Refer to: Sayre SA: Continuing education: A medical school responsibility? (Medical Education). West J Med 131: 77-81, Jul 1979
Medical Education
Continuing Education: A Medical School Responsibility? SIMON A. SAYRE, MD, Los Angeles
of medical school deans sheds some light on current attitudes and practices regarding continuing education. The role of medical schools as leaders in continuing medical education should be clarified.
A
survey
THE HISTORY of medical education in the United States has clearly been influenced by the public's perception of health care needs. The Flexner Report responded to a widely recognized uneven quality of professional care resulting from an unsupervised (and in many instances substandard) system of undergraduate instruction. With this mandate, medical schools developed rigorous criteria for admissions and created a demanding course of study that required total commitment to the process of becoming a physician. From the knowledge explosion that accompanied and followed World War II came an awakening to the need for specialization in medical education. Emphasis shifted to internship and residency training. Although postgraduate house officer education is accredited in some non-
affiliated hospitals, most teaching hospitals are associated with medical schools which provide varying amounts of faculty time. Again, public expectations of high level technical expertise resulted in an educational revolution, this time in postgraduate training. The consumer protection movement of the 1970's has been concerned with the issue of conDr. Sayre is Coordinator, Division of Medicine, Department of Extension; AsContinuing Education in Health Sciences, UCLA Gynesistant Clinical Professor, Department of Obstetrics and UCLA cology, UCLA Medical School, and formerly Lecturer, School of Public Health, Los Angeles. Reprint requests to: Simon A. Sayte, MD, University Extension, UCLA Continuing Education in Health Sciences, P.O. Box 24902, Los Angeles, CA 90024.
tinuing professional competence. Politicians and other public spokesmen are focusing on assurance of professional quality extending throughout the lifetime of every practicing physician. In an era of rapidly expanding technological change, the question of currency in professional behavior is germane. By the beginning of 1978 a total of 17 states had mandated continuing medical education requirements for relicensure of physicians, with other states moving in this direction. Medical societies of 15 states and the District of Columbia had also made continuing medical education a condition of membership.' The United States Department of Health, Education, and Welfare is actively involved in the issue of professional competence. The Bureau of Health Manpower perceives the medical malpractice crisis as evidence of the public's dissatisfaction with present means of maintaining quality health care. In a recent monograph, the Bureau of Health Manpower explores possible pathways by which state and federal agencies might develop effective strategies to assure continuous excellence in professional performance.2 A recent article in THE WESTERN JOURNAL OF MEDICINE examined the present status of continuing medical education, and concluded with a call for research and development to further the state of the art.3 THE WESTERN JOURNAL OF MEDICINE
77
CONTINUING MEDICAL EDUCATION
Against the backdrop of public concern and some appropriate response practicing physiciansthe object of this controvery-see the emergence of a multimillion dollar enterprise dedicated to improving them in the name of the public good. Each week most practicing physicians receive literally scores of educational brochures and public relations announcements that proclaim the benefits of attending particular programs. The sponsors of these offerings include local and state medical societies, colleges and academies of the medical specialties, university hospitals, communty hospitals, proprietary hospitals, chemical laboratories, independent medical school professors and some commercial self-appointed educational institutes. Courses cover the entire range of medical and biological sciences, but there is an obvious clustering of subjects believed to be particularly attractive to clinicians. The programs are usually offered on university campuses and in nearby hotels when sponsored by medical school departments. Other sponsoring agencies offer their courses at domestic and international recreational locations or on cruise ships, urging the potential attendee to combine his continuing education with vacation, making it all a tax deductible package. It is estimated that more than 1.4 billion dollars is now spent (in terms of direct payment and physician time) on continuing education.4 ReNumber of schools 20 19 18 17 16 15
