Effects of a signature on rates of change: a randomized controlled trial involving continuing education and the commitment-to-change model.

PURPOSE: Physicians frequently are asked to sign commitments to change practice, based upon their involvement in continuing medical education (CME) activities. Although use of the commitment-to-change model is increasingly widespread in CME, the effect of signing such commitments on rates of change is not well understood. METHOD: Immediately after a CME session, 110 physicians were asked to specify a change they intended to make in practice and to designate a level of commitment to change. To determine the effects of a signature on rates of change, physicians were randomly assigned to control (signature) and experimental (non-signature) groups. Follow-up surveys were conducted at two and three months to determine rates of change. RESULTS: In all, 88 physicians completed the first questionnaire, and 64 of them completed the follow-up. Consistent with prior studies involving the commitment-to-change model, those expressing an intention to change were significantly more likely to change on follow-up (p =.035). There was no significant difference between signature and non-signature groups (p =.99), regardless of age or gender. CONCLUSIONS: Signatures appear unimportant to assuring compliance with commitments to change used in CME conferences. A physician's behavior can be expected to change if the specified change is consistent with the physician's beliefs and sense of what is important. The relative influences of components of the commitment-to-change model require further study to determine more clearly their roles in causation and measurement.

Information about barriers to planned change: a randomized controlled trial involving continuing medical education lectures and commitment to change.

PURPOSE: To determine whether practicing physicians receiving only clinical information at a traditional continuing medical education (CME) lecture (control group) and physicians receiving clinical information plus information about barriers to behavioral change (study group) would alter their clinical behaviors at the same rate. METHOD: In a randomized controlled trial, the investigators matched 13 pairs of U.S. and Canadian medical schools, assigning one school from each pair to study or control conditions. Following the commitment-to-change model, the investigators asked the primary care physicians attending control or study lectures on the management of cardiovascular risks whether they intended to make behavioral changes as a result of participating in the lectures and, if so, to indicate the specific changes. Thirty to 45 days later, the investigators surveyed the responding physicians to learn whether they had implemented those changes. RESULTS: Information about barriers to change did not increase the likelihood that physicians in the study group would report successful changes; they were no more likely to change than those in the control group. However, the physicians in both study and control groups were significantly more likely to change (47% vs 7%, p < .001) if they indicated an intent to change immediately following the lecture. CONCLUSIONS: Successful change in practice may depend less on clinical and barriers information than on other factors that influence physicians' performances. To further develop the commitment-to-change strategy in measuring the effects of planned change, it is important to isolate and learn the powers of individual components of the strategy as well as their collective influence on physicians' clinical behaviors.

Continuing medical education: a new vision of the professional development of physicians.

The authors describe their vision of what continuing medical education (CME) should become in the changing health care environment. They first discuss six types of literature (e.g., concerning learning and adult development principles, problem-based/practice-based learning, and other topics) that contribute to ways of thinking about and understanding CME. They then state their view that the Association of American Medical Colleges (AAMC) has made a commitment to helping CME be more effective in the professional development of physicians. In presenting their new vision of CME, the authors describe their interpretation of the nature and values of CME (e.g., optimal CME is highly self-directed; the selection and design of the most relevant CME is based on data from each physician's responsibilities and performance; etc.). They then present seven action steps, suggestions to begin them, and the institutions and organizations they believe should carry them out, and recommend that the AAMC play a major role in supporting activities to carry out these steps. (For example, one action step is the generation and application of new knowledge about how and why physicians learn, select best practices, and change their behaviors). Six core competencies for CME educators are defined. The authors conclude by stating that collaboration among the appropriate academic groups, professional associations, and health care institutions, with leadership from the AAMC, is essential to create the best learning systems for the professional development of physicians.

Scholarship in teaching: an imperative for the 21st century.

At some medical schools broader definitions of scholarship have emerged along with corresponding changes in their academic reward systems. Such situations are not common, however. The definition of scholarship generally applied by medical schools is unnecessarily narrow and excludes areas of legitimate academic activity and productivity that are vital to the fulfillment of the school's educational mission. The authors maintain that creative teaching with effectiveness that is rigorously substantiated, educational leadership with results that are demonstrable and broadly felt, and educational methods that advance learners' knowledge are consistent with the traditional definition of scholarship. Faculty whose educational activities fulfill the criteria above are scholars and must be recognized by promotion. The authors specifically address scholarship in education, focusing on teaching and other learning-related activities rather than on educational research, which may be assessed and rewarded using the same forms of evidence as basic science or clinical research. They build on Boyer's work, which provides a vocabulary for discussing the assumptions and values that underlie the roles of faculty as academicians. Next, they apply Glassick et al.'s criteria for judging scholarly work to faculty members' educational activities to establish a basis for recognition and reward consistent with those given for other forms of scholarship. Finally, the authors outline the organizational infrastructure needed to support scholars in education.

Physician substance abuse: prevention through reeducation.

