Ray S. Davis, M.D.
Associate Clinical Professor
Division of Allergy & Pulmonary Medicine
ST. Louis Childrens Hospital
Washington University in St. Louis School of Medicine

Private Practice with Allergy Consultants P.C.
ST. Louis, Missouri

“Half of what you learn in medical school is wrong…
the problem is figuring out which half.” ²⁶

Introduction

The goal of continuing medical education (CME) is to update physicians regarding new drugs, therapies and newly published guidelines in an effort to change physicians’ knowledge and behavior from that which was learned in medical school and residency training programs. One way to define a successful CME program is that after participating in the program, the participants will be motivated to change their clinical practice behavior by incorporating their new knowledge to achieve better patient care and improved outcomes. ¹ Unfortunately, the most commonly utilized method of CME in the US, the traditional lecture, has been proven not to be effective in changing physician behavior. ² A more effective model is the small group interactive case discussion, also known as problem-based learning (PBL). In contrast to lectures, PBL has been shown to change physician behavior, improve acceptance and adherence to new guidelines and improve patient outcomes successfully in studies encompassing a multitude of disease states in medicine. ^1-15 Moreover, the small group PBL model has been used successfully by a wide variety of other health care professions including nursing, ¹⁶ physical therapy, ¹⁷ dentistry , orthodontics ,optometry, ¹⁸ respiratory therapy ¹⁹, and veterinary medicine . Despite evidence-based studies demonstrating that PBL is a more effective approach to physician learning than the traditional lecture format, PBL is rarely utilized for CME in most institutions across the US (Table 1).

Discussion

An Expert Panel Report on asthma was first published with guidelines for better diagnosis and management of asthma in 1991 with updates in 1997 and most recently, June 2002. ¹⁹ Since the original report in 1991, the use of inhaled corticosteroid (ICS) anti-inflammatory medications has been considered the cornerstone in preventative management of asthma. The use of these anti-inflammatory medications has been shown to improve patients’ quality of life and clinical outcomes with regard to preventing emergency room visits and hospitalizations. ^1,20-22 Several studies have concluded that the NIH guidelines for better management of asthma are poorly adhered to by physicians and that better adherence and greater use of inhaled corticosteroid medication could improve patient outcomes. ^23-24 The efficacy of ICS medication has been demonstrated and it is considered preferred therapy for all levels of persistent asthma. However, studies have shown that physicians in the US are not prescribing ICS regularly for patients who should have ICS and that the NIH Guidelines are not being followed. ^23-24 Moreover, there are many parallels between chronic asthma and hyperlipidemia guidelines, not least of which is that in both disease states, the guidelines are not followed well by many primary care physicians. ¹⁵

Physicians’ lack of adherence to guidelines may be due in part to the fact that most changes in physician beliefs and behavior post graduation from medical school and residency training occur from traditional CME. However, a review of the literature has shown that the traditional CME “lectures” fail to change physician behavior. ² Despite this, the majority of CME in America continues to be done by large group lectures with slide presentations of various studies, facts, figures, p-values and graphs, which inundate the clinician with “information overload” (See Table 1). Not uncommonly, a typical university CME course will expose the clinician to a series of multiple lectures, one right after the other in quick succession over four to six hours. This makes it difficult for the clinician to memorize the data and assimilate it into direct patient care when later confronted with patients. There appears to be a “disconnect” in what is heard in a traditional lecture and how the physician actually can process and utilize the information, demonstrating that true learning has taken place.

PBL, however, is an alternative method of CME in which small groups of healthcare providers are guided through a carefully written case study. The case study progressively discloses information after participants are made to think and interact with their peers in a problem-solving manner, essentially role-playing as though they were in a patient’s exam room. The ultimate goal is to change physician behavior to reflect changes recommended in updated guidelines. The interaction with peers in the context of a clinically relevant case motivates the learner to participate and to then retain proper management skills better than if the same information were “spoon-fed” in a passive, didactic lecture. This learning in the context of a clinically relevant case translates into true long term learning and change in clinical behavior. This is in contrast to learning in an abstract manner from passively listening to didactic lectures. Moreover, studies have consistently shown that physicians enjoy the PBL format and prefer it to traditional lectures. ^9-12,15

Whereas, studies have shown that traditional lectures do not change physician behavior, several studies have shown conclusively that small group interactive case-based conferences do change physician behavior. Davis, in his landmark review of the literature between 1993-1999, regarding the impact of various CME formats on changing physician performance reported no significant effect of the lecture-based CME format. However, Davis found a significant improvement in physician performance in five out of six interactive case-based studies. In addition, Davis’ review found that in five out of seven studies in which there was a combination format of interactive case discussion in association with some lectures, physician performance significantly improved. ²

Recent studies have demonstrated that the PBL format has improved physician compliance with published guidelines for better management of hyperlipidemia, ^4,30 congestive heart failure, ⁵asthma, ^1,3,27 diabetes, ⁷ osteoporosis, ⁸ chronic headache and migraines. ¹⁴ Specifically, more aggressive and appropriate use of pharmacotherapy was shown by doctors who participated in these PBL conferences demonstrating a significant change in the physicians’ behaviors.

Several articles in the cardiovascular literature have shown that PBL could be used to teach physicians better adherence to guidelines and more appropriate use of pharmacotherapy. Casebeer utilized PBL conferences to attempt to improve adherence to the National Cholesterol Education Program guidelines. ⁴ Previously, national acceptance of the guidelines to prevent heart disease had been poor, ¹⁵ similar to what had been seen with the NIH guidelines for asthma. ^23-24 Casebeer, et al. studied ²⁸ community physicians with a series of three interactive case-based audio conferences. By multiple measures, the study found that physicians who participated in the PBL-style conferences demonstrated “adherence-enhancing behaviors, which improved patients’ knowledge of hypercholesterolemia, decreased self-reported consumption of dietary fat, and decreased total cholesterol levels” in their population of patients. ⁴

Kiessling, et.al studied two hundred and fifty consecutive patients with coronary artery disease along with their general practitioners (N=54) in Finland. ²⁸ They utilized “case method learning” in a randomized, controlled study to determine whether this interactive teaching method could change physician behavior as well as patient outcomes better than just handing out hyperlipidemia guidelines along with traditional lecture based learning. They found that the patients whose doctors participated in the interactive case based learning had significantly lower LDL levels over a 2 year follow up than did those patients whose doctors received the guidelines and traditional lecture education. Furthermore, they found that in 167 patients followed by specialists in cardiology during the same time period, had a similar lowering of their LDL levels when compared to the PBL –trained group of general practitioners. ²⁸

In another cardiology study, Borduas, et al. showed that the PBL format improved general practitioners’ knowledge regarding congestive heart failure (pre- and post-testing), chart documentation of important guideline facts, and increased prescriptions for angiotensin-converting enzyme inhibitor therapy. ⁵

With regard to asthma, Zeitz, et al. studied prescribing among family practitioners evaluating the PBL format for asthma management. The study found that the physicians who participated in the PBL conferences recognized and treated asthma patients with a 50% higher use of inhaled corticosteroids than they had used previously, with the control group not showing any increased use of corticosteroid medications. ¹ Clark’s study of 74 pediatricians had similar goals to the Zeitz study. Physicians were randomized into an “interactive seminar group” and a control group and the clinicians in the “interactive group” prescribed ICS medications for newly diagnosed asthmatics significantly more often. ³ In a study by Davis, et.al., 17 out of 20 primary care physicians increased their prescribing of inhaled corticosteroids for asthmatic patients by over 100 % per month for up to 6 months following their participation in PBL sessions designed to promote better adherence to the NIH guidelines.²⁷(See Table 2). Change in behavior (real learning) to this degree has only been shown to occur from problem-based learning and not from traditional didactic lectures.

In evaluating diabetes management, physicians who participated in PBL conferences showed the most clinical improvement in their patients’ diabetes (measured by HbA1C) at 9 and 15 months after the PBL conferences. These patients were compared to a control group in which the physicians did not participate in a PBL conference. ⁷ With regard to osteoporosis, primary care physicians who participated in PBL conferences greatly improved their scores on tests measuring their knowledge, skills and pharmacotherapy choices. ⁸ In a study of family practitioners who participated in either a PBL series or lecture series regarding chronic headache/migraine management, the participants who attended the PBL sessions performed significantly better on post-tests and also expressed greater satisfaction with the type of program (85% of the PBL attendees rated it excellent vs. 35% rating the lectures as excellent). One of the important goals achieved by the PBL sessions was to improve physicians’ appropriate use of medications to treat migraine headaches. ¹⁴

In summary, problem-based learning (PBL) has been shown in many studies, regardless of the disease state, to be a much more effective way of teaching physicians continuing medical education. Unfortunately, relatively few physicians have been properly trained in the techniques of “skilled facilitation” of PBL and rely upon the traditional methods of “reading slides from Powerpoint” which has been demonstrated to be an ineffective method of learning. More physician educators in this country need to be taught the techniques of PBL facilitating in order to increase the amount of CME done by problem-based learning.

Table 1

A one question survey was sent by email to 121 medical schools in North America who are members of the Society for Academic Continuing Medical Education. Thirty-nine schools (32%) responded to the survey . The responses, graphically depicted in the table below, identify that of the responding institutions, the majority ( 38%) stated PBL was utilized in up to only 10% of their activities during the last year. Fifteen percent of the respondents reported they did not use PBL in their CME activities at all, while only 13% reported utilizing PBL in more than 20% of their activities.

Table 2
Demonstrates tremendous (>100%) increases in monthly I.C.S. prescriptions in 17 out of 20 primary care physicians during the 6 months after the PBL sessions. The control group (N=38) showed no increase in prescriptions. ²⁷

References

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