Participation in CME activities.

OBJECTIVE: To compare the continuing medical education (CME) activities of family physicians in the province of Quebec with more than 25 years in practice with those with less than 25 years in practice. DESIGN: Mailed questionnaire survey. SETTING: Family practices in the province of Quebec. PARTICIPANTS: All physicians (n = 722) with more than 25 years in practice (expressed as older) and a matched sample of 721 physicians with less than 25 years in practice (expressed as younger). MAIN OUTCOME MEASURES: Types of CME activities and time spent on them, participant characteristics. RESULTS: Older physicians spent more time in individual CME activities than younger ones (21 hours vs 18 hours monthly). Younger physicians, however, spent more time in group CME activities than older ones did (100 hours vs 80 hours yearly). Excluding physicians who devoted no time to CME activities, only two activities differentiated between the two groups: older physicians spent more time than their younger colleagues reading and listening to audiocassettes. CONCLUSIONS: Older physicians maintained their clinical competence by participating in different CME activities from younger physicians. They participated in as many CME activities as their younger colleagues.

When to recommend compulsory versus optional CME programs? A study to establish criteria.

When should remedial continuing medical education (CME) be compulsory for family physicians? When should it be optional? Should it be structured or not? In 1993-1994, the authors addressed this need for criteria by conducting a study that used reports on 14 physicians who had undergone a structured oral interview (SOI) at the College of Physicians of Quebec. (The SOI is a day-long encounter during which two specially trained physician-interviewers present a physician with standardized clinical cases that focus on ten specific aspects of a family physician's competence.) The 14 SOI reports were reviewed by 12 external physician-judges in an attempt to see how consistently they could link the ten aspects of competence, as shown in the reports, to five particular types of recommended remedial CME programs (the strictest being "compulsory program with suspended license" and the most lenient being "simple suggestions for improvement"). There was substantial agreement among the judges when choosing between compulsory and optional programs (kappa = 0.63, p < .05). The main criteria used when recommending an optional program were overall strengths and the quality of clinical reasoning. The same two criteria were also used for recommending a compulsory program, but the judges also considered three additional factors: the physician's ability to recognize his or her limits and how he or she handled referrals and prescribed medications. Many of the criteria used by the judges were based on unique information that came out of observations and interactions during the SOIs, such as quality of argumentation, sustaining a train of thought, sense for the case as a whole, or awareness of one's limits. Finally, the external judges corroborated the decisions previously made by the College of Physicians of Quebec concerning the appropriate CME programs for the 14 physicians.

Physician-assessment and physician-enhancement programs in Canada.

In the mid-1980s, the licensing authorities in Quebec, Ontario and Manitoba have introduced programs to conduct in-depth assessments of the clinical skills and abilities of physicians with suspected deficiencies. These assessments are intended to supplement the provincial licensing authorities' existing peer review or patient-complaint mechanisms by confirming the physicians' overall level of competence and identifying specific clinical strengths and weaknesses. An "educational prescription", based on the results of the assessment, focuses on aspects of clinical practice in which the physicians need or wish to enhance their skills. In some situations, licensure decisions are based on the assessment information. This article describes the programs in Quebec, Ontario and Manitoba. Each program comprises a different process of personal assessment and individualized continuing medical education to help physicians improve their clinical competence, and each is built on sound principles of clinical competence assessment and educational planning.

Physician-assessment and physician-enhancement programs in Canada.

Since the mid-1980s, the licensing authorities in Quebec, Ontario and Manitoba have introduced programs to conduct in-depth assessments of the clinical skills and abilities of physicians with suspected deficiencies. These assessments are intended to supplement the provincial licensing authorities' existing peer review or patient-complaint mechanisms by confirming the physicians' overall level of competence and identifying specific clinical strengths and weaknesses. An "educational prescription," based on the results of the assessment, focuses on aspects of clinical practice in which the physicians need or wish to enhance their skills. In some situations, licensure decisions are based on the assessment information. This article describes the programs in Quebec, Ontario and Manitoba. Each program comprises a different process of personal assessment and individualized continuing medical education to help physicians improve their clinical competence, and each is built on sound principles of clinical-competence assessment and educational planning.

Structured oral interview. One way to identify family physicians' educational needs.

OBJECTIVE: To design and test a structured oral interview that would elicit information on the educational needs of physicians in order to help them plan individualized continuing education. DESIGN: Seven different sets of problems were prepared, each including 40 cases, of which 26 are common. Each pilot test candidate was interviewed by two physician-interviewers during a 1-day session. After each answer, candidates were told the predetermined correct answer. PARTICIPANTS: Six candidates were selected at random from among Montreal physicians aged 50 and older with no hospital privileges. All had to have no history of professional complaints or prosecution and to be unknown to the interviewers. MAIN OUTCOME MEASURES: Inter-rater reliability and perceived difficulty of the cases. RESULTS: Candidates rated the interview process and cases used pertinent, credible, and not too difficult. Candidates' performance level was about 50%. Agreement between interviewers averaged 91.2%. CONCLUSIONS: A structured oral interview appears to be a credible instrument for helping determine practising physicians' deficiencies in clinical knowledge and reasoning.

Why are clinical problems difficult? General practitioners' opinions concerning 24 clinical problems.

This study was conducted to describe the difficulties perceived by general practitioners concerning 24 common clinical problems and to compare their perceptions with those of faculty members in family medicine. A random sample of 467 general practitioners and all 182 faculty members in family medicine in Quebec were sent one of four open-ended questionnaires, each of which dealt with six clinical problems; 214 general practitioners and 114 faculty members participated. A total of 5111 difficulties were reported; the number reported by each subject varied from 0 to 13 (mean 2.6 [standard deviation 2.09]) per problem. The problems that generated the most difficulties were depression, confusion in the elderly, chronic back pain, loss of autonomy in the elderly and sexually transmitted disease. The most frequent difficulties were with the patient's noncompliance with treatment, clinical diagnosis, failure of a specific treatment, inadequate health care resources and the physician's own emotional reactions. The difficulties for each problem were the same in the two groups 70% of the time. Physician's perceptions of their difficulties can be useful in the planning of initial training and continuing medical education.

Paraplegia following transurethral surgery.

We have presented a case of paraplegia following spinal anaesthesia administered for a transurethral prostatic resection. Further investigation revealed a metastatic peridural compressive lesion at the level of T4. We have discussed some of the contributory factors involved, chiefly the lumbar puncture (perimedullary vascular engorgement, alterations in C.S.F. dynamics) and the possible role of intra-operative water intoxication (swelling of spinal cord cells).