e u n i p r o f e s s i o n a l as w e l l as j o i n t i n q u i r y i n t o s h a r e d p r o b l e m s r e l a t e d to patients and health care (12). 306 REFERENCES 1. American Medical A s s o c i a t i o n , Proceedings: National Conference of State Medical Association Representatives on Continuing Medical Education, Chicago, I l l i n o i s , Department of Continuing Medical Education, American Medical A s s o c i a t i o n , November 12-14, 1968. 2. Axford, R., \"Curriculum and Content,\" In, Aker, G., Smith, R., Kidd, R., (eds.), Handbook of Adult Education, MacMillan Company, New York, 1970, p. 402. 3. Conley, V., Larson, C., \"Among Regional Medical Programs\u00E2\u0080\u0094An Enduring Commitment,\" Journal of Continuing Education i n Nursing, 1:28-33, (November-December, 1970). 4. Copeland, H., \"Change and Continuing Education,\" In, McHenry, R., (ed.), Ends and Means: The National Conference on Continuing Education i n Nursing, 1970, Syracuse U n i v e r s i t y P u b l i c a t i o n s i n Continuing Education, New York, 1971, pp. 100-115. 5. Dryer, B., \"Lifetime Learning f o r Physicians: P r i n c i p l e s , P r a c t i c e s and Purposes,\" Journal of Medical Education, 37:1-134, (June, 1962). 6. Hartman, C , \"Funding Continuing Education Programs,\" American Journal of Pharmaceutical Education, 33:774-781, (December, 1969). 7. Knowles, M., \"Gearing Adult Education f o r the Seventies,\" Journal of Continuing Nursing Education, 5:11-15, (May, 1970). 8. M i l l e r , G., \"Continuing Education f o r What?\" Journal of Medical Education, 42:320-326, ( A p r i l , 1967). 9. M i l l e r , G., \"The Orthopedic T r a i n i n g Study,\" The Journal of the American Medical A s s o c i a t i o n , 206:601-606, (October 14, 1968). 10. 0'Shea, R., Black, S., \"Short Courses f o r Dentists: Some Survey Results,\" Journal of the American College of Dentists, 32:32-41, (January, 1965). 11. Report of I n s t i t u t e s f o r Teaching Personnel, Registered Nurses' As s o c i a t i o n of Ontario, August 1966-July 1967. 12. Report of an In t e r p r o f e s s i o n a l Task Force, Continuing Education f o r the Health Professions, U n i v e r s i t y of I l l i n o i s , College of Medicine, Center f o r the Study of Medical Education, 1966. 13. R i s i n g , J . , \"Continuing Education f o r Health Personnel,\" Proceedings of the Second Annual Convention of the A s s o c i a t i o n of Schools of A l l i e d Health Professions, Washington, D.C, 1969, pp.166-172. 14. Stuen, M. et a l , \"Report of a Post Graduate P s y c h i a t r i c Education P r o j e c t , \" Northwest Medicine, (October, 1962), pp. 856-859. 3 0 7 1 4 a . V e r n e r , C , D i c k i n s o n , G . , \" T h e L e c t u r e : A n A n a l y s i s a n d R e v i e w o f R e s e a r c h , \" A d u l t E d u c a t i o n , 1 7 : 8 5 - 1 0 0 , ( W i n t e r , 1 9 6 7 ) . 1 5 . W e b s t e r , T . , O z a r i n , L , \" F e d e r a l 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 i n M e n t a l H e a l t h P r o g r a m s , \" H o s p i t a l a n d C o m m u n i t y P s y c h i a t r y , 1 9 : 1 8 7 - 1 9 2 , ( J u n e , 1 9 6 8 ) . 1 6 . \" W h y C o n t i n u i n g E d u c a t i o n ? \" P e n n s y l v a n i a M e d i c i n e , 7 1 : 1 1 5 - 1 1 7 , ( S e p t e m b e r , 1 9 6 8 ) . 1 7 . W i l l i a m s o n , J . e t a l . , \" P r i o r i t i e s i n P a t i e n t C a r e R e s e a r c h 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 , \" 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 , 2 0 4 : 9 3 - 9 8 , ( A p r i l 2 2 , 1 9 6 8 ) . "@en . "Thesis/Dissertation"@en . "10.14288/1.0101870"@en . "eng"@en . "Administrative, Adult and Higher Education"@en . "Vancouver : University of British Columbia Library"@en . "University of British Columbia"@en . "For non-commercial purposes only, such as research, private study and education. Additional conditions apply, see Terms of Use https://open.library.ubc.ca/terms_of_use."@en . "Graduate"@en . "Continuing education in the health professions: a literature review pertinent to North America"@en . "Text"@en . "http://hdl.handle.net/2429/33995"@en .