searchers and entrepreneurs are developing and testing innovative technologies using programmed learning methods, audiovisual aids and computerized teaching programs. Continuing medical education is a reality that will, no doubt, have an impact on the professional life of each practicing physician within the next decade. Out of this complex array of disorganized activity, some leadership must emerge. Goals and objectives must be defined and standards of educational quality must be set. American medical schools should, by rights, assume the responsibility because they traditionally have been the primary repository of medical research and teaching expertise. That their people have the skills and talents necessary has been shown clearly at the undergraduate and postgraduate (house officer) levels. With this hypothesis in mind, what is the current status of continuing medical education in the medical schools throughout the United States? A questionnaire was sent to 113 deans of medical schools in December 1977. By March 1, 1978. there had been responses from 98 schools (87 percent). The questions and an analysis of the answers follow: 1. Do you have a department of continuing education? All of the schools had some formal programs of continuing education, although they were ad-
19
14
13 12 11
NO ANS 1-10 Number of courses offered
11-20
21-30
31-40
41-50
51-60
61-70
71-80
81-90
91-100
101-110
111-320
Figure 1.-Distribution of continuing medical education courses offered by American medical schools. 78
JULY 1979
*
131
*
1
CONTINUING MEDICAL EDUCATION
ministered differently-by a department, division, office, or the like. 2. Is the department of continuing education under the jurisdiction of the dean of the medical school? If not, under whose jurisdiction does it operate? Interpretation of these answers was occasionally difficult because the organization tables of the schools vary widely. It seems, however, that the dean supervises this activity directly (or through an assistant dean), in 86 of the institutions that responded. A total of 12 departments of continuing medical education apparently operate somewhat more independently under a separate university organization such as a university extension. 3. Does the department of continuing education receive financial support from the medical school or university, or both? Of the departments, 83 are funded to some extent by their institutions. The most common arrangement requires that support for programs be derived from attendance fees, but the schools supply the dollars for basic operating expenses. Fifteen respondents replied that they are on zero base budgeting, and must generate all their support money from attendance fees. 4. How many formal, didactic continuing medical education courses have you planned for the current academic year? The range was extremely wide from 3 to 364 courses. Only eight schools, however, offered 100 or more courses (and they may have included informal, regular, in-house programs, such as grand rounds in this total). Most responses were in the 31- to 40-course range (see Figure 1) and the median was 35 courses.
5. Do you plan to expand your continuing education program next year? Attesting to growing awareness of community needs in continuing medical education, 81 schools responded in the affirmative. Fourteen did not plan any increase in course offerings (of these two said that budgetary restrictions limited their operation). Two were not sure, and one failed to answer. 6. What do you charge for a class hour of
education? The answers were somewhat difficult to interpret because 11 schools did not respond and five gave vague replies, such as "varies." Eightytwo schools firmly stated a single average figure or a narrow range (for example, $5 to $10 or $10 to $15). Most were in the $5-to-$10 range with a median of $10 (see Figure 2). 7. What is the range of honoraria for an hour of presentation? Twenty-eight schools do not pay full-time faculty for participation in continuing medical education because it is considered part of their teaching responsibility. One school distributed a percentage of the net income to the cooperating clinical departments that determine the use of excess funds. Six schools said that the honorarium not only includes the presentation, but also requires a full day of participation in the course (panels, workshops, and the like). Interpreting the figures in terms of maximum honorarium, the peak of the curve is $150 (see Figure 3). Nine schools pay as much as $500 for a guest speaker. One would assume that these speakers are exceptional, with national or international reputations.
Number of schools
601
59
50 4030
20' 10'
n8
I l -1 6-10 1-5 Cost per class hour ($)
H
O
11-15
16i-20
I
LI 21-25
n >25
Indef
Figure 2.-Range of fees charged by American medical schools for continuing medical education.
THE WESTERN JOURNAL OF MEDICINE
79
CONTINUING MEDICAL EDUCATION
8. Approximately what percentage of your courses are given on campus? Three schools gave no continuing medical education courses on campus; one school stated that this was due to lack of adequate facilities which forced them to use hotels. Five schools replied that they gave all classes on campus. The median was 70 percent of programs offered at the medical school or university facility (see Figure 4). Four schools did not respond. 9. Do you give courses at vacation or recreational locations? Please state your opinions of this practice. Forty-five deans replied yes and fifty-three replied no. Attitudes towards the practice tended to be negative, even among those who do give
courses in recreational areas. Many schools condemned this practice.
