DATE: April 8, 2004

SUBJECT: Effectiveness / CME [Evidence of CME Effectiveness Literature Search]

DATABASES USED: RDRB; PubMed (Medline)

YEARS COVERED: 1999-2004

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1: Acad Med.1999 Dec;74(12):1288-94. Continuing medical education for life: eight principles.Abrahamson S, Baron J, Elstein AS, Hammond WP, Holzman GB, Marlow B, Taggart MS, Schulkin J. University of Southern California School of Medicine, Los Angeles, USA.-Continuing medical education (CME) is being pressured to change in response to-increasing and changing educational needs of practicing physicians, fostered by-technical innovations, evolution of practice styles, and the reorganiztion of health care delivery. Leadership in the reform of CME falls primarily to the-medical specialty soceties in light of their traditional responsibilities for-accrediting CME and maintaining professional standards. To address the need for reform, the American College of Obstetricians and Gynecologists in 1997 organized a conference to assemble CME program administrators from several medical specialties and academicians with expertise in postgraduate learning. At the conference, issues facing CME were examined. The authors, who were conference participants, state and explain eight principles that emerged from conference discussions. (For example: "Educational activities should be supportive of and coordinated with the transition to evidence-based medicine.") The principles reflect the interspecialty and interdisciplinary consensus achieved by the conference participants and can serve as useful guideposts for educators as they work to improve CME in their institutions. The authors conclude by noting the need for a more systematic and rigoously analytic approach, where CME content is determined according to assessed needs and CME is evaluated by measuring outcomes; for this to happen, CME educators and faculty must be brought up to date through training, including the use of problem-based learning. CME must also instill collegiality, interaction, and collaboration into the learning environment instead of being a solitary learning activity. Finally, CME must not only emphasize the acquisition of knowledge but also instruct physicians in the process of decision making to help them better use their knowledge as they make clinical judgments.

2: Ann Acad Med Singapore. 2000 Jul;29(4):498-502.
Theory and practice in continuing medical education.
Amin Z.
Department of Neonatology, KK Women's and Children's Hospital, Singapore.
zubair@kkh.com.sg

INTRODUCTION: Continuing medical education (CME) represents the final and often most poorly understood stage of physician education. The understanding of contemporary theories of physician education and characteristics of effective CME interventions will help CME providers and physician learners to plan productive CME activities and improve learning. This article aims to provide readers with emerging evidences on effective CME, particularly in relation to theories of physician learning and their implications for CME planning. The article also summarises attributes of effective CME interventions.
METHODS: The data and evidence were collected from contemporary medical education journals and published books on medical education. Two electronic databases, Medline and ERIC (Educational Research Information Clearinghouse) were searched for suitable articles.
RESULTS: Physician learning is a distinct phenomenon with high inclination towards autonomy and self-directed learning. CME interventions are more likely to be fruitful if they are modelled with strong theoretical background, catered towards individual learning needs and preferences, and focused on the learning component of education. Many widely practised CME interventions fail to be effective as those are not based on the above principles.
CONCLUSION: Evidence suggests that careful planning and evaluation of CME will improve the key measure of physician's performance and health care outcome.
Publication Types: Review; Review, Tutorial

3: Arch Intern Med. 2000 Feb 14;160(3):301-8. Improving preventive care by prompting physicians. Balas EA, Weingarten S, Garb CT, Blumenthal D, Boren SA, Brown GD. School of Medicine, University of Missouri, Columbia 65211, USA. ABalas@health.missouri.edu

