Lifelong Learning, the Key to “Preserving the Passion”

I’ve been hearing from colleagues who have asked me about the “Emergency Medicine Continuous Certification” program of the American Board of Emergency Medicine, which was announced in the Fall/Winter 2000-2001 issue of the ABEM Memo a publication mailed to all ABEM diplomates and others associated with the ABEM. The Board’s early sharing of information and the detailed description of the proposed process, along with candid acknowledgements of methods yet to be developed and work yet to be done gives me confidence that standards are being upheld, yet the impact of this new process on diplomates has been and will continue to be considered.[1] Questions about specifics of the program and your comments are best addressed to the ABEM, either by letter or by email. (The details of the EMCC program have been updated since original publication of this piece.)

The EMCC will entail annual self-assessment testing following review of “Board-selected literature on specific topics in the specialty.” I suppose all of us certified by ABEM will find ourselves engaging in review of the same content more-or-less at the same time, whereas presently we pick and choose among many formal and informal CME content providers. Unquestionably, the real and growing public concern about physician knowledge and skills is appropriately enhancing attention to physician accountability both as directly transmitted to the ABEM and as manifested by other components of medicine’s private self-regulating specialty structure. Yet, most of us have managed to stay current without the encouragement of EMCC. While I support this pending and timely implementation of EMCC, I can’t help but admire my many colleagues who continuously strive for excellence by engaging in their own “lifelong learning” plan.

In conversations with colleagues prompted by the ABEM newsletter, we have frequently moved into discussions about “keeping up.” For those of us in academic centers or regularly engaged in teaching residents and students, keeping up is part of our daily work and daily challenge and motivation is regularly provided by the bright, aggressive resident who wants to demonstrate that s/he can “out knowledge” us. But as I speak to those of you practicing in the majority of EDs across the country, I’m constantly humbled by the efforts you undertake in “keeping up.”

Marcus Reidenberg, an internist and clinical-pharmacologist who taught clinical correlation sessions during my pharmacology course in medical school, recommended a three-part approach to keeping up with new pharmaceutical developments: a medicine text, a pharmacology text and a subscription to The Medical Letter. With ever more therapeutic agents available, it has been challenging even in hospitals with a strong formulary system where one only has to learn a single H2-blocker or third-generation cephalosporin and while I’ve stopped buying the two textbooks, for more than 25 years now I’ve subscribed to The Medical Letter. Arriving in it’s usual 4-8 page (rarely more) format every two weeks, I can honestly say it is about the only publication that doesn’t get “stacked” before it gets read, and mostly I read it cover-to-cover. With The Medical Letter and a drug database in my Palm™ I seldom am taken by surprise by a new drug.

As I’ve become more of a physician-executive and less of a clinician-educator, I’ve found my time for reading the medical literature more and more limited; or maybe it’s the recent requirement for reading glasses that has driven me to replace music on the audio tape/CD player with audiotape based CME. I won’t tout any particular provider of audiotape programs, but I’ve found these tapes to be a wonderful way to spend time during my regular train commutes between Philadelphia and New York.

On summer vacations and other longer trips, when the occasional opportunity to read presents itself far from the stack of journals in the corner, what do you read? Over the past 20 years I’ve become accustomed to carrying The Yearbook of Emergency Medicine in my bag.[2] Whatever works for you, it is certainly useful to have a single volume to carry on a longer trip that can be read in “small bites.”

Does everyone in your group keep current or do you as the group leader cast about for ways to help your colleagues keep learning? Medical Staff CME requirements are a potent inducement for gaining minimal compliance, but are your colleagues really learning what will be most useful to them in their own practice? Probably not if their CME is devoted to only one or two trips to courses or symposia; probably yes if they add to this general learning reading and study about the difficult clinical problems they have faced in giving care in the ED. Research, which examined the daily practices of exceptional physicians, has identified the combination of general topic CME with patient-oriented study as leading to the best results in “keeping up.”[3]

The addition of this “practice-based CME” whether formally recognized for credit or not; though practiced as a student and resident by most of us is only variably carried on by practitioners. Too rare is the practice, common in sports, of inviting observation of even simple commonplace activities such as performing a physical examination or eliciting a patient’s history. Yet every great sports figure is supported by coaches who commonly drill those they train in the fundamentals. As Manning and DeBakey point out, “The things that human beings do best they do every day. You will therefore practice better medicine if you engage in daily study and daily evaluation of your performance.”[4]

Just as many of you have adopted computer technology creatively to enhance your learning and patient care, so too must all of us who practice medicine adopt learning and evaluation strategies that give the public confidence that our intent to do good for our patients is supported by expert knowledge and skill.

[1] Disclosure: I’m a senior director of ABEM. Which means in English that I was a director (1986-95). I currently do oral exams for the board. I was trained in EM finishing in 1978, first certified by ABEM in 1980 and recertified in 1990 and 1999.

[2] Disclosure: I was an Associate Editor of the Yearbook of Emergency Medicine from 1980 through 1999 and received royalties based on sales during that period. Former colleagues of mine presently edit the publication.

[3] Manning PR & DeBakey L: Medicine-Preserving the Passion. Springer-Verlag, New York, 1987.

[4] ibid, page 276