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2 Myths and Mistakes in Graduate and Continuing Medical Education Teaching about genetics and genomics requires touching on a broad range of issues that are relevant throughout the health care system be- cause these disciplines bring together the science of medicine, patient centeredness, ethical decision making, and commercial support, said David A. Davis, the senior director of continuing education and perfor- mance improvement with the Association of American Medical Colleges (AAMC). Davis described some of the myths and mistakes in graduate and continuing professional education in medicine and traced how these myths and mistakes contribute to a serious problem in the health care system: the gap between what is known by medical researchers about genetic influences on health and how this knowledge is applied in current medical practice. EDUCATION MYTHS A number of myths have been perpetuated about educating health professionals, Davis said. The first myth is that it is always good to pro- vide people with more information. When there is no information, giving information to individuals tends to improve their performance. However, once an optimal point is reached, improvements tend to decline or disap- pear, Davis said, citing the YerkesâDodson Law (Yerkes and Dodson, 1908). The second myth is that education only occurs through lectures or by attending conferences. But health care providers âlearn every hour of every day,â Davis said, not just in conferences or courses. A related myth is that lectures change behavior. Didactic sessions largely do not lead to 7
8 IMPROVING GENETICS EDUCATION improved professional practice (Forsetlund et al., 2009). Behavior changes are much more likely to be elicited by audit and feedback or by more interactive sessions, Davis said. A fourth myth is that continuing medical education is only for physi- cians or about the receipt of credit. In fact, all health care providers need such education, Davis said, and they actually have many reasons for par- ticipating in educational activities. Finally, it is a myth that continuing medical education and, to some extent, graduate medical education, are isolated activities unrelated to health systems, health care delivery, or patient outcomes, Davis said. âIf we think about it that way, we are bound to fail in genomics education.â THE CLINICAL CARE GAP Today, a gap exists between the knowledge available to inform health care and what actually happens in health care settings, Davis said. That gap may manifest itself in a lack of information about a fast- spreading infectious disease, the errors that occur in emergency rooms, the proper use of diagnostic imagers, doctorâpatient communications, health disparities among counties or states, or the difference between ideal evidence-based practice, as represented by the many published guidelines available to doctors, and current practice, as represented by the paper records in many doctorsâ offices. The clinical care gap, Davis said, has several origins, including the evidence supporting or the guideline directing a practice, the educational delivery system, clinician training, and issues with the health care sys- tem. Clinicians can be overwhelmed by the amount of information that exists. The national guideline clearinghouse maintained by the Agency for Healthcare Research and Quality has approximately 3,000 sets of guidelines.1 For each, clinicians must consider such factors as the relative advantage of a guideline to a clinician and a patient, the compatibility of a guideline with practice, its complexity, its cost, its observability in practice, and its sustainability. Guidelines must also be carefully thought about, Davis said, because they do not traditionally incorporate experien- tial evidence. 1 See http://www.guideline.gov (accessed November 11, 2014).
MYTHS AND MISTAKES 9 Clinicians undergo many years of training, Davis said, and some forms of education are more effective than others. For example, flipped classrooms, in which students listen to lectures outside the classroom and work on specific problems with their instructors, have been shown to be more effective in many cases than traditional lecture-based classes. Ef- fective education may take the form of predisposing individuals to change, as well as enabling and reinforcing that change. As is the case with people in general, physicians are not very self-aware, Davis said. âWe do not know what we do not know. Thinking about education, ab- sent things like feedback and observable data, means that learning may fall fallow.â Finally, many complex aspects of the health care system influence the translation of evidence to practice, including the roles of health care teams, the availability and utilization of resources, governance, and leadership. CONTINUING MEDICAL EDUCATION AND THE CLINICAL CARE GAP Does continuing medical education, Davis asked, change the behav- ior of physicians and improve health outcomes? It can, he said, but many of the myths surrounding and mistakes present within continuing medical education can contribute to the clinical care gap. A major portion of continuing medical education fails to reflect the research literature on educational effectiveness, Davis said. For example, the research shows that providing knowledge is necessary but not suffi- cient for change. Rather, as discussed earlier, effective education often involves predisposing people to change, enabling change, and reinforcing change in addition to providing knowledge. Other results of education research also bear on medical education, Davis said. For example, approach- es that elicit interactivity are better instructional tools than lectures; these approaches include case discussions, reflection, and audience-response sys- tems. Needs assessments followed by performance feedback are also im- portant to effective instruction. And learning can occur in many placesâ online, from patients, from reminders at the point of care, from simula- tions, from small-group learning activities, from algorithms and care pathways, and from todayâs ubiquitous âsmartphones and tablets.â Finally, continuing medical education and graduate medical educa- tion do not occur in isolation. Many factors influence them, including accreditation requirements, quality improvement initiatives, new tech-
10 IMPROVING GENETICS EDUCATION nologies, the information explosion, the Affordable Care Act, and benchmark techniques. Continuing medical education is a very large enterprise, Davis noted. According to data from the Accreditation Council for Continuing Medi- cal Education, physicians participated almost 14 million times and allied health professionals participated more than 9 million times in 2011,2 par- ticipating in 953,000 hours of instruction and 133,000 activities. Yet, despite all this activity, the clinical care gap persists, Davis said. âWe need to think about better ways to do it.â LESSONS LEARNED The framing and language of the message that is wanted to be con- veyed need to be carefully thought out, Davis said. Is a 70-page guideline needed, or could it be a simple guidance that is consistent with current practices? The relative advantage a guideline might have, its compatibil- ity with practice and complexity, the added costs to providers and pa- tients, and the sustainability of the practice over time should be considered, Davis said. More effective means of education are available, Davis said, and they need to be used (IOM, 2010). Just-in-time learning, for example, enhances interactivity and provides information that is likely to be more relevant to the task at hand. (Discussed in detail in Chapter 3.) All health professionals should be involved in continuing medical education, not just physicians, Davis said. In addition, the staging of ed- ucational innovations or interventions needs to be considered. For exam- ple, evidence-based practice can be conveyed through role models rather than didactically, although ensuring a sufficient supply of faculty may be a problem. Leverage change, Davis suggested. Identify other things that are oc- curring in the health care system that may be able to reduce the clinical care gap and leverage those to elicit the desired change. For example, Davis mentioned an implementation planning guide for continuing medi- cal education called the PROCEED model that is based on the idea of 2 Individuals might attend multiple activities during a year, thus these numbers do not reflect the total number of health professionals that participate in continuing medical education; http://www.accme.org/news-publications/publications/annual-report-data/accme- annual-report-data-2011 (accessed November 11, 2014).
MYTHS AND MISTAKES 11 predisposing an individual to change, enabling that change to occur, and reinforcing that change (Davis et al., 2003). Predisposing, enabling, and adopting might involve workshops, small-group learning sessions, or just-in- time learning activities. Adherence might involve reinforcement through such means as audits, feedback, and point-of-care reminders. Another exist- ing resource is the MedEdPORTAL website (www.mededportal.org) of AAMC, which provides genetics teaching resources. Finally, as in all areas of education, messages can be spread by embedding them within current education and practice approaches and by using a train-the-trainer model. âWe do not need to re-create the wheel,â Davis concluded.