OBJECTIVES: To assess the impact of prompting physicians on health maintenance, answer questions regarding the mode of delivery, and identify opportunities and limitations of this information intervention. METHODS: Systematic electronic and manual searches (January 1, 1966, to December 31, 1996) were conducted to identify clinical trial reports on prompting clinicians. Three eligibility criteria were applied: (1) randomized controlled clinical trial, (2) clinician prompt, alert, or reminder in the study group and no similar intervention in the control group, and (3) measurement of the intervention effect on the frequency of preventive care procedures. Data were abstracted by independent reviewers using a standardized abstraction form, and quality of methodology was scored. A series of meta-analyses on triggering clinical actions was performed using the random-effects method. The statistical analyses included 33 eligible studies, which involved 1547 clinicians and 54 693 patients.
RESULTS: Overall, prompting can significantly increase preventive care performance by 13.1% (95% confidence interval [CI], 10.5%-15.6%). However, the effect ranges from 5.8% (95% CI, 1.5%-10.1%) for Papanicolaou smear to 18.3% (95% CI, 11.6%-25.1%) for influenza vaccination. The effect is not cumulative, and the length of intervention period did not show correlation with effect size (R = -0.015, P = .47). Academic affiliation, ratio of residents, and technique of delivery did not have a significant impact on the clinical effect of prompting.
CONCLUSIONS: Dependable performance improvement in preventive care can be accomplished through prompting physicians. Vigorous application of this simple and effective information intervention could save thousands of lives annually. Health care organizations could effectively use prompts, alerts, or reminders to provide information to clinicians when patient care decisions are made. Publication Types: Meta-Analysis

4: Acad Med. 2000 Dec;75(12):1167-72. Continuing medical education: a new vision of the professional development of physicians. Bennett NL, Davis DA, Easterling WE Jr, Friedmann P, Green JS, Koeppen BM, Mazmanian PE, Waxman HS. Department of Continuing Education, Harvard Medical School, Boston, Massachusetts 02115, USA. Nancy_Bennett@hms.harvard.edu

The authors describe their vision of what continuing medical education (CME) should become in the changing health care environment. They first discuss six types of literature (e.g., concerning learning and adult development principles, problem-based/practice-based learning, and other topics) that contribute to ways of thinking about and understanding CME. They then state their view that the Association of American Medical Colleges (AAMC) has made a commitment to helping CME be more effective in the professional development of physicians. In presenting their new vision of CME, the authors describe their interpretation of the nature and values of CME (e.g., optimal CME is highly self-directed; the selection and design of the most relevant CME is based on data from each physician's responsibilities and performance; etc.). They then present seven action steps, suggestions to begin them, and the institutions and organizations they believe should carry them out, and recommend that the AAMC play a major role in supporting activities to carry out these steps. (For example, one action step is the generation and application of new knowledge about how and why physicians learn, select best practices, and change their behaviors). Six core competencies for CME educators are defined. The authors conclude by stating that collaboration among the appropriate academic groups, professional associations, and health care institutions, with leadership from the AAMC, is essential to create the best learning systems for the professional development of physicians.

5: Ann Intern Med. 1999 Dec 7;131(11):822-9. Comment in: Ann Intern Med. 1999 Dec 7;131(11):859-60. Ann Intern Med. 2000 May 16;132(10):844. Effect of clinician communication skills training on patient satisfaction. A randomized, controlled trial. Brown JB, Boles M, Mullooly JP, Levinson W. Center for Health Research, Portland, OR 97227-1098, USA. jonathan.brown@kp.org

BACKGROUND: Although substantial resources have been invested in communication skills training for clinicians, little research has been done to test the actual effect of such training on patient satisfaction.
OBJECTIVE: To determine whether clinicians' exposure to a widely used communication skills training program increased patient satisfaction with ambulatory medical care visits.
DESIGN: Randomized, controlled trial.
SETTING: A not-for-profit group-model health maintenance organization in Portland, Oregon.
PARTICIPANTS: 69 primary care physicians, surgeons, medical subspecialists, physician assistants, and nurse practitioners from the Permanente Medical Group of the Northwest.
INTERVENTION: "Thriving in a Busy Practice: Physician-Patient Communication," a communication skills training program consisting of two 4-hour interactive workshops. Between workshops, participants audiotaped office visits and studied the audiotapes. MEASUREMENTS: Change in mean overall score on the Art of Medicine survey (HealthCare Research, Inc., Denver, Colorado), which measures patients' satisfaction with clinicians' communication behaviors, and global visit satisfaction.
RESULTS: Although participating clinicians' self-reported ratings of their communication skills moderately improved, communication skills training did not improve patient satisfaction scores. The mean score on the Art of Medicine survey improved more in the control group (0.072 [95% CI, -0.010 to 0.154]) than in the intervention group (0.030 [CI, -0.060 to 0.1201).
CONCLUSIONS: "Thriving in a Busy Practice: Physician-Patient Communication," a typical continuing medical education program geared toward developing clinicians' communication skills, is not effective in improving general patient satisfaction. To improve global visit satisfaction, communication skills training programs may need to be longer and more intensive, teach a broader range of skills, and provide ongoing performance feedback. Publication Types: Clinical Trial; Randomized Controlled Trial

