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193 Robert D. Fox chapter 17 Four Pillars in the Evolution of Continuing Medical Education In any essay on history, the dates and events need to be correct but the analysis fails if no themes emerge that help readers to understand and explain the present based on the past. Currently, in continuing professional development (CPD),∞ I have seen and heard evidence of many problems, often accompanied by complaints, worries, and very little optimism for a brighter future. What I hear from my colleagues is that the science that underlies the practice of CPD is irrelevant to the everyday problems that those who o√er education to physicians face. I also hear that, though there are new standards for quality for CPD activities, those who provide continuing medical education (CME) and those who teach in programs often complain that meeting these standards is too hard if not impossible. It is also common to overhear discussions among my colleagues and to read on a regular basis the belief that any involvement in the enterprise by the pharmaceutical industry is guaranteed to introduce bias, taint the educational e√ort, and undermine quality. I believe that most see industry as devious and destructive . Finally, when I talk to clinicians and policy makers, they often complain that CME professionals cannot demonstrate that their efforts to facilitate learning are e√ective or that they are even prepared properly to take on this responsibility. It is not only what I hear that disturbs me, it is also what I see. The social systems in organizations and the individual actors concerned with improving medical performance and outcomes do not collaborate well or often. In fact, pluralism rules the day as each stakeholder involved in the CME enterprise promotes his or her or its special interests, often in competition with the others in the system. Even specialization within CME, which normally improves practice, in this case has resulted in a disintegration of the CME process into pieces and parts. This is in contrast to the evidence that suggests that learning and change for physicians is holistic, a natural part of the overall process of providing quality care. I have also observed that the practices most used to develop education for clinicians are primarily a function of mimicry rather than investigation and systematic learning. In fact, rather than sound scientific evidence and reasoning, change is driven by novelty and a ‘‘flavor of the month’’ mentality. In many cases, isolated findings from small, poor studies become justification for the adoption of ‘‘innovative’’ educational methods and techniques that provide a market edge or a public relations advantage. Large literature reviews are often labeled as metanalysis when they do not use common variables, measures , or reanalysis of primary data. These are the problems I hear about and read about. These are the problems I have seen develop during the 30 years I have studied, written about, and participated in the CME enterprise. This analysis of how we find ourselves plagued by the problems described above is formed around 194 physician learning four themes or, if you will, four pillars that form the foundations for CME today and CPD tomorrow . The purpose of this essay is to describe how these themes have emerged from developments in four of the critical systems connected to attempts to o√er e√ective learning and practice improvement in order to explain how we arrived at our present position. In order to do this I wish to o√er a few words about my methodology. Historiography is the research method of historians. Among the many ways it puts structure and process on the study of history, it controls quality by rating the quality of data according to systematic criteria. Secondary data sources, for example, are secondhand accounts written by those who interview or study primary data sources such as eyewitness and written documents of the time. However, one eyewitness is seldom enough. As one eyewitness, I did not feel that I could provide an accurate picture of the history of CME. Since most of this essay is taken from the Shickman lecture delivered at the 2007 American Medical Association Conference on CME Provider/Industry Collaboration , I submitted it in outline form to a panel of nine colleagues, each of whom had experienced the history either fully or in part but from di√erent vantage points than my own. I asked these colleagues to examine my record for accuracy and freedom from bias. What follows, therefore, is an...

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