Physicians may be far more likely than other professionals and the general public to experience problems with drug and alcohol dependence. The availability of drugs, difficulty of detection, reluctance to confront addictive behaviors, unwillingness to admit weakness, and the lack of ways to detect and manage impaired physicians exacerbate the complexities of preventing and treating the problem. This literature review explores the complicating factors and suggests that prevention can be enhanced through medical education, candid disclosure of facts, acceptance, and understanding of substance abuse as a medical disorder.

Getting evidence into practice: the work of the Cochrane Effective Practice and Organization of care Group (EPOC).

Policy makers and continuing educators often face difficult decisions about which educational and quality assurance interventions to provide. Where possible, such decisions are best informed by rigorous evidence, such as that provided by systematic reviews. The Cochrane Collaboration is an international organization that aims to help people make well-informed decisions about health care by preparing, maintaining, and ensuring the accessibility of systematic reviews of the benefits and risks of health care interventions. International collaborative review groups prepare Cochrane reviews for publication in The Cochrane Library, a collection of databases available on CD-ROM and the World Wide Web and updated quarterly. The Cochrane Effective Practice and Organization of Care Group (EPOC) aims to prepare and maintain systematic reviews of professional, financial, organizational, and regulatory interventions that are designed to improve professional practice and the delivery of effective health services. EPOC has 17 reviews and 20 protocols published in Issue 3, 2000, of the Cochrane Library, with further protocols in development. We also have undertaken an overview of previously published systematic reviews of professional behavior change strategies. Our specialized register contains details of over 1,800 studies that fall within the group's scope. Systematic reviews provide a valuable source of information for policy makers and educators involved in planning continuing education and quality assurance initiatives and organizational change. EPOC will attempt to keep the Journal of Continuing Education in the Health Professions informed on an ongoing basis about new systematic reviews that it produces in the area of continuing medical education and quality assurance.

Where to look when assessing CME needs.

Although more and more hospitals are providing accredited continuing medical education (CME) programs, there is little information to aid the individual physician and the hospital-based CME planner in assessing current educational needs. A basic framework along with readily available data sources are provided for conducting needs assessment studies at a community hospital level.

A survey of accredited and other rehabilitation facilities: education, training and cognitive rehabilitation in brain-injury programmes.

Although it is routinely acknowledged that cognitive rehabilitation therapy comprises a major part of the services provided to survivors of brain injury, there continues to be no general consensus regarding the methods and training of those who provide cognitive rehabilitation services. This survey of 398 head-injury rehabilitation facilities includes information on which disciplines are providing and supervising cognitive rehabilitation therapy, which therapy formats are used, and a first attempt to define the costs and providers for cognitive therapy staff training in Commission on Accreditation of Rehabilitation Facilities (CARF) approved and other (non-CARF) facilities. The education and training of junior and senior staff members is compared, and respondents suggest changes in the education and training of those who provide cognitive rehabilitation therapy. The results of this survey suggest no significant differences in the organization and delivery of cognitive rehabilitation therapy in CARF and non-CARF programmes. They indicate that cognitive rehabilitation therapy and the education and training of providers deserve further study and definition, given the widespread provision of cognitive rehabilitative services.

The case of Powhatan Correctional Center/Virginia Department of Corrections and Virginia Commonwealth University/Medical College of Virginia.

OBJECTIVE: To implement a cost/benefit analysis of telemedicine subspecialty care provided between the Powhatan Correctional Center (PCC) of the Virginia Department of Corrections (Corrections) and the Medical College of Virginia campus of Virginia Commonwealth University (MCV/VCU). METHODS: We evaluated the costs and benefits of the implementation of telemedicine for HIV-positive inmates. Benefits included dollar savings in transportation and medical reimbursement. Costs included those of operating the telemedicine system and of medical care. Non-dollar benefits included implementing more consistent and timely treatment of inmates and reducing security risk. RESULTS: Over the 7-month study period, the total number of HIV consults by telemedicine was 165. The Department of Corrections was able to achieve transportation and medical savings of $35,640 and $21,123, respectively. The operating costs for the telemedicine services totaled $42,277. The net benefit, which is the difference between cost savings and total operating costs, was $14,486. CONCLUSION: Telemedicine increased access to care for HIV-positive inmates and generated cost savings in transportation and care delivery.

Cost-minimization analysis: A follow-up study of a telemedicine program.

OBJECTIVE: To present the follow-up findings to a cost-benefit analysis of telemedicine subspecialty services provided between the Powhatan Correctional Center (PCC) of the Virginia Department of Corrections and the Medical College of Virginia Campus of Virginia Commonwealth University (MCV Campus). METHODS: Costs included those of operating the telemedicine system, transportation, litigation avoidance, and the medical care itself. RESULTS: Over a 12-month study period, the total number of consults completed through telemedicine was 290. The cost per visit of treating inmates at the MCV Campus clinics was $401. The cost per visit of treating inmates at PCC via telemedicine was $387, a net saving of $14 per visit with the use of telemedicine. CONCLUSION: As a result of implementing telemedicine, the Department of Corrections for the State of Virginia was able to achieve a cost saving of $14 per visit. Nonmonetary cost savings, such as greater security and increased access to care, should be considered a net benefit as well.