Discussion If medical schools are to provide greatly needed leadership in continuing medical education, as they provided in undergraduate instruction at the time of the Flexner Report, standards of quality in processes and content must be developed and a universal commitment to excellence will be required. This study was designed to determine the current position of the medical schools regarding continuing medical education, which is being molded at present by many conflicting forces. Our sampling seems to indicate that American
Number of respondents
251 20
-
15
10' 5-
fl2 25 50 Maximum honorarium ($)
75
100
150
200
250
300
>300
Figure 3.-Maximum honorarium paid to continuing medical education instructors. Number of schools 201
181
0 1-10 11-20 Percent of courses on campus
21-30
31-40
41-50
51-60
61-70
71-80
81-90
91-100
Figure 4.-Percentage of continuing medical education courses given on medical school campuses. 80
JULY 1979
*
131
*
1
CONTINUING MEDICAL EDUCATION
medical schools recognize the need for continuing medical education. The wide range in the number of courses offered, however, reflects indecision regarding proper levels of commitment. If the continuous education of practicing physicians is an academic responsibility, postgraduate medical schools would be a logical extension of undergraduate and house-officer training and the concept of a total postgraduate curriculum would follow. Question 3 introduces the key issue of financing. As with undergraduate training, funding responsibility must ultimately be shared. In this free society, dominated by fee-for-service medicine, clinicians can certainly support the direct costs of each program. However, the infrastructure of institutions cannot be dependent on attendance fees if we are to move from programming trendy subjects to total curriculum development. A dependable stream of dollars is necessary for assuring quality and the widest possible assortment of opportunities. The divided focus of a continuing medical education program on zero based budgeting must result in academic compromise. Some responses to this question indicated that the institutional goal was to make continuing medical education totally self-supporting, which in this context seems counterproductive. Rather, schools should work together to develop a strategy to assure ongoing and dependable financing for continuing medical education. Questions 6 and 7 may seem narrow, but they relate to broad issues critical to the viability of medical school programming. With the appearance of state requirements for professional reeducation, control and financing are problems for government licensing bodies. Within the medical establishment there are many agencies which consider themselves appropriate -leaders in the development of continuing education. Among these, community hospitals and medical societies have been particularly vocal. Ultimately, however, these agencies, which are predominantly concerned with services for and care of patients, must turn to the vast resources of teaching and research talent of medical schools.
Two problems emerge. On one, hand practicing physicians, unaccustomed to paying for ongoing education, are outraged by what they perceive as a special state-imposed financial burden mediated by the educating agency (for example, the medical school); and on the other hand, full-time medical school faculty members, already heavily burdened by undergraduate teaching, patient care and research responsibilities resent new demands that have little or no academic or financial reward. With the evolution and growth of continuing medical education, these conflicts must be resolved. At present, they can be burdensome to coordinators of active continuing medical education programs, particularly when planning the budget. The final two questions shed light on the quandary planners face in finding a locale for their programs. The frequent use of off campus auditoriums reflects the low priority schools place on their commitment to community education. This commitment is a relatively new concept and one would hope that adequate on-campus facilities wili become part of future plans. Whether or not to use recreational sites generates considerable emotion. Both viewpoints can be convincingly argued. One question not asked, however, was "do you plan undergraduate programs in Tahiti?" The answers and conclusions seem obvious.
Summary The current status of continuing medical education is reviewed. Results from questionnaires sent to deans of American medical schools are given. Issues involved in the development of the questionnaire and generated by the answers are discussed. REFERENCES 1. Continuing Medical Education Fact Sheet. American Medical Association, Apr 1, 1977 2. Competence in the Medical Professions: A Strategy. DHEW Publication No (HRA) 77-35. Health Resources Administration, 1977, pp 1-8 3. Manning PR: Continuing medical education in midpassage. West J Med 128:260-265, Mar 1978 4. Miller LA: The current investment in Continuing Medical Education, chap 14, In Egdall RH, Gertman PM (Eds): Quality Health Care. Germantown, MD, Aspen Systems Corp, 1977, pp 143-160
THE WESTERN JOURNAL OF MEDICINE
81
Medical Education
Continuing Education: A Medical School Responsibility? SIMON A. SAYRE, MD, Los Angeles
of medical school deans sheds some light on current attitudes and practices regarding continuing education. The role of medical schools as leaders in continuing medical education should be clarified.
