A conceptual framework for planning and assessing learning in continuing education activities designed for clinicians in one profession and/or clinical teams.

PURPOSE: The purpose of this article is to provide a more actionable description of the components of the outcomes framework published in 2009. METHODS: Synthesis of recent research in the learning sciences. RESULTS: The authors propose a conceptual framework to be used planning learning activities and assessing learning in CPD. CONCLUSIONS: CPD practitioners will have a more explicit approach to help clinicians provide the very best care to their patients.

The Emerging Role of Reinforcement in the Clinician's Path from Continuing Education to Practice.

INTRODUCTION: Continuing education (CE) activities may affect clinicians' knowledge, skills, self-efficacy, and/or performance. Studies have suggested that self-efficacy may moderate or mediate the relationship between knowledge/competence and performance. Some results have shown that increases in knowledge/competence contributed to increases in self-efficacy. However, clinicians do not always learn something "new" when they participate in CE activities; rather, their knowledge or skills may be reinforced. This study examined whether self-efficacy was greater when clinicians reinforced what they already knew compared with when they learned something new. METHODS: Hierarchical linear modeling was conducted to examine the moderating role of status of knowledge/competence post-CE (reinforced/improved) in the relationship between post-CE knowledge/competence score and self-efficacy across 153 online continuing medical education- and/or CE-certified activities. RESULTS: The hierarchical linear modeling showed that learners with higher post-CE scores have higher post-self-efficacy ratings. Reinforced learners had higher post-CE-self-efficacy ratings than improved learners, controlling for post-CE score. DISCUSSION: This study contributes to an expanded understanding of the path from CE to practice. There was benefit to self-efficacy for learners who reinforced but did not improve their knowledge/competence. This study also suggests that pre-post questions can be considered part of the learning process.

Can mentors prevent and reduce burnout in new chairs of departments of obstetrics and gynecology: results from a prospective, randomized pilot study.

OBJECTIVE: This study assessed burnout in new chairs of obstetrics and gynecology and whether mentoring by experienced chairs would prevent or reduce burnout. STUDY DESIGN: We performed a year-long prospective, randomized trial. Questionnaires were sent to new chairs to obtain demographic information and to identify need for mentoring and level of burnout. Fourteen chairs in the intervention group selected a mentor; 13 chairs served as controls. After 1 year, questionnaires were completed to determine stress and burnout and the impact of mentoring. RESULTS: Financial issues were the major stressors. New chairs identified human resources, finances, and relationships with school leaders as areas of greatest need for mentoring. Few chairs exhibited burnout. No differences were observed in burnout at the start of the study or after 1 year in the study groups. Mentors and new chairs found the mentoring relationship difficult to establish and maintain. CONCLUSION: Long-distance mentoring by experienced chairs did not alter burnout in new chairs of obstetrics and gynecology. Local mentors appear to be more effective.

Integrating Foundational Sciences in a Clinical Context in the Post-Clerkship Curriculum.

PURPOSE: To design, implement, and launch courses that integrate foundational science learning and clinical application in a post-clerkship undergraduate medical school curriculum. METHOD: In Academic Year (AY) 15-16, as part of a comprehensive curricular revision, Vanderbilt University School of Medicine (VUSM) formally implemented "Integrated Science Courses" (ISCs) that combined rigorous training in the foundational sciences with meaningful clinical experiences. These courses integrated foundational sciences that could be leveraged in the clinical environment, utilized a variety of instructional modalities, and included quantitative and qualitative (competency-based milestones) student assessments. Each ISC underwent a rigorous quality improvement process that required input on foundational science content, student experience, and student performance assessment. RESULTS: Eleven ISCs were delivered to 173 students in AY15-16, with some students taking more than one ISC. Immediately after completing each course, 93% (n=222) of ISC enrollees completed a course evaluation. Students (91%; n=201) 'agreed' or 'strongly agreed' that foundational science learning informed and enriched the clinical experiences. Furthermore, 94% (n=209) of students thought that the clinical experiences informed and enriched the foundational science learning. Ninety-four percent of the students anticipated using the foundational science knowledge acquired in future clinical training and practice. CONCLUSION: The teaching of foundational sciences in the clinical workplace in the post-clerkship medical curriculum is challenging and resource-intensive, yet feasible. Additional experience with the model will inform the mix of courses as well as the breadth and depth of foundational science instruction that is necessary to foster scientifically-based clinical reasoning skills in each student.

A conceptual model of CME to address disparities in depression care.

The gap between best practices and actual practice in depression care--the difference between "what should be" and "what is"--is wider for ethnic and racial minorities than for the general population. Education alone is not reducing the gap or improving outcomes. Interventions such as the chronic care model have demonstrated improvements in physician performance and patient health status, both in the general population and among ethnic and racial minorities. Recent reviews of continuing medical education (CME) have shown that it is effective when the planned activities include (1) needs assessment and a focus on higher-level outcomes, (2) multiple ongoing activities that are sequenced for learning, (3) planning that considers the context in which the learned principles will be applied, (4) interactivity, and (5) active learning. The authors describe an approach to planning CME reflecting these five factors and suggest that CME planned in this way be combined with the chronic care model to enhance outcomes further.

