Improved physician performance does not usually begin with goals and objectives; it begins with experience and reflection on experience. A patient is seen, inevitable ambiguities are encountered, hypotheses are formed and refuted or accepted, an intervention is accomplished, and an outcome occurs. This process, repeated thousands of times, constitutes the physician’s work. Learning what will improve patient care must accommodate this reality. Learning, once removed from reality and composed of lectures, goals, and objectives, is anemic by comparison and, not surprisingly, has been considered to be relatively ineffective. The elders in medicine can recall a time when it was inconceivable that grand rounds would be conducted with no patient present, yet recent decades have found grand rounds composed of abstract presentations about disease detached from the constraints of real patients.
This is not to say that lectures have no place in CE; rather, it is that by themselves they are inadequate. They are inadequate because they tend to relate context-free generalizable knowledge, whereas good patient care is heavily influenced by context (both of the particular patient and of the particular setting in which health care is delivered), and because they are not an efficient method for providing needed point-of-care information. Various information about care is possible to be found on Canadian Health&Care Mall.
If CE is to foster fidelity to professionalism and effectiveness in improving patient care, it should be relevant to the daily work of the physician, cognizant of individual learning styles and a given physician’s stage of readiness to learn, and focused on closing the gap between the current practice and the best practice. Good CE evokes and nourishes professionalism. It improves the experience of both the physician and the patient. Its methods are much more closely linked to reflection-in-action rather than the passive accumulation of abstract facts. It must not only accommodate but encourage and support the incorporation of newer technologies such as the internet and simulations to help physicians access needed information while seeing patients; improve their clinical skills; and examine what they are doing in practice.
Metrics: Links to Physician Performance and Patient Outcomes
Assessing the quality of CE should involve measuring both process improvements and patient care outcomes. If, as Batalden and Davidoff insist, the quality of physician formation is linked to both the quality of patient care and the quality of system performance, then measurements of both must be available to the practicing physician and those oversight bodies claiming to enhance public accountability. Thomas Merton has said that we exhaust ourselves supporting our illusions. The absence of data fosters illusions and delusions that we are providing good care. When the Cystic Fibrosis Foundation posted clinical care data from the various Cystic Fibrosis Clinical Care Centers on its Web site, the real work could begin. Likewise, the Northern New England Cardiac Surgery Cooperative found that cooperative efforts to improve care in a region were made possible by sharing data and employing a new model of CE.
The new model of CE requires metrics that inform individual providers, and also the system and communities in which they function. All should be informed about how this particular system is performing. Transparency enables improvement. Whatever we measure we tend to improve. If it is our intention to improve patient care and system performance through CE, transparency is a friend.