A
survey
THE HISTORY of medical education in the United States has clearly been influenced by the public's perception of health care needs. The Flexner Report responded to a widely recognized uneven quality of professional care resulting from an unsupervised (and in many instances substandard) system of undergraduate instruction. With this mandate, medical schools developed rigorous criteria for admissions and created a demanding course of study that required total commitment to the process of becoming a physician. From the knowledge explosion that accompanied and followed World War II came an awakening to the need for specialization in medical education. Emphasis shifted to internship and residency training. Although postgraduate house officer education is accredited in some non-
affiliated hospitals, most teaching hospitals are associated with medical schools which provide varying amounts of faculty time. Again, public expectations of high level technical expertise resulted in an educational revolution, this time in postgraduate training. The consumer protection movement of the 1970's has been concerned with the issue of conDr. Sayre is Coordinator, Division of Medicine, Department of Extension; AsContinuing Education in Health Sciences, UCLA Gynesistant Clinical Professor, Department of Obstetrics and UCLA cology, UCLA Medical School, and formerly Lecturer, School of Public Health, Los Angeles. Reprint requests to: Simon A. Sayte, MD, University Extension, UCLA Continuing Education in Health Sciences, P.O. Box 24902, Los Angeles, CA 90024.
tinuing professional competence. Politicians and other public spokesmen are focusing on assurance of professional quality extending throughout the lifetime of every practicing physician. In an era of rapidly expanding technological change, the question of currency in professional behavior is germane. By the beginning of 1978 a total of 17 states had mandated continuing medical education requirements for relicensure of physicians, with other states moving in this direction. Medical societies of 15 states and the District of Columbia had also made continuing medical education a condition of membership.' The United States Department of Health, Education, and Welfare is actively involved in the issue of professional competence. The Bureau of Health Manpower perceives the medical malpractice crisis as evidence of the public's dissatisfaction with present means of maintaining quality health care. In a recent monograph, the Bureau of Health Manpower explores possible pathways by which state and federal agencies might develop effective strategies to assure continuous excellence in professional performance.2 A recent article in THE WESTERN JOURNAL OF MEDICINE examined the present status of continuing medical education, and concluded with a call for research and development to further the state of the art.3 THE WESTERN JOURNAL OF MEDICINE
77
CONTINUING MEDICAL EDUCATION
Against the backdrop of public concern and some appropriate response practicing physiciansthe object of this controvery-see the emergence of a multimillion dollar enterprise dedicated to improving them in the name of the public good. Each week most practicing physicians receive literally scores of educational brochures and public relations announcements that proclaim the benefits of attending particular programs. The sponsors of these offerings include local and state medical societies, colleges and academies of the medical specialties, university hospitals, communty hospitals, proprietary hospitals, chemical laboratories, independent medical school professors and some commercial self-appointed educational institutes. Courses cover the entire range of medical and biological sciences, but there is an obvious clustering of subjects believed to be particularly attractive to clinicians. The programs are usually offered on university campuses and in nearby hotels when sponsored by medical school departments. Other sponsoring agencies offer their courses at domestic and international recreational locations or on cruise ships, urging the potential attendee to combine his continuing education with vacation, making it all a tax deductible package. It is estimated that more than 1.4 billion dollars is now spent (in terms of direct payment and physician time) on continuing education.4 ReNumber of schools 20 19 18 17 16 15
searchers and entrepreneurs are developing and testing innovative technologies using programmed learning methods, audiovisual aids and computerized teaching programs. Continuing medical education is a reality that will, no doubt, have an impact on the professional life of each practicing physician within the next decade. Out of this complex array of disorganized activity, some leadership must emerge. Goals and objectives must be defined and standards of educational quality must be set. American medical schools should, by rights, assume the responsibility because they traditionally have been the primary repository of medical research and teaching expertise. That their people have the skills and talents necessary has been shown clearly at the undergraduate and postgraduate (house officer) levels. With this hypothesis in mind, what is the current status of continuing medical education in the medical schools throughout the United States? A questionnaire was sent to 113 deans of medical schools in December 1977. By March 1, 1978. there had been responses from 98 schools (87 percent). The questions and an analysis of the answers follow: 1. Do you have a department of continuing education? All of the schools had some formal programs of continuing education, although they were ad-