A conceptual model for using action inquiry technologies to address disparities in depression.

Disparities in depression care remain an important problem in the United States. Action inquiry technologies may assist individuals and communities in their attempts to reduce or eliminate these disparities--and the multiple factors contributing to them--through a recurring cycle of planning, action, evaluation, and new actions based on reflections about what occurred during previous actions. This article will briefly review different action inquiry methods--specifically, participatory action research (PAR) in communities and action research in physicians' practices and offices of continuing medical education (CME). The authors develop a conceptual model in which those involved in providing, receiving, and improving depression care can use action inquiry strategies that are coordinated using the domains-based outcomes assessment model. This conceptual model may help CME planners collaborate with others to address disparities in depression care.

Addressing disparities in diagnosing and treating depression: a promising role for continuing medical education.

Depression is a very common reason that individuals seek treatment in the primary care setting. However, advances in depression management are often not integrated into care for ethnic and racial minorities. This supplement summarizes evidence in six key areas--current practices in diagnosis and treatment, disparities, treatment in managed care settings, quality improvement, physician learning, and community-based participatory research--used to develop an intervention concept described in the concluding article. Evidence of gaps in the care for minorities, while discouraging, presents unique opportunities for medical educators to develop interventions with the potential to change physician behavior and thereby reduce disparities and enhance patient outcomes.

Improving depression care for ethnic and racial minorities: a concept for an intervention that integrates CME planning with improvement strategies.

Depression is one of the most common reasons that individuals seek treatment in the primary care setting. Research in the past 15 years has shown that dramatic improvement in the management of patients with depression is possible. Advances in pharmacotherapy and delivery of depression care have been reported, but few currently benefit members of ethnic and racial minorities. Educating physicians and other health professionals has been suggested as one approach to address the issues related to disparities in depression care. There is little evidence, however, that education alone is effective. The authors of this article believe that incorporating physician learning activities that are planned using approaches that have been shown to be effective in interventions currently demonstrating some success in improving depression care provided to ethnic and racial minorities will enhance the impact and sustainability of these interventions. This article--the conclusion of this supplement--will describe an intervention concept that integrates a quality improvement model (the Institute for Health Improvement's Breakthrough Series Collaborative model) with an evidence-based approach to planning CME and supports the integration by using action inquiry technologies and community-based participatory research methods. Relevant approaches from implementation research are discussed, and suggestions for testing the intervention concept are provided.

Fostering the Development of Master Adaptive Learners: A Conceptual Model to Guide Skill Acquisition in Medical Education.

Change is ubiquitous in health care, making continuous adaptation necessary for clinicians to provide the best possible care to their patients. The authors propose that developing the capabilities of a Master Adaptive Learner will provide future physicians with strategies for learning in the health care environment and for managing change more effectively. The concept of a Master Adaptive Learner describes a metacognitive approach to learning based on self-regulation that can foster the development and use of adaptive expertise in practice. The authors describe a conceptual literature-based model for a Master Adaptive Learner that provides a shared language to facilitate exploration and conversation about both successes and struggles during the learning process.

Society for Academic Continuing Medical Education Intervention Guideline Series: Guideline 1, Performance Measurement and Feedback.

The Society for Academic Continuing Medical Education commissioned a study to clarify and, if possible, to standardize the terminology for a set of important educational interventions. In the form of a guideline, this article describes one such intervention, performance measurement and feedback, which is a common intervention in health professions education. In the form of a summary report, performance measurement and feedback is an opportunity for clinicians to view data about the care they provide compared with some standard and often with peer and benchmark comparisons. Based on a review of recent evidence and a facilitated discussion with the US and Canadian experts, we describe proper terminology for performance measurement and feedback and other important information about the intervention. We encourage leaders and researchers to consider and build on this guideline as they plan, implement, evaluate, and report efforts with performance measurement and feedback. Clear and consistent use of terminology is imperative, along with complete and accurate descriptions of interventions, to improve the use and study of performance measurement and feedback.

Society for Academic Continuing Medical Education Intervention Guideline Series: Guideline 2, Practice Facilitation.

The Society for Academic Continuing Medical Education commissioned a study to clarify and, if possible, standardize the terminology for a set of important educational interventions. In the form of a guideline, this article describes one such intervention, practice facilitation, which is a common strategy in primary care to help practices develop capacity and infrastructure to support their ability to improve patient care. Based on a review of recent evidence and a facilitated discussion with US and Canadian experts, we describe practice facilitation, its terminology, and other important information about the intervention. We encourage leaders and researchers to consider and build on this guideline as they plan, implement, evaluate, and report practice facilitation efforts. Clear and consistent use of terminology is imperative, along with complete and accurate descriptions of interventions, to improve the use and study of practice facilitation.

Society for Academic Continuing Medical Education Intervention Guideline Series: Guideline 3, Educational Meetings.

The Society for Academic Continuing Medical Education commissioned a study to clarify and, if possible, to standardize the terminology for a set of important educational interventions. In the form of a guideline, this article describes one such intervention, educational meetings, which is a common intervention in health professions' education. An educational meeting is an opportunity for clinicians to assemble to discuss and apply important information relevant to patient care. Based on a review of recent evidence and a facilitated discussion with US and Canadian experts, we describe proper educational meeting terminology and other important information about the intervention. We encourage leaders and researchers to consider and to build on this guideline as they plan, implement, evaluate, and report educational meeting efforts. Clear and consistent use of terminology is imperative, along with complete and accurate descriptions of interventions, to improve the use and study of educational meetings.

Society for Academic Continuing Medical Education Intervention Guideline Series: Guideline 4, Interprofessional Education.

The Society for Academic Continuing Medical Education commissioned a study to clarify and, if possible, to standardize the terminology for a set of important educational interventions. In the form of a guideline, this article describes one such intervention, interprofessional education (IPE), which is a common intervention in health professions education. IPE is an opportunity for individuals of multiple professions to interact to learn together, to break down professional silos, and to achieve interprofessional learning outcomes in the service of high-value patient care. Based on a review of recent evidence and a facilitated discussion with US and Canadian experts, we describe IPE, its terminology, and other important information about the intervention. We encourage leaders and researchers to consider and to build on this guideline as they plan, implement, evaluate, and report IPE efforts. Clear and consistent use of terminology is imperative, along with complete and accurate descriptions of interventions, to improve the use and study of IPE.

In vivo feasibility of image-guided transvaginal focused ultrasound therapy for the treatment of intracavitary fibroids.

OBJECTIVE: To determine the feasibility of uterine tissue ablation in vivo using a transvaginal focused ultrasound applicator guided by ultrasound imaging. DESIGN: Randomized in vivo animal study. SETTING: Academic research environment. ANIMAL(S): Healthy anesthetized sheep. INTERVENTION(S): Uterine treatment location was determined using a computerized targeting system. Five sonications 10 seconds in duration and averaging 2,000 W/cm(2) of focal ultrasound intensity were applied in each animal's uterus. Animals were euthanized either immediately or 2, 7, or 30 days post-treatment. MAIN OUTCOME MEASURE(S): Gross and microscopic analysis of the dissected uterus was used to quantitatively and qualitatively determine the ablated region and treatment side effects. RESULT(S): Treatments resulted in coagulative necrosis. Histopathological analysis showed that over 7 days, inflammatory cells appeared and smooth muscle bundles regenerated. By day 30, treated tissues healed and scar tissue formed. None of the animals showed abnormal behavior or medical problems. Complications in three animals were damage to the vaginal wall and colon, possibly due to inadequate applicator cooling and an empty bladder during treatment. CONCLUSION(S): Transvaginal image-guided high-intensity focused ultrasound has potential for treating uterine fibroids. Further safety testing of this treatment will prepare it for human use.

An image-guided high intensity focused ultrasound device for uterine fibroids treatment.

A high intensity focused ultrasound (HIFU) device was developed for treating uterine fibroid tumors. This prototype device enables image-guided therapy by aligning a commercially available abdominal ultrasound image probe to a vaginal HIFU transducer so the HIFU focus is in the image plane. The device was designed based on anatomical constraints of the female pelvic structures. HIFU was generated using a 3.5 MHz PZT-8 crystal, 25.4 mm in diameter, bonded to an aluminum lens. Computer simulations were performed to ensure that effective focusing was achievable at a fixed focal depth of 40 mm. Transducer efficiency was empirically determined to be 58%, and the half pressure maximum focal dimensions were 11 mm in length and 1.2 mm in width. A water-filled latex condom surrounding the transducer provided acoustic coupling, a stand-off, and allowed water circulation for transducer cooling. In vitro experiments in a tissue-mimicking gel phantom and in turkey breast demonstrated ultrasound image-guided lesion formation, or tissue necrosis, at the focus due to HIFU induced thermal and cavitation effects. The HIFU treatment site appeared as a hyperechoic spot on the ultrasound image at intensities above 1250 W/cm2. The results of in vitro experiments and in vivo ergonomic testing in six human volunteers indicated that the device has the potential of providing a nonsurgical approach for uterine fibroid treatment. Future in vivo studies in large animal models and fibroids patients are planned.

Practice-based learning and improvement.

Workplace learning is becoming increasingly important in all fields. While workplace learning in medicine, also called practice-based learning and improvement (PBLI) is not new, understanding how it works and how it fits with an individual physician's continuing professional development is new. In this article, we describe seven issues associated with PBLI and then pose questions for reflections, as continuing medical education (CME) planners consider working with PBLI.