Dear Readers,

As the new academic year begins, you are most likely busy implementing the new CPD strategies and programs your educational teams have planned over this hot and turbulent summer. In keeping with this order, we wish to introduce you to our revised mission and new column editors appearing for the first time in this issue.  Last winter, the SACME Communications Committee, under the direction of Leslie Doering, embarked on a process to further distinguish and coordinate the content of our three SACME publications---Intercom, CE News and Pulse Points.  The CE News mission has been reinformed and is published here for your information. 

Along with our revised mission, we have expanded our editorial team in the hope of creating a more sustainable and interesting newsletter offering useful content.  We are delighted to introduce our talented new column editors/authors.  They are : Mila Kostic, Helen Mawdsley, EdD, Mohammad Salhia, and Eleftherios K. Soleas, PhD. Our column authors aim to bring new content in areas of strong interest to our readers.  As all our columns continue to evolve, we hope that periodically you will contact our column editors and provide them with your suggestions for article topics and other comments. 

All the best,

Martin and Robert

CE News Mission Statement The mission of CE News is to curate relevant and timely information that will inspire and enhance the work of SACME members and the broader CPD community by nurturing an open forum to share, highlight, and discuss emergent and best practices in teaching, learning, and education scholarship. Strategic Goals These strategies will be used to accomplish the mission: • Monitor and report on trends in the planning, design, delivery and evaluation of CPD activities via special interest features, standing column articles, podcasts and other formats. • Feature scholarly publications in health professions education practice and research. • Highlight key innovations and landscape changes in CPD. • Report on successful models for effective interprofessional CPD activities. • Announce upcoming funding opportunities in CPD. • Publish an Annual Meeting Proceedings Report as requested by the SACME leadership. • Nurture a network of content editors and contributing authors. • Utilize digital learning technology to optimize the readers’ experience as well as to access and search an historical archive.

This column is meant to enable discussions, ask questions, and share wonderings about the various dimensions of equity, inclusion and belonging from different angles and perspectives. We will explore a variety of topic areas as they relate to health professions education, while also encouraging reflection and story sharing about our unique experiences as health care educators and scholars.

Starting with Me, Myself and I – Reflecting on My Own Privilege

By Mohammad Salhia, MEd

As I sat down to craft this editorial, I struggled a bit with where to start. Of course, I was tasked with saying a few words about equity, inclusion, and diversity (EDI), and though I am steeped in this work between my home organization, doctoral studies, and SACME, I wasn’t quite sure where to start. So, I started jotting down some words for inspiration, and spent time alone to reflect on what was emerging for me. How could something I often talk about socially and professionally, and am reading so much on, be so hard to start writing about? After all, this should be “easy,” right? Wrong. We live in a time where the dialogue on EDI is increasingly complex. In fact, it is my personal belief (as is this entire commentary, I should note), that there is so much to say and theorize about equity and inclusion that we have somehow created a climate where the discussion is, perhaps, becoming more inequitable and inaccessible.

I continue to reflect on why, from my vantage point, and with all my intersectionality, I believe this to be a truth. In many ways, the EDI conversation is so much about a greater whole, and a social contract. Of course, this is the end goal, and yet I often wonder if in positioning it as such, we (the “royal We”) miss the point that at some level, this all starts with our own selves, as individuals, by inspecting and deconstructing our own lived experiences. We have all uniquely lived life in some capacity, and have likely observed or been the recipient of different forms of prejudice or discrimination. As I contemplated this, and engaged in my own self-reflection of the words and ideas popcorning through my mind, I paused at the idea of privilege, and I wondered if this offers a foundation for my observation.

Oxford Languages define privilege as “a special right, advantage, or immunity granted or available only to a particular person or group.” We have been hearing this word often as it relates to race, racism, anti-racism, socioeconomic status, etc. It also appears in our vernacular – “that is so privileged,” or “check your privilege” are phrases I hear friends, family, colleagues, and myself often say when calling out, or identifying, different forms of unearned advantage play out in our daily happenings at work, walking down the street, driving through different neighbourhoods, or perhaps while watching television. Privilege, I feel, is a construct and an idea that is inherent in many things we touch.

My positionality and the way I see the world has never been so fluid. An extension of this, then, is the opportunity to challenge my own biases and blind spots, as I facilitate discussions about biases and blind spots. What does really privilege look like, and more specifically, what does my own? I am, without a doubt, privileged. I have earned advantages I worked hard for (e.g. my credentials, role/title), and unearned advantages that were simply part of the hand of cards the universe dealt me (e.g. I’m born and identify as a cis-gendered male, I was born in a resource-rich “first world” country). I, of course, bear unearned disadvantage. Some may argue, for example, that being a person of colour impacts my belonging in some contexts, or that identification with the LGBT2S+ community does the same. I also came from very humble beginnings, growing up in a seven-family household in a two-bedroom dwelling. Though this is true, in the greater context of me, myself, and I, I still believe I have privilege.

So to this end, I asked myself an important question: what does my own privilege really look like? Acknowledging this, and furthermore, any biases I might hold, is, in my mind, a personal responsibility one has as a means to contribute to equity in the fullest sense of the word. It makes one an active agent in driving this process and allows one to “see” themselves in the work.

I am a complex person who does not identify as being part of the “dominant majority,” and I believe I have privilege. I have privilege in terms of my family supports and the structures I grew up with, my access to education, and the professional and social circles I occupy. The latter offer support systems, a network of people, mentors, and the resources and the supports that come with my professional and academic engagements. Second, I consider my membership at SACME a privilege, and, by virtue of being able to write this commentary, I have the privilege of a platform and a voice I perhaps may not have otherwise had. This platform gives me permission, and enables me, to ask more complex, difficult, or uncomfortable questions. It also, I believe, allows me to challenge the perceived status quo of a system, while working with many to plant the seeds for a different kind of membership engagement and opportunity for our Society to look inwardly and ask itself questions about its enablement of equity, inclusion, and belonging.

My point is that privilege is all around us, and if we spend a few minutes thinking about it, we might just describe it in ways we haven’t traditionally. For me, privilege is therefore beyond skin colour and ethnicity. It is a combination of advantages that are either earned or unearned by virtue of one’s unique convergence of circumstances, or their intersectionality. Some things we work hard for; others are part of the cards we’ve been dealt. It is important to note that my words are not meant to invalid the experience of those whose intersectionality makes them the subject of systemic injustices and inequities, or that traditional archetypes of advantage do not exist as part of the greater social norms established via centuries of Westernization and colonialization. Of course, these things exist, and unraveling their social influence is, I feel, a driver of EDI work. They do, however, provoke an important, reflexive exercise about aspects of one’s lived identity in the context of their surroundings and unique, overall personal experience.

I’m still learning. I claim not to be an expert of EDI. I am, however, as we all are, an expert at being a human being - at feeling, experiencing emotion, and living compassionately and empathetically; and at feeling excluded, as if I didn’t belong, that I shouldn’t belong, or that I’m “less than.” Think about this. Have you felt this way?

This all starts with you and where you are at with this dialogue. I have an invitation for you. Take five minutes after reading this. What is emerging for you and what are you feeling? Sit with that and unpack it a little bit. How do you define privilege, and what does it look like to you? This is an important discussion to have as part of a broader social journey. It is part of a social exercise to make equity, inclusion, and diversity an accessible conversation for each one of us to participate in, while acknowledging how systemic and sociocultural marginalization affect social and institutional belonging. Indeed, contemplate our individual and collective privilege it is important as we consider our EDI focus at SACME.

Mohammad Salhia is Director, Continuing Education, The Michener Institute of Education at UHN, Toronto, Ontario, Canada. msahlia@michener.ca.

This column aims to provide a list of insightful publications on topics of interest to teaching faculty and professionals in CME/CPD. 

By William Rayburn, MD, MBA

Tuesdays are great for teaching tips: A spaced education strategy for faculty development. DOI: 10.4300/JGME-D-20-01249.1

Difficulty in meeting faculty development requirements is consistently reported in the literature due to competing workload requirements. This report from the Case Western Reserve University describes their Tuesday’s Teaching Tips (TTT) program developed as a 14-week encapsulated course via email utilizing spaced education as a strategy to reimagine delivering course content with evaluation and feedback. Course evaluations revealed that 98% of 84 faculty across 15 specialties felt that the information gained would enhance patient care or medical education. Faculty were very receptive to this teaching strategy as it was designed to be easily accessible, eliminated the need to “go to a training,” was time efficient, and used simple strategies to practice.  Kalynych C, Edwards L, West D, Snodgrass C, Zenni E. J Grad Med Ed 2021; 13: 434-5.

Psychological safety in feedback: What does it look like and how can educators work with learners to foster it. DOI: 10.1111/medu.14154

Feedback pays a central role in health professional workplace learning. This can risk exposing their limitations or offending the educator, however. The authors attempted to answer what does psychological safety look like in a workplace feedback and how can educators work with learners to foster it.   An analysis of 36 videos of routine formal feedback episodes led to identification of four themes: 1) setting the scene for dialogue and candor, 2) educator as ally, 3) a continuing improvement orientation, and 4) encouraging interactive dialogue. This study builds on the importance of psychological safety in feedback by clarifying what psychological safety in workplace feedback conversations might look like and identifying associated educator approaches.  Johnson C, Keating J, Molloy E. Med Educ 2020; 54: 557-70

Continuing board certification: Seeing our way forward. DOI: 10.3122/jabfm.2020.S1.190439

The breadth and dept of new information, combined with the pressures of system barriers and administrative burdens, can make it challenging for clinicians to stay current and maintain their own competency. Certification boards have a critical role to set and evolve standards for competence and to conduct rigorous assessments of physicians.  The authors present four key areas to address to move forward with a board certification system that is effective, relevant, and respected. These that boards should: set and communicate the specific expectations of specialists, use technology to create practice-relevant assessments, collaborate with educators, and establish and meet standards for professionalism and ethics that reflect their position as regulatory bodies.  McMahon G, Newton W. JABFM 2020; 33: S10-S14.

Exploring the factors that influence ethical Spanish use among medical students and solutions for improvement. DOI: 10.1080/10401334.2021.1949996

Physicians and physicians-in-training are in vulnerable positions to use second language skills in situations that step beyond their abilities. This article explores how hierarchy intensifies previously established factors, including a lack of adequate training or evaluation and other structural barriers, in contributing to learners' inappropriate use of Spanish with limited-English proficiency patients. An approach is proposed that includes student education, standardization of clinic rules regarding interpretation, and comprehensive faculty development to address this important patient care issue.  Meacham J, Salazar M, Perez R, et al. Teach Learn Med 2021; 27:1-8.

Measuring impacts of continuing professional development (CPD): The development of the CPD impacts survey (CPDIS). DOI: 10.1080/0142159X.2021.1887834

Evaluating CPD programs is essential. This study developed a CPD impacts survey (CPDIS) by conducting a systematic scoping review, qualitative interviewing, using existing survey instruments to develop the initial survey items, and completing the survey by past participants from two international health professions education institutes. A three-component solution from the survey involved learnings and self-efficacy, networking and building community, and achievement and validation. The CPDIS will allow more efficient and accurate evaluation of the utility and value of CPD programs and to inform about their improvement and quality.  Allen L, Palermo C, Armstrong E, Hay M. Med Teach 2021; 43: 677-85.

Twelve tips for facilitating and implementing clinical debriefing (CD) programs. DOI: 10.1080/0142159X.2020.1817349

High demand clinical practice would benefit from workplace practices such as clinical debriefing (CD) to support everyday learning and patient care. Debriefing, defined as a 'guided reflective learning conversation', is most often undertaken in small workplace settings. Emerging evidence suggests that debriefing may enhance learning while simultaneously balancing psychological safety, learning goals, and emotional well-being. The twelve tips in this article resulted from a recent Association for Medical Education in Europe (AMEE) debriefing symposium. These tips encompass the benefits of CD:  team focus, interdisciplinary, implementation in stages, and use of a clear structure. Coggins A, Zaklama R, Szabo R, et al. Med Teach 2021; 43: 509-17

Examining associations between physician data utilization for practice improvement and lifelong learning. DOI: 10.1097/CEH.0000000000000268

Health care is becoming increasingly data-driven, and greater data accessibility has created more opportunity to use data to improve quality of care.  This pan-Canadian survey was administered to psychiatrists, radiation oncologists, and general surgeons to assess factors that influence the use of data for practice improvement and orientation to lifelong learning. Significant predictors of data use in practice included frequency of assessing learning needs, helpfulness of data to improve practice, and frequency to develop learning plans. Associations between practice data use and perceived data utility, reflections on learning needs, and learning plan development were demonstrated. Sockalingam S, Tavares W, Charow R, et al. JCEHP 2019; 39: 236-42.

Curricular needs for training telemedicine physicians: A scoping review. DOI: 10.1080/0142159X.2020.1799959

An ideal curriculum for educating physicians to practice in the emerging use of telemedicine has not been established. This review of peer-reviewed articles identified 43 curricula from 11 countries. Instructional methods included mostly hands-on experiences and lectures, along with directed reading online modules, reflection, simulations, and group discussions. The authors suggest centering curricula on a competency-based, outcomes-oriented framework using multiple teaching modalities complementing hands-on experiences.  Stovel R, Gabarin N, Cavalcanti R, Abrams H. Med Teach 2020; 42

Using quality improvement tools to enhance workplace learning in an anesthesia unit. DOI: 10.1080/0142159X.2020.1799960

Quality improvement (QI) tools can be used in medical education to facilitate improvement in learning outcomes and competencies of junior doctors. This report from the National University Hospital in Singapore presents a stepwise competency checklist devised to guide and monitor the learning of junior faculty. QI tools, namely the Fishbone diagram and Pareto chart, were used to identify modifiable root causes and prioritize interventions. Monthly competency scores from test results ranged 30-50% at baseline and improved to 60-75% after 6 months. Focused improvement cycles that are aligned to learning outcomes were key to the success of using QI tools in medical education.  Wai Foong T, Tiong H-F, Yang Ong S, Gee Chen F.  Med Teach 2020; 42:1228-33.

Exploiting the power of information in medical education. DOI: 10.1080/0142159X.2021.1925234

The explosion of medical information demands a thorough reconsideration of medical education, including what we teach and assess, how we educate, and whom we educate. Physicians of the future will need to be self-aware, self-directed, resource-effective team players who can synthesize and apply summarized information and communicate clearly. Training in metacognition, data science, informatics, and artificial intelligence is needed. Education programs must shift focus from content delivery to providing students explicit scaffolding for future learning, such as the Master Adaptive Learner model. Additionally, educators should leverage informatics to improve the process of education and foster individualized, precision education. Finally, attributes of the successful physician of the future should inform adjustments in recruitment and admissions processes. This paper explores how member schools of the American Medical Association Accelerating Change in Medical Education Consortium adjusted all aspects of educational programming in acknowledgment of the rapid expansion of information. William B. Cutrer, W. Anderson Spickard III, Marc M. Triola, Bradley L. Allen, Nathan Spell III, Steven K. Herrine, John L. Dalrymple, Paul N. Gorman & Kimberly D. Lomis (2021) Exploiting the power of information in medical education, Medical Teacher, 43:sup2, S17-S24.

Health systems science education: The new post-Flexner professionalism for the 21st century. DOI: 10.1080/0142159X.2021.1924366

The foundations of medical education have drawn from the Flexner Report to prepare students for practice for over a century. These recommendations relied, however, upon a limited set of competencies and a relatively narrow view of the physician’s role. There have been increasing calls and recommendations to expand those competencies and the professional identity of the physician to better meet the current and future needs of patients, health systems, and society. We propose a framework for the twenty-first century physician that includes an expectation of new competency in health systems science (HSS), creating ‘system citizens’ who are effective stewards of the health care system. Experiential educational strategies, in addition to knowledge-centered learning, are critically important for students to develop their professional identity as system citizens working alongside interprofessional colleagues. Challenges to HSS adoption range from competing priorities for learners, to the need for faculty development, to the necessity for buy-in by medical schools and their associated health care systems. Ultimately, success will depend on our ability to articulate, encourage, support, and evaluate system citizenship and its impact on health care and health care systems.  Jeffrey M. Borkan, Maya M. Hammoud, Elizabeth Nelson, Julie Oyler, Luan Lawson, Stephanie R. Starr & Jed D. Gonzalo (2021) Health systems science education: The new post-Flexner professionalism for the 21st century, Medical Teacher, 43:sup2, S25-S31. 

Perspectives:  Teaching the Teachers With Milestones: Using the ACGME Milestones Model for Professional Development. doi.org/10.4300/JGME-D-20-00891.1

Janae K. Heath, C. Jessica Dine, Ann E. Burke, Kathryn M. Andolsek. J Grad Med Educ (2021) 13 (2s): 124–126.  Full text only.

William Rayburn, MD, MBA is an emeritus distinguished professor, chair of obstetrics and gynecology, and associate dean at the University of New Mexico School of Medicine, Albuquerque, NM and a clinical professor of obstetrics and gynecology and graduate studies at the Medical University of South Carolina, Charleston, SC. wrayburnmd@gmail.com

Determining Fair Market Value for CME

By Heather Clemons, MS, MBA, ATC, CHCP and Joenathan Rodriguez, MPH

Most CME providers want to assure that their CME activity fee schedules are competitive and appropriate for their market area.  A periodic survey by the CME office is one good way to determine where you stand among other area providers.  In an effort to develop a ‘fair market value’ registration fee schedule Sharp HealthCare did just such a survey via the SACME member listserv this past summer.  Staff surveyed other CME/CPD professionals regarding their strategy and typical fee schedule. The survey focused on the typical calculation model, average per credit hour rates for those providers that charged for education.  As a result of this information the Sharp HealthCare CME Department was able to develop a recommended registration fee schedule for both enduring and live activities.

A total of 69 respondents provided responses to the survey and of those 75% (52) reported that they charged a fee for CME activities. For those who do charge, determining what factors are included in the fee calculation are distributed across an array of fee models.  The most popular model considers the learner’s affiliation and profession and the number of credit hours offered (21%, n=10). The profession of the learner is the most frequently used model consideration based on the survey results with the top 5 models including it.  In cases where a fee for service schedule is used, these factors may or may not be relevant. (Click here to review complete survey results and comments.)

The other factor that impacts the fee calculation is whether the activity is enduring material (online module), a webinar, a course, or a conference.  The results show that 85% (45 of 53) of respondents charge different fees for different event types. Considering all these factors, the most common per credit hour fee rates selected were $15 - $25 (45%) and $30 - $45 (37%).

Setting a fee schedule is a complex endeavor that is influenced by a number of factors. While this basic survey did not explore the topic in depth, it did provide some basic guidelines that providers can consider when developing their own schedules.  At the end of the day the biggest factor may be whether or not the provider has the authority and autonomy to set per activity fees.  Many comments highlighted the impact that faculty, activity committees and clinical departments have on registration rates along with other challenges to developing a consistent system.

Heather L. Clemons, MS, MBA, ATC, CHCP, is Lead CME Associate, Sharp HealthCare and Joenathan Rodriguez, MPH is a CME Associate, Sharp HealthCare, San Diego, CA. Heather.Clemons@sharp.com

This column speaks to practice innovations, emerging trends, and practical high-impact tools as well as what these mean for CME/CPD.

Using a Common QI Method in a Health Professions Education Context

By Helen Mawdsley, EdD and Eleftherios K. Soleas, PhD

Quality improvement and patient safety (QIPS) projects in healthcare often use a Plan-Do-Check-Act (PDCA) or Plan-Do-Study-Act (PDSA) cycle, such as taught by the Institute for Healthcare Improvement Open School virtual QI curriculum and described in the AMA PI-CME accredited activity process. While many clinicians and faculty members may be familiar with developing or leading a QI project within a healthcare setting using a PDSA structure, we would like to draw attention to QI projects focused on health professions education.  QI projects in this space represent a coupling of the healthcare system and the education system, which means that we have more data sources to explore; however, we also have more relationships and interactions to account for.  We maintain that there is a strategic benefit to conceptualizing QI projects in this coupled space, as many faculty members have a requirement to perform as leaders in QI projects and teach others about the QI process. 

We would like to initiate this new column by providing a foundational review to guide your QI journey. We recognize that some readers of this column are seasoned QI experts and are prepared to engage in conducting a QI project within the health professions education context.  We hope you will consider reaching out to us and sharing your own experiences in future issues.

The PDSA cycle is the typical structure for a QI project. These cycles have shown to be useful in healthcare settings, as long as the implementation is compliant with the principles underlying these cycles (Taylor, 2014).  Given the importance of these principles, let's explore where PDSA cycles originated.  Following this, we will discuss how the PDSA can be applied in a health professions education and CPD context. 

In the 1950s, Deming, an engineer and statistician, used the Shewhart cycle, which has developed over time to be known as the PDCA cycle (Noguchi, 1995).  While PDCA and PDSA have become almost interchangeable terms currently, we can see why PDCA was used first, as Deming's work was founded in an industrial context where the purpose was to detect variation outside of pre-determined parameters.  Over time, an emphasis on exploring why variation exists may explain the multiple terms used, yet the nuanced difference between these terms remains. 

The purpose of a PDSA cycle is to provide opportunities for learning and informed action, with the intent to make something better.  PDSA cycles are intended to capture small, incremental, and iterative steps.  This is important because this intention helps to:

• provide a sustainable scope to a QI project through multiple, manageable phases,

• provide multiple opportunities for learning and unlearning through multiple feedback loops, and

• enable navigation of complex environments without overt reductionism. 

Let's focus on that third point for a moment.  As we mentioned earlier, QI projects in a CPD context represent the coupling of the healthcare system and education system, recognized as complex systems.  It is important to understand what this complexity means for your QI project.  In order to proceed with a QI project, we need to reduce complexity to a point where we can move forward with our QI project; however, we also need to understand that reducing a part of a larger complex system discards some of the meaning in the system. In this way, any QI project is an exercise in reduction, but this can be mitigated through project design.  A series of smaller scoped QI projects can provide a sustainable momentum to see progress, multiple opportunities for feedback to the QI process and the project's final outcome, and can reduce some of the assumptions placed on the amount of prediction that can reasonably occur while working within complexity.

How to facilitate designing a meaningful project

As you are about to embark on a QI project, it is important to define the problem of practice (PoP).  The PoP is the gap in theory, knowledge, or practice creating barriers to desired performance.  While a PoP may not be commonly seen in a healthcare setting, it is a common term in educational research.  In the health professions education and CPD context, the PoP provides the tangible link between how we identify, teach, and learn about clinical issues in a meaningful and relevant manner (Olsen, 2019).  When designing a QI project in health professions education, it is important to explore and define why the PoP exists, who is impacted by the PoP, and engage in viewing the PoP from multiple positionalities to explore the impact of the PoP.  Some of these positionalities may include perspectives from patients/clients, clinicians, learners, healthcare staff and administrators, educational staff and administrators, regulatory bodies, and even current political mandates.  Taking time to explore and articulate the PoP through multiple lenses can ensure that your project is meaningful and valuable to you, your practice, and your larger community.  Another reason to firmly establish a PoP is that it may help offset criticisms of QI.  QI projects have been accused of lacking academic rigour and legitimacy, which can be attributed to a poorly designed QI project, as well as the hidden curriculum (Brown et al., 2020).  The process of developing a clear and robust PoP, as well as the defined PoP itself, can help mitigate some of these issues. 

When you are leading a QI project in health professions education or teaching others about how to do their own QI project, the mandate of the QI is the quality improvement in question, but it should also consider placing some emphasis on upskilling others to be able to implement QI.  For instance, improving the cultural safety of a program of CPD would be a perfect topic for a QI project. This project would only be enhanced by imparting the skills and documenting strategies to do QI elsewhere. In this way, you can facilitate a successful QI project and support teaching and learning how to design and implement a meaningful and relevant QI project elsewhere. 

After the PoP is defined, as best as is possible at this stage, it is time to plan how to address the PoP.  One way to do this is to develop some research questions that form the basis of identifying relevant data sources to inform your project.  At this point, the data sources which would best respond to your question may or may not exist. That's okay – move forward how you can, and note these gaps as limitations in your study, as well as offer these gaps as opportunities for future research or data infrastructure development.  It is important at this stage to also think about the iterative phases of your project, what will be explored in this iteration, and what will be in a subsequent iteration.  For example, a full PDSA cycle can be completed to gather baseline data only, or your first PDSA cycle may already include an intervention to a previously defined PoP.  Consider the available data sources, such as referral data, previous knowledge test outcomes from other programming, performance evaluations from a learning management system, multisource feedback forms, or the last peer assessment that a person completed.

During this planning stage, it is also time to consider who and how the data will be analyzed.  For example, are you employing quantitative, qualitative, or mixed methods in how you will respond to your research questions? If so, do you need to build a team to help analyze this data? It is important to include this expertise during the planning phase, as how data is collected can limit what type of analysis can be done.  Including this expertise sooner than later will help your project succeed and add to your QI project's credibility

How to document and disseminate

Now that planning and team-building have been done, it is time to proceed with baseline data or implement an intervention (get ethics clearance if needed). As you move forward, gather data to respond to your research questions, study the data, situate it within the context of your PoP, and determine what future actions would be meaningful to those impacted by the PoP.  This work will inform the conclusion of this specific PDSA cycle and provide momentum for the next cycle.  It is important to share these learnings, as your findings may be helpful to others.  Some options include presenting your work at committees within your organization, writing white papers, presenting at conferences, and in peer-reviewed journals.  Another option is to write us and tell us about your work! We would like to dedicate space in upcoming issues to share our experiences in QI in the health professions education and CPD context.

How to incorporate sustainability

QI projects are usually comprised of an iterative series of PDSA cycles.  The PoP which inspired this work in the first place is important to address, and so finding a way to maintain momentum can help to add value to your project.  There are a few things to consider when facilitating sustainability in a QI project:

• Chasing perfection vs. striving for improvement.

QI projects require us to find our weaknesses and talk about failures.  Even if the QI project focuses on the successful improvement of something down the road, the PoP at the centre is about an authentic struggle in our practice.  This requires courage and awareness to accurately describe and assess the PoP throughout the QI project and a space for this conversation. 

• Consider scaffolding or phasing of the project

When defining the PDSA cycles, opt for creating numerous smaller cycles, which build over time.  This can be hard, as each PDSA cycle will have less to show at first; however, this provides an opportunity to provide results sooner. 

• Use feedback to inform future PDSA cycles

A QI project with numerous iterative cycles provides more opportunities to build on system feedback.  Incorporating feedback frequently will help refine the research questions and PDSA cycle development to ensure that the findings are relevant and reliable.  In contrast, limiting options for system feedback will reduce any possible refinements, encouraging the project to deviate from its intended outcomes. 

We hope that this article has inspired you to explore QI projects, and we encourage you to share your tips on approaching a QI project by commenting on this article or emailing us.  Also, if you have a QI project you would like to share, we would happily consider highlighting it in a future column. Please contact us at Helen.Mawdsley@umanitoba.ca or eks3@queenssu.ca. 

Helen Mawdsley, EdD is Director of Research, Office of Continuing Competency and Assessment, at Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Canada. Helen.Mawdsley@umanitoba.ca

Eleftherios K. Soleas, PhD, OCT, BScH, BEd is Director of Continuing Professional Development, Professional Development & Educational Scholarship, Faculty of Health Sciences, Queen's University, Canada. eks3@queenssu.ca

References

1. American Medical Association PRA Credit System. Performance Improvement Continuing Medical Education (PI-CME). https://www.ama-assn.org/education/ama-pra-credit-system/performance-improvement-continuing-medical-education-pi-cme.
2. Brown, A., et al. (2020). "A Tale of Four Programs: How Residents Learn About Quality Improvement during Postgraduate Medical Education at the University of Calgary." Teach Learn Med: 1-17.  DOI: 10.1080/10401334.2020.1847652
3. Cleghorn, G. D. and L. A. Headrick (1996). "The PDSA cycle at the core of learning in health professions education." The Joint Commission journal on quality improvement 22(3): 206-212.DOI: 10.1016/s1070-3241(16)30223-1
4. Institute for Healthcare Improvement Open School. PDSA Cycles (Parts 1 & 2). http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/Whiteboard6.aspx  
5. Noguchi, J. (1995). The legacy of W. Edwards Deming. Quality Progress. Milwaukee, American Society for Quality. 28: 35. https://uml.idm.oclc.org/login?url=https://www.proquest.com/magazines/legacy-w- edwards-deming/docview/214740392/se-2?accountid=14569
6. Olson, C. A. (2019). "What is an Educational Problem? Guidance for Authors Submitting to JCEHP." The Journal of continuing education in the health professions 39(4): 225-227. DOI: 10.1097/CEH.0000000000000273  
7. Taylor, M. J., et al. (2014). "Systematic review of the application of the plan–do–study–act method to improve quality in healthcare." BMJ Quality & Safety 23(4): 290-298. DOI: 10.1136/bmjqs-2013-001862

This column aims to generate a conversation on how continuing education and practice development is currently viewed and developed around the world, especially through the lens of the educator. We will acknowledge a variety of experiences and systems of continuing professional development (CPD) to support healthcare professionals’ (HCP) lifelong learning. 

Column Editor:  Helena Prior Filipe, MD, MMEd

CPD in Australia and New Zealand: An Evolution is Underway

By Heather G. Mack, MBBS, MBA, PhD, FRANZCO, FRACS

CPD in Australia and New Zealand until now has been largely controlled by medical professional societies (“colleges”), which set the curriculum and requirements for ongoing education. Each society has its own requirements; these are expected meet the standards of the MBA and/or MCNZ as appropriate.  In my specialty, for example, continuing professional development (CPD) for ophthalmologists has been evolving over the past two decades, influenced by our professional body the Royal Australian and New Zealand College of Ophthalmologists (RANZCO), the Medical Board of Australia (MBA) and the Medical Council of New Zealand (MCNZ), as well as society’s expectations. 

I began my role as Chair of RANZCO’s CPD committee in 2003, when Fellows were expected to demonstrate continuing education by recording attendance at educational events and journal reading. My committee and I redesigned the program to include activities in a range of competencies and at differing levels of reflection. Based on CanMEDS we designed three categories: clinical expertise, governance (leader) and professional values (communicator, collaborator, health advocate, scholar, professional); and two levels: level 1- passive learning e.g., attending lectures, and level 2- active learning with written reflective elements e.g., clinical audit. Fellows were required to earn points (usually 1 point per hour of learning) in clinical expertise and at least one other category to a total of 50 points, plus undertake 30 hours of reflective activity (typically one clinical audit) per year.

The program was transformative, embedding the concept of reflective practice. It received the first commendation of a CPD program by the Australian Medical Council. It met the new requirement for audit introduced by the MCNZ, and easily met the requirements of the newly formed MBA in when it was established in 2010.

Over time Australia has had its share of poor patient outcomes due to poor medical practice. Prior to establishment of the Medical Board of Australia, each Australian state had separate registers of practitioners, and it was possible for poorly performing practitioners to move to another state and recommence practice. Society expects increased accountability of its medical practitioners, and this led to the development of a single Australia-wide practitioner register (MBA), which then developed formal standards of practice, including participation in CPD.

The MBA and MCNZ have signalled the need to further improve CPD. Starting in 2023, Australian medical practitioners will need to formulate an annual professional development plan targeted to their learning goals and which strengthens their practice. Practitioners will be required to perform 25 hours of performance and outcome review, 12.5 hours of traditional lecture activities and a further 12.5 hours of their choice of activity. CPD will be performed through ‘CPD homes’, which will typically be the medical colleges. The MCNZ has adopted more formal recertification, and similarly requires medical practitioners to demonstrate participation in CPD, peer reviews, audits of medical practice and continual medical education. In response to these changes RANZCO is currently modifying the existing CPD program to facilitate development of personal learning plans and reflective/audit activities.

CPD in Australia and NZ is moving from a list of lectures attended to meaningful lifelong learning. We await with interest the results of forthcoming changes, which have potential to alter the educational role of the colleges, and future evaluation studies.

Professor Heather Mack is the immediate past President of the Royal Australian and New Zealand College of Ophthalmologists (RANZCO). She shares her perspective of the evolution of CPD for ophthalmologists in Australia and New Zealand.

Helena Prior Filipe, MD, MMEd, is a consultant in the College of Ophthalmology of the Portuguese Medical Association International Council of Ophthalmology, University of Lisbon, Portugal, hpriorfilipe@gmail.com

 

Becoming an International Virtual CPD/CME Provider to the Americas 

By Alvaro Margolis, MD MS FIAHSI

With our new virtual learning competencies, many CME providers are considering expanding their regional and national presence to an international audience.  The Americas are a unique and challenging region to explore.  Latin America is a large and heterogeneous middle-income region, with one million physicians.  One third of the region by several counts is Brazil, where Portuguese is spoken, while the rest of the countries speak Spanish. This dynamic creates an opportunity for online regional activities to be delivered in the two native languages.  In this brief article, I hope to provide you with an overview the major elements to be considered when engaging in these complex, international CPD projects, especially across the Americas.

Over a decade ago, we sought to provide much needed CME/CPD programs in a variety of specialties to a Latin American audience.  Over this period, my team has implemented educational activities throughout this region (1,2).  Typically, these activities offer a sequential, mostly asynchronous curriculum, delivered to large audiences, however, they are still able to provide an active learning experience through social interaction and reflection. The virtual program includes automated formats to support meaningful dialogue for large audiences (3).  Some of these activities have had a North American academic partner as a part of the institutional design of the program (5, 6).  Each project has had similar learning experiences and planning criteria resulting in successful educational outcomes. 

American academic institutions seeking to offer CME/CPD courses in the Americas may wish to identify and recruit an academic partner institution in the region for a jointly offered activity. The advantages of a local institutional partner in the region cannot be overstated in terms of planning, marketing and implementation processes.

A number of best practices are discussed here when initiating an international program.  First, the educational program curriculum should address the unmet, practical learning needs of the target audience(s).  The program should not be focused solely on scientific ‘breakthrough advances’ which at the moment may not yet have any practical treatment application, especially in the non-academic and often resource-constrained, clinical practice settings of the region. 

If working with a Latin American academic partner, the clinical practice needs of the target audience should be determined via a needs assessment survey preferably developed jointly by the U.S. host and the Latin American academic institutional partner/planner and their regional faculty. The challenge of addressing clinical practice needs of these diverse healthcare systems must be considered as well. To this point, the best approach we have found is to design a course curriculum that includes a live, team-based analytic deliverable where course participants from the same institution discuss how to apply what was learned in the course to their respective working environment.  

Second, everything should be translated into the native language of the target audience (e.g. convening, registration, customer support, educational materials, activities, and online interactions).  Sometimes people who speak English as a first language underestimate the challenge for non-native speakers to study and interact with colleagues and faculty in a foreign language, such as English.  Beyond this, an awareness of the cultural differences among the countries should be considered when working with an international faculty, even in the same language such as Spanish.  For example, in some countries people tend to be very polite and diplomatic, while in other countries people are quite direct.  Such cultural characteristics are especially important to understand when negotiating contracts.    

Third, in such a large geography as the Americas, online learning can still be complemented with face-to-face live activities, either centrally or distributed across a region (7,8), including not only formal CME but also team-based learning in the workplace, as discussed earlier. 

Fourth, in general, the US-based CME accreditation is not “value added” in Latin American countries, since each country has a different accreditation system. In fact, some countries are only now developing a system.  Of course, the principles behind accreditation and CME best practices should still be followed, particularly regarding educational design and management of conflicts of interest. However, the actual accreditation process itself is not typically required in most Latin American countries.  When it is, it is likely to be very different than the ACCME process.  If working with a regional partner, allow them take the lead for the local accreditation process.

Fifth, since there is such a large number of physicians in the region, financing a program is typically achieved through learner registration fees, although grants and vendor exhibit fees are certainly possible.  Further, in the registration payment process, allowing participants to use local currencies and payment methods is highly encouraged since many will not have an international credit card.

In conclusion, large international educational programs throughout the Americas are achievable, but these projects require careful consideration of the factors discussed herein to be successful.  Once an activity is established, the repetition of programs between the same partner institutions over the years creates a common procedural knowledge and a cultural experience that facilitates and improves both the work process and program quality.

References

1. A. Margolis and A. López-Arredondo, Eight years of MOOCs for physicians across Latin America, 2019 IEEE Learning With MOOCS (LWMOOCS), 2019, pp. 133-137, https://ieeexplore.ieee.org/document/8939603
2. Margolis A, Joglar F, de Quirós FG, et al, Hersh WR. 10x10 comes full circle: Spanish version back to United States in Puerto Rico. Stud Health Technol Inform. 2013;192:1134. PMID: 23920908. https://pubmed.ncbi.nlm.nih.gov/23920908/
3. Margolis A, López-Arredondo A, García S, , et al. 2019, Social learning in large online audiences of health professionals: Improving dialogue with automated tools, MedEdPublish, 8, [1], 55, https://doi.org/10.15694/mep.2019.000055.2
4. Medina-Presentado JC, Margolis A, Teixeira L, et al Online continuing interprofessional education on hospital-acquired infections for Latin America. Braz J Infect Dis. 2017 Mar-Apr;21(2):140-147. https://pubmed.ncbi.nlm.nih.gov/27918888/
5. Kidney transplant course with the University of Virginia, Latin American version. https://redemc.net/renalcasos
6. Palmer, B. Meeting Professionals: What Would You Do? PCMA Convene.  November 30, 2020. https://www.pcma.org/medical-education-conference-simulation/
7. Cohen H, Margolis A, González N, et al. Implementation and evaluation of a blended learning course on gastroesophageal reflux disease for physicians in Latin America. Gastroenterol Hepatol. 2014 Aug-Sep;37(7):402-7. https://pubmed.ncbi.nlm.nih.gov/24679378/
8. Margolis A, Balmer J, Zimmerman A, López-Arredondo A, 2020, The Extended Congress: Reimagining scientific meetings after the COVID-19 pandemic, MedEdPublish, 9, [1], 128, https://doi.org/10.15694/mep.2020.000128.1

Alvaro Margolis, MD MS FIAHSI is a SACME member and president of EviMed, an international virtual provider of CME/CPD. For more information contact Dr. Margolis via email at   alvaro.margolis@evimed.net

This column aims to provide insight and practical information on the impact of e-learning on CME/CPD and the latest trends in technology available to enhance the online learning experience.

Column Editor: Vjeko Hlede, PhD 

Blended Learning Compared to Traditional Learning in Medical Education: Systematic Review and Meta-Analysis

Alexandre Vallée, Jacques Blacher, Alain Cariou, Emmanuel Sorbets

Abstract

Background: Blended learning, which combines face-to-face learning and e-learning, has grown rapidly to be commonly used in education. Nevertheless, the effectiveness of this learning approach has not been completely quantitatively synthesized and evaluated using knowledge outcomes in health education.

Objective: The aim of this study was to assess the effectiveness of blended learning compared to that of traditional learning in health education.

Methods: We performed a systematic review of blended learning in health education in MEDLINE from January 1990 to July 2019. We independently selected studies, extracted data, assessed risk of bias, and compared overall blended learning versus traditional learning, digital blended learning versus traditional learning, computer-aided instruction blended learning versus traditional learning, and virtual patient blended learning versus traditional learning. All pooled analyses were based on random-effect models, and the I² statistic was used to quantify heterogeneity across studies.

Results: A total of 56 studies (N=9943 participants) assessing several types of learning support in blended learning met our inclusion criteria; 3 studies investigated offline support, 7 studies investigated digital support, 34 studies investigated online support, 8 studies investigated computer-assisted instruction support, and 5 studies used virtual patient support for blended learning. The pooled analysis comparing all blended learning to traditional learning showed significantly better knowledge outcomes for blended learning (standardized mean difference 1.07, 95% CI 0.85 to 1.28, I²=94.3%). Similar results were observed for online (standardized mean difference 0.73, 95% CI 0.60 to 0.86, I²=94.9%), computer-assisted instruction (standardized mean difference 1.13, 95% CI 0.47 to 1.79, I²=78.0%), and virtual patient (standardized mean difference 0.62, 95% CI 0.18 to 1.06, I²=78.4%) learning support, but results for offline learning support (standardized mean difference 0.08, 95% CI -0.63 to 0.79, I²=87.9%) and digital learning support (standardized mean difference 0.04, 95% CI -0.45 to 0.52, I²=93.4%) were not significant.

Conclusions: From this review, blended learning demonstrated consistently better effects on knowledge outcomes when compared with traditional learning in health education. Further studies are needed to confirm these results and to explore the utility of different design variants of blended learning.

Reference:

Vallée A, Blacher J, Cariou A, Sorbets E., Blended Learning Compared to Traditional Learning in Medical Education: Systematic Review and Meta-Analysis. J Med Internet Res. 2020 Aug 10;22(8):e16504  PMCID: PMC7445617.  DOI: 10.2196/16504

CE News is interested in promoting best practices around blended learning activities in CPD at our member institutions.  Share your experience by sending us a brief case study describing your blended learning activity including format, methods, target audience (faculty, residents, students), challenges, evaluation, outcomes and lessons learned for CPD practice.  Please send your case study directly to Dr. Vjeko Hlede, Column Editor at v.hlede@asahq.org no later than December 15 for publication in the Winter 2022 issue.

Vjekoslav Hlede, PhD is a Senior Learning Management Specialist with the American Society of Anesthesiologists, Chicago. 

Back to the Future of the Virtual Journal Club

The aim of this column is to review selected archived VJC sessions as these CPD practice topics continue to evolve and resonate with our members.

By Mila Kostic, CHCP, FACEHP

SACME’s Virtual Journal Club (VJC) was founded with a goal of helping support and further our capacity for scholarship in the field of continuing professional development in the healthcare. As we considered the diversity of academic experience, variety of backgrounds and professional roles in our field that shaped the needs and interests of our community, we decided to focus our approach less on the critique of the journal article, as the traditional approach to academic journal clubs, and more on the creation of a series of transformational discussions around the value of available evidence to our practice.

Over the last eight years, SACME’s VJC has provided our members and a larger CPD community with an opportunity to learn, share and engage with colleagues in a webinar format that allowed learners to listen-in or contribute actively with their comments and questions.

I have enjoyed hosting the VJC and working with many leaders in our field and scholars from the larger medical education context and facilitating many interesting sessions and conversations over the years and invite you to check-out our archive of about 40 recorded sessions that are free and readily available to all the members on our website: https://www.sacme.org/VJCarchive.  With a goal of drawing attention to some of the timeless topics of interest, this new column in CE News will serve to revisit some of the sessions and authors from the archives.

This Fall we are also back with our live virtual journal club hosting a series of sessions that will again draw attention to the scholarly approach to our work by being explicit in deepening our understanding of relevant theoretical frameworks for our practice of CPD and, in this way, enabling us to be better prepared to contribute and build onto the evidence from practice and in support of our field. Also, we will be introducing additional means of engagement and social media communication channels allowing for more generative exchanges and co-creation for our community of learners.

As we develop this column, feel free to reach out to me directly with your ideas and thoughts about our VJC at mkostic@stanford.edu.

 

Mila Kostic, CHCP, FACEHP is host and facilitator of the SACME Virtual Journal Club.

New Medical Education Research Grant Opportunity: Ilene B. Harris Legacy Research Fund (Letter of Interest deadline 10/15/2021)

The University of Illinois at Chicago (UIC) Department of Medical Education is pleased to announce a call for letters of intent for the first round of the Ilene B. Harris Legacy Research Fund.  The goal of the fund is to further the mission of the Department by supporting health professions education research projects that address important problems or questions in health professions in ways that advance innovation and/or methodological approaches. Proposals from medical education scholars employed at any non-profit institution of higher education are welcome. Projects are limited to 1 year and $40,000.  For full details, and to apply, see: https://uic.infoready4.com/#competitionDetail/1837545

Questions can be addressed to Prof. Alan Schwartz (alansz@uic.edu).

The Ilene B. Harris Legacy Research fund is a gift of Professor Morton Harris in honor of Ilene Harris, Professor and former Head of the UIC Department of Medical Education. Through this program, the Department continues to recognize and advance Ilene Harris's commitments to the development of leadership and scholarship in the field of health professions education.

Patient-centered Outcomes Research Institute (PCORI).  Upcoming Funding Opportunities.  Check for research areas and upcoming application deadlines.

Royal College of Physicians and Surgeons of Canada (RCPSC) offers a variety of grants to support medical educators, clinicians and researchers. Find more information here.

September/October

AHME/AAMC.  Teaching 4 Quality Certificate Course, September 22 –October 27.  An all virtual, longitudinal curriculum, Te4Q is a faculty development course that aims to enhance the teaching skills of clinical faculty in a quality improvement/patient safety context. Teams are encouraged. An optional QIPS project is offered to earn a course certificate.  More information available in the next few weeks. Check www.ahme.org or www.aamc.org for complete details. 

ACEHP.  Spotlight on Leadership: Conversations For Leaders In the Healthcare CPD Landscape, Thursday, September 30, 2021: 

1:00-2:00pm ET
How the "Urgency of Now" Created a New and Sustainable Value for CME/CE
2:00-3:00pm ET
Barriers to Entry and for Advancement in the Organization for Women and Other Underrepresented Groups
3:00-4:00pm ET
Implementing Change Management Practices in a CPD Office
4:00-5:00pm ET
Leading in Times of Crisis – Adapting to Change, Taking the Risks

Register today 

November/December

AAMC Annual Meeting: Learn Serve Lead 2021: The Virtual Experience, November 8-10, 2021. Complete information at: https://www.aamc.org/professional-development/events/learn-serve-lead

January/February 2022

Alliance for Continuing Education in the Health Professions (ACEHP): Alliance 2022 Annual Conference, January 12-15, 2022, Gaylord Rockies Resort & Convention Center, Aurora, CO.  47th Annual Conference

Other News

ACGME, AAMC & AACOM Announce New Clinician Educator Milestones (CEM)

The Accreditation Council for Graduate Medical Education (ACGME), Accreditation Council for Continuing Medical Education (ACCME), Association of American Medical Colleges (AAMC), and American Association of Colleges of Osteopathic Medicine (AACOM) recently announced  the newly developed Clinician Educator Milestones (CEM) across the continuum of medical education.  A Clinician Educator is defined as a faculty member who has formally incorporated educational principles and scholarship into their role for more effective teaching and learning. 

All clinical faculty have been invited to participant in a survey to evaluate the CEMs. You are asked to complete a survey related to your role as a clinician educator, provide your opinion of the newly developed CEM, and complete a self-assessment using two randomly assigned Milestone sets.  A careful review of the CEM and Supplemental Guide (a companion guide for the Milestones) will take approximately 60-90 minutes. A self-assessment and survey will take approximately 30 minutes. 

This study will collect data from August 10, 2021, through September 19, 2021.  If you are interested in participating, please review the Consent Information Sheet before starting the survey.  Once you have reviewed and understand the Consent Information Sheet, please review the Clinician Educator Milestones and Supplemental Guide.  The survey can be found here. 

A paper discussing the purpose, intent, and process for the design of these Milestones is available for your information: Clinician Educator Milestones White Paper.