19
14
13 12 11
NO ANS 1-10 Number of courses offered
11-20
21-30
31-40
41-50
51-60
61-70
71-80
81-90
91-100
101-110
111-320
Figure 1.-Distribution of continuing medical education courses offered by American medical schools. 78
JULY 1979
*
131
*
1
CONTINUING MEDICAL EDUCATION
ministered differently-by a department, division, office, or the like. 2. Is the department of continuing education under the jurisdiction of the dean of the medical school? If not, under whose jurisdiction does it operate? Interpretation of these answers was occasionally difficult because the organization tables of the schools vary widely. It seems, however, that the dean supervises this activity directly (or through an assistant dean), in 86 of the institutions that responded. A total of 12 departments of continuing medical education apparently operate somewhat more independently under a separate university organization such as a university extension. 3. Does the department of continuing education receive financial support from the medical school or university, or both? Of the departments, 83 are funded to some extent by their institutions. The most common arrangement requires that support for programs be derived from attendance fees, but the schools supply the dollars for basic operating expenses. Fifteen respondents replied that they are on zero base budgeting, and must generate all their support money from attendance fees. 4. How many formal, didactic continuing medical education courses have you planned for the current academic year? The range was extremely wide from 3 to 364 courses. Only eight schools, however, offered 100 or more courses (and they may have included informal, regular, in-house programs, such as grand rounds in this total). Most responses were in the 31- to 40-course range (see Figure 1) and the median was 35 courses.
5. Do you plan to expand your continuing education program next year? Attesting to growing awareness of community needs in continuing medical education, 81 schools responded in the affirmative. Fourteen did not plan any increase in course offerings (of these two said that budgetary restrictions limited their operation). Two were not sure, and one failed to answer. 6. What do you charge for a class hour of
education? The answers were somewhat difficult to interpret because 11 schools did not respond and five gave vague replies, such as "varies." Eightytwo schools firmly stated a single average figure or a narrow range (for example, $5 to $10 or $10 to $15). Most were in the $5-to-$10 range with a median of $10 (see Figure 2). 7. What is the range of honoraria for an hour of presentation? Twenty-eight schools do not pay full-time faculty for participation in continuing medical education because it is considered part of their teaching responsibility. One school distributed a percentage of the net income to the cooperating clinical departments that determine the use of excess funds. Six schools said that the honorarium not only includes the presentation, but also requires a full day of participation in the course (panels, workshops, and the like). Interpreting the figures in terms of maximum honorarium, the peak of the curve is $150 (see Figure 3). Nine schools pay as much as $500 for a guest speaker. One would assume that these speakers are exceptional, with national or international reputations.
Number of schools
601
59
50 4030
20' 10'
n8
I l -1 6-10 1-5 Cost per class hour ($)
H
O
11-15
16i-20
I
LI 21-25
n >25
Indef
Figure 2.-Range of fees charged by American medical schools for continuing medical education.
THE WESTERN JOURNAL OF MEDICINE
79
CONTINUING MEDICAL EDUCATION
8. Approximately what percentage of your courses are given on campus? Three schools gave no continuing medical education courses on campus; one school stated that this was due to lack of adequate facilities which forced them to use hotels. Five schools replied that they gave all classes on campus. The median was 70 percent of programs offered at the medical school or university facility (see Figure 4). Four schools did not respond. 9. Do you give courses at vacation or recreational locations? Please state your opinions of this practice. Forty-five deans replied yes and fifty-three replied no. Attitudes towards the practice tended to be negative, even among those who do give
courses in recreational areas. Many schools condemned this practice.
