Education, Disclosures, and Bias, Oh My! (Part One of Two) August 6, 2010

Part 1: The Case for In-Person, National Meetings

In this time of hyper-scrutiny of financial relationships between health care providers and industry, medical education is an arena that requires some reflection, as industry-sponsored programs may be at risk of extinction.

Before reaching the issue of what role industry should have in supporting medical education programs, the fundamental question is whether or not medical education programs should be continued at all. The answer is a resounding “Yes,” in my opinion. The practice of medicine is evolving at such a rapid pace, that only through discourse, teaching, and interaction, can health care providers (especially those with fewer opportunities for daily collaboration) attempt to maximize quality and keep up with the ever-changing standard of care (See my previous post, “Silo Busting“). 

Education is one of my passions and I feel so fortunate that I have been able to participate in many educational meetings, conferences, symposiums, and scientific sessions over the years (both as a speaker and an attendee). There is no substitute for those “Aha!” moments where one learns something new or suddenly understands a concept in a new way. As we move into an era where quality of health care delivery is measured and higher quality means higher reimbursement, medical education has become more important than ever for all stakeholders in health care.

The next logical question is one of the educational venue. For optimal exchange of ideas, health care providers from different geographic regions must be brought together. If this is to be done in-person, then the costs of travel and lodging and the venue itself (amongst other things) necessarily follow. If educational programs are to be delivered via an on-line or other electronic format (either live or pre-recorded), then there will be production costs, and the questions of educational penetration and effectiveness arise. It is not to be overlooked that, even in this age of computers and data streaming, standard in-person classroom teaching remains our educational paradigm, rather than self-study programs or correspondence courses.

Let me reflect on that last point for a moment. Learning requires a certain depth of concentration – the type of focus that is best achieved when other distractions are eliminated. While the cell phones and pagers of other lecture attendees might be a mild distraction in an auditorium setting, think of how many more distractions exist while one attempts to watch an on-line lecture at the office – phone calls, pages, emails, knocks on the door, overhead announcements, and the ongoing, fast-paced, chaotic environment that characterizes health care in 2010. Even if one were to have the self-discipline to initiate an educational activity at work by logging on to a website or popping a CD-ROM disk into the computer, I fear that interruptions, a lack of focus, the loss of that intangible human-human interaction element, and the inability to ask questions all would conspire to diminish the quality of learning.  And this (less effective) educational moment is less likely to occur in the first place, given the daily health care pressures we each assume, and the prioritization of clinical productivity over educational activities (See my previous post, “How can we Prevent the Erosion of Academic Teaching?“).  

If self-study and on-line teaching were to become the new medical educational paradigm for reasons of cost (as opposed to attending conferences, symposiums, and scientific sessions), I believe that distraction-free protected time would need to be built into each person’s monthly schedule in order to maximize the benefits of this learning method.  While hospital administrators almost certainly would cringe at the lost hours of manpower, RVUs, and revenue, this response is short-sighted and does not take into account the goal of improved quality of health care delivery.

Educational programs must continue, and this will require either physical absence to attend a conference or temporal absence to learn in peace. Trying to “have it all” by asking the health care provider to simultaneously engage in patient-care tasks and in-office educational activities is a multitasking recipe for failure. As health care providers, we must advocate for ourselves, and insist on having a formal plan in place to allow for meaningful ongoing medical education. One might argue that physicians and other health care providers should be autonomous with regard to self-study, and must be solely responsible for their own education, as per the model of meeting continuing medical education (CME) requirements. But I would counter-argue that the process of documenting 50 hours per year of CME credit is not at all comparable to the type of learning that results in improved knowledge and quality of care. 

Because of the pressures mentioned above, the former pursuit tends to be weighted heavily toward activities that are convenient rather than relevant to the individual, such as “one-size-fits-all” intra-institutional conferences that frequently do not fall within the provider’s area of specialty or niche of educational need. This discrepancy between the convenient and the relevant becomes even wider for subspecialty practitioners, such as those in the field of electrophysiology. How many of those 50 credit hours are spent in EP-specific activities, and of those, how many actually addressed a specific knowledge gap for that individual? The primary EP-specific outlet that permits EP physicians and other providers to satisfy knowledge deficits is the Heart Rhythm Society Annual Scientific Sessions, which proves my point that the best learning occurs when one ventures outside institutional boundaries. And, although a variety of teaching modalities will always be utilized, those boundaries are best crossed in a physical sense, rather than a virtual sense.

Face-to-face teaching, in contrast to sitting in front of a computer screen, affords the additional opportunity to ask questions and solicit clarification. A single didactic script will not suit all viewers because of the spectrum of prior education, knowledge, vocabulary, learning styles, and experience that characterizes those on the receiving end of the interaction. But there is a significant cost associated with transporting people to a common location. Who is responsible for covering this educational expense? Hospitals? Government? HMOs? Health care providers themselves? Patients? Industry? Medical industry has played an enormous role in paying for travel and accommodations for both faculty and conference attendees, and there is a passionate ongoing debate about whether this is appropriate and how much bias is introduced to education and health care. I will reflect on these issues in Part 2 of this entry…