Plenary Session:
How Physicians Learn around the World
By Tamar Hosansky, Editor, Medical Meetings Magazine

MONTREAL—The consensus of the meeting's plenary speakers was that if CME is to meet new global challenges, providers must understand how physicians learn, as well as how cultural differences impact their decisions.

"I'm interested in knowing what it is that you would like to gain from [this session]," said Henry B. Slotnick, PhD, Visiting Professor, School of Medicine, University of Wisconsin-Madison. Pointing out that adult learners want practical solutions to problems they already have, he suggested that speakers do as he demonstrated—engage attendees by asking them what they want to learn. "We want to get people to undo their harness and pull forward. If you know how physicians learn, you're in a better position to do that."

The first thing CME providers need to do is recognize that doctors learn in stages. In the first stage, physicians recognize they have a problem and want to learn how to solve it. "If we want to teach a doctor how to prescribe a drug, we can't go to them and say, 'Here's this wonderful product,'" Dr. Slotnick explained. "We have to make sure the problem we're solving is a problem they have."

In the second stage, physicians need to know if there is a solution to their problem. "Physicians won't look for a solution if they don't think one exists," Dr. Slotnick said, adding that "they woefully underestimate the existence of solutions."

The third question doctors ask themselves is whether there are resources for learning solutions to their problem. Physicians look for resources that are available, clinically applicable, and familiar. For instance, a doctor sits at her desk attempting to solve a problem. Does she turn to her computer? The materials on her bookcase? The journals she receives? "What we want to do," he said, "is match the resources we have to doctors' needs."

If providers understand doctors' different learning stages, he said, they can develop CME activities that best meet doctors' learning needs.

Welcome to the World of Cultural Diversity

But in a global medical education environment, understanding the stages of physician learning is not enough. CME providers also need to understand cultural differences in learning styles when developing educational activities. "Cultural diversity is something that you all have to deal with," said Mary Lou Fuller, PhD, Professor Emeritus, Department of Teaching and Learning, University of North Dakota, Grand Forks. "The better job you do in preparing health-care professionals to understand cultural differences, the better job they will do in helping patients," she said.

The first step, said Dr. Fuller, is to understand the spectrum of cultural competence in the medical profession:
  • Cultural Destructiveness—On one end of the spectrum is cultural destructiveness. For example, from 1988 to 1991, a new measles vaccine was tested on a group of Hispanic and black mothers—who were not told that the treatment was experimental and not approved in the U.S.

  • Cultural Incapacity—This refers to people or organizations that are not intentionally destructive, as in the first example. "This group probably would be more sensitive if they only knew what to do," she said.

  • Cultural Blindness—This describes "people who think, 'I should be doing something, but I don't know what to do.'" As an example, Fuller read a letter from a physician describing one of his favorite patients: "I like him because I realize how hard I have had to work all my life to overcome the racist feelings that... never allowed me to act completely natural in his presence." That doctor, said Fuller, "is uncomfortable with his own discomfort."

  • Cultural Precompetence—These are people who take the attitude that "We are all the same," and deny our differences.

  • Cultural competence—This means more than learning the language, although that certainly helps, Fuller said. It also means understanding the nuances of the culture.
"You need culturally knowledgeable personnel and you need to make a continuing commitment of time and personnel and resources," Dr. Fuller challenged participants. "Welcome to the world of cultural diversity."

The Person Behind the Professional

Offering yet another aspect of physician learning, Suzanne Murray, President, AXDEV Global, Montréal, Québec and Norfolk, Va.; and co-founder, McGill Centre for Studies in Aging, Faculty of Medicine, McGill University, said that CME providers need to look at the health professional as a person, not only as a physician or as a nurse. "We need to really move from focusing on disease and patient medicine to a much more person-centered care," she said.

Health professionals' attitudes and values are driving their judgments and clinical decision-making. To design effective CME, she said, providers need to explore the barriers to behavior change and discover how physicians rethink their values.

But individual physician change is not the only factor, she continued. Organizational culture is key. "It's great to assess what an individual can do to change, but if we don't look at their particular environment, their medical association or faculty, that change will not occur," Murray concluded.

Does French CME Have a Future?

Here's an example of how organizational culture can frustrate change: In France, CME is mandatory but the law is not enforced, reported Hervé Maisonneuve, MD, MS, CPA, DEA, Editor and Medical Director, Webs'surg; and former Evaluation Director and Clinical Guidelines Director, Agence Nationale d'Accréditation et d'Évaluation en Santé, Strasbourg, France. "It doesn't work at all. There's too much fighting between the numerous players—private versus public physicians, general practitioners versus specialists, and professional organizations versus government," he said.

This battle has been going on for years. Most recently, in March 2002, the Kouchhner Law was put into effect, said Dr. Maisonneuve. It proposes three solutions for implementing mandatory CME: physicians participate in accredited education, their knowledge is evaluated by an accredited body, and they submit dossiers to a regional committee. Three national committees representing the various players have been established to evaluate the system.

While all players are in favor of a CME system, there are many questions about how it will be put into play, stated Dr. Maisonneuve. Currently under discussion are whether the mandatory credit system will be enforced using incentives or sanctions (incentives seem to be winning the day), how to handle conflicts of interest with industry, the use of evidence-based medicine and guidelines, and implementation of a re-licensure system.

Despite the other speakers' emphasis on the globalization of CME, Dr. Maisonneuve said that because of language and other local issues European CME is not viewed as a viable alternative for French physicians. Nonetheless, he is optimistic. "Is there a future for CME in France? Yes," he said.