Discussion If medical schools are to provide greatly needed leadership in continuing medical education, as they provided in undergraduate instruction at the time of the Flexner Report, standards of quality in processes and content must be developed and a universal commitment to excellence will be required. This study was designed to determine the current position of the medical schools regarding continuing medical education, which is being molded at present by many conflicting forces. Our sampling seems to indicate that American
Number of respondents
251 20
-
15
10' 5-
fl2 25 50 Maximum honorarium ($)
75
100
150
200
250
300
>300
Figure 3.-Maximum honorarium paid to continuing medical education instructors. Number of schools 201
181
0 1-10 11-20 Percent of courses on campus
21-30
31-40
41-50
51-60
61-70
71-80
81-90
91-100
Figure 4.-Percentage of continuing medical education courses given on medical school campuses. 80
JULY 1979
*
131
*
1
CONTINUING MEDICAL EDUCATION
medical schools recognize the need for continuing medical education. The wide range in the number of courses offered, however, reflects indecision regarding proper levels of commitment. If the continuous education of practicing physicians is an academic responsibility, postgraduate medical schools would be a logical extension of undergraduate and house-officer training and the concept of a total postgraduate curriculum would follow. Question 3 introduces the key issue of financing. As with undergraduate training, funding responsibility must ultimately be shared. In this free society, dominated by fee-for-service medicine, clinicians can certainly support the direct costs of each program. However, the infrastructure of institutions cannot be dependent on attendance fees if we are to move from programming trendy subjects to total curriculum development. A dependable stream of dollars is necessary for assuring quality and the widest possible assortment of opportunities. The divided focus of a continuing medical education program on zero based budgeting must result in academic compromise. Some responses to this question indicated that the institutional goal was to make continuing medical education totally self-supporting, which in this context seems counterproductive. Rather, schools should work together to develop a strategy to assure ongoing and dependable financing for continuing medical education. Questions 6 and 7 may seem narrow, but they relate to broad issues critical to the viability of medical school programming. With the appearance of state requirements for professional reeducation, control and financing are problems for government licensing bodies. Within the medical establishment there are many agencies which consider themselves appropriate -leaders in the development of continuing education. Among these, community hospitals and medical societies have been particularly vocal. Ultimately, however, these agencies, which are predominantly concerned with services for and care of patients, must turn to the vast resources of teaching and research talent of medical schools.
Two problems emerge. On one, hand practicing physicians, unaccustomed to paying for ongoing education, are outraged by what they perceive as a special state-imposed financial burden mediated by the educating agency (for example, the medical school); and on the other hand, full-time medical school faculty members, already heavily burdened by undergraduate teaching, patient care and research responsibilities resent new demands that have little or no academic or financial reward. With the evolution and growth of continuing medical education, these conflicts must be resolved. At present, they can be burdensome to coordinators of active continuing medical education programs, particularly when planning the budget. The final two questions shed light on the quandary planners face in finding a locale for their programs. The frequent use of off campus auditoriums reflects the low priority schools place on their commitment to community education. This commitment is a relatively new concept and one would hope that adequate on-campus facilities wili become part of future plans. Whether or not to use recreational sites generates considerable emotion. Both viewpoints can be convincingly argued. One question not asked, however, was "do you plan undergraduate programs in Tahiti?" The answers and conclusions seem obvious.
Summary The current status of continuing medical education is reviewed. Results from questionnaires sent to deans of American medical schools are given. Issues involved in the development of the questionnaire and generated by the answers are discussed. REFERENCES 1. Continuing Medical Education Fact Sheet. American Medical Association, Apr 1, 1977 2. Competence in the Medical Professions: A Strategy. DHEW Publication No (HRA) 77-35. Health Resources Administration, 1977, pp 1-8 3. Manning PR: Continuing medical education in midpassage. West J Med 128:260-265, Mar 1978 4. Miller LA: The current investment in Continuing Medical Education, chap 14, In Egdall RH, Gertman PM (Eds): Quality Health Care. Germantown, MD, Aspen Systems Corp, 1977, pp 143-160
THE WESTERN JOURNAL OF MEDICINE
81