6: J Contin Educ Health Prof. 2002 Fall;22(4):214-21. Erratum in: J Contin Educ Health Prof. 2003 Spring;23(2):67. Randomized controlled trials of continuing medical education: what makes them most effective? Cauffman JG, Forsyth RA, Clark VA, Foster JP, Martin KJ, Lapsys FX, Davis DA. Department of Family Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

INTRODUCTION: It is essential that professional standards of excellence are demonstrated in the continuing medical education (CME) curriculum and research. METHODS: This review examines 20 randomized controlled trial (RCT) studies in CME and their effect on physician performance and/or patient health care outcomes. A systematic evaluation of the 20 RCT articles was performed. The investigators of the trials were interviewed using a standardized interview schedule. Citations from science and social science publications were compiled to obtain an unobtrusive measure of the influence of the trials.
RESULTS: Investigators were most often motivated to build on earlier research of others, their own earlier research, or a combination of others' earlier research and their own. The most effective educational strategies used multiple interventions, two-way communications, printed and graphic materials in person, and locally respected health personnel as educators. Statistically significant findings more often related to physician performance than to patient health care outcomes. The most effective studies were the ones in which the educational methods were cost effective, findings could be generalized to other physician groups, the studies were implemented elsewhere in multisite health care and health-related programs and had the most citations. Investigators interviewed about their RCTs provided advice for future directions of CME curriculum development and research.
DISCUSSION: CME program directors should determine what physicians need to learn, should reach out to nonparticipating physicians, and should focus on relevant problem areas. These problem areas should be ones in which it is possible to make changes, particularly in patient health care outcomes. Publication Types: Review, Review, Tutorial

7: JAMA. 1999 Sep 1;282(9):867-74. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Continuing Education and the Centre for Research in Education, University of Toronto, Faculty of Medicine, Ontario, Canada. dave.davis@utoronto.ca

CONTEXT: Although physicians report spending a considerable amount of time in continuing medical education (CME) activities, studies have shown a sizable difference between real and ideal performance, suggesting a lack of effect of formal CME.
OBJECTIVE: To review, collate, and interpret the effect of formal CME interventions on physician performance and health care outcomes.
DATA-SOURCES: Sources included searches of the complete Research and Development-Resource Base in Continuing Medical Education and the Specialised Register of the Cochrane Effective Practice and Organisation of Care Group, supplemented by-searches of MEDLINE from 1993 to January 1999. STUDY SELECTION: Studies were included in the analyses if they were randomized controlled trials of formal didactic and/or interactive CME interventions (conferences, courses, rounds, meetings, symposia, lectures, and other formats) in which at least 50% of the participants were practicing physicians. Fourteen of 64 studies identified met these criteria and were included in the analyses. Articles were reviewed independently by 3 of the authors.
DATA EXTRACTION: Determinations were made about the nature of the CME intervention (didactic, interactive, or mixed), its occurrence as a 1-time or sequenced event, and other information about its educational content and format. Two of 3 reviewers independently applied all inclusion/exclusion criteria. Data were then subjected to meta-analytic techniques.
DATA SYNTHESIS: The 14 studies generated 17 interventions fitting our criteria. Nine generated positive changes in professional practice, and 3 of 4 interventions altered health care outcomes in 1 or more measures. In 7 studies, sufficient data were available for effect sizes to be calculated; overall, no significant effect of these educational methods was detected (standardized effect size, 0.34; 95% confidence interval [CI], -0.22 to 0.97). However, interactive and mixed educational sessions were associated with a significant effect on practice (standardized effect size, 0.67; 95% CI, 0.01-1.45).
CONCLUSIONS: Our data show some evidence that interactive CME sessions that enhance participant activity and provide the opportunity to practice skills can effect change in professional practice and, on occasion, health care outcomes. Based on a small number of well-conducted trials, didactic sessions do not appear to be effective in changing physician performance. Publication Types: Meta-Analysis

8: J Contin Educ Health Prof. 2003 Spring;23 Suppl 1:S53-62. Information mastery: integrating continuing medical education with the information needs of clinicians. Ebell MH, Shaughnessy A. Department of Family Practice, Michigan State University, East Lansing Michigan, USA.

Traditional continuing medical education (CME) has been disconnected from the actual practice of medicine and has not focused on providing the most useful information in the most efficient way. Physicians have different information needs at different times. When asked at the end of a day of patient care, physicians will typically report having had one question for every four or five patients. However, direct observation during patient care reveals many more questions. In the outpatient primary care setting, most studies have found, on average, that about two clinical questions are generated during every three patient encounters, with even higher numbers reported in the inpatient teaching setting. Thus, a physician seeing 25 patients in a typical day of outpatient care may have 15 clinical questions. Because clinical questions are the result of critical reflection by a clinician on his or her practice, they are central, to physician learning. This connection between "need" and learning is consistent with generally accepted theories of adult learning. When applied to continuing education, this connection suggests that physicians will learn best when learning is in the context of patient care, answers their questions, does not take too much time, and is directly applicable to their work. Pursuing answers to these questions and answering them with the best available evidence, at the time the answer is needed, may well change the physician's general approach to patient care.

9: Med Care. 2000 Feb;38(2):175-86. Comment in: Med Care. 2000 Aug;38(8):877-9. Provision of feedback on perceived health status to health care professionals: a systematic review of its impact. Espallargues M, Valderas JM, Alonso J. Health Services Research Unit, Institut Municipal d'Investigacio Medica Barcelona, Spain.

OBJECTIVE: To assess the impact on the process and the outcomes of care of feeding back information on perceived health status to health care professionals in clinical practice.
DESIGN: Systematic review of controlled trials.
Data identification: Search in electronic databases (MEDLINE 1966-1997), manual searches, and requests to experts in the field.
DATA ANALYSIS: Differences between intervention and control group were considered in process of care (use of health services, diagnosis, and treatment), patient outcomes (health status), and patient satisfaction. In a subgroup of 13 interventions that dealt with the provision of feedback about the patient's mental health, the impact on the process of care was subjected to meta-analysis.
RESULTS: We identified 21 studies that satisfied the selection criteria. Eleven of 20 (55%) found significant differences (P <0.05) in at least 1 of the process indicators in favor of the intervention group. Of 11 trials that assessed patient outcomes, only 4 (36%) detected significant improvements. A similar trend but lower percentages were observed among the 8 interventions that provided general health status information. Eleven interventions that evaluated feedback information about the patient's mental health status showed a higher rate of diagnosis in the intervention group (combined odds ratio [OR]=1.91; 95% confidence interval [CI] 1.28 to 2.83). Seven of 9 studies evaluating treatment failed to show an effect on this indicator (combined OR=1.15; 95% CI 0.76 to 1.75).
CONCLUSIONS: The provision of feedback on perceived health status to health professionals seems to have an effect on the process of care but not on patient functional or health status. This is especially true with regard to mental health status information. Nevertheless, there is still need for a more through evaluation of this type of intervention. Publication Types: Review; Review, Tutorial

10: J Eval Clin Pract. 2001 May;7(2):223-41. Effectiveness of educational interventions on the improvement of drug prescription in primary care: a critical literature review. Figueiras A, Sastre I, Gestal-Otero JJ. Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Spain.

This paper is a critical review of studies of educational programmes designed to improve prescription practices in ambulatory care. Scientific articles were selected from the following bibliographical indices: MEDLINE, IME, ICYT and ERIC. The searches covered the time period between 1988 and 1997. The search criteria included: primary-care, educat*, prescription* and other related keywords. The inclusion criteria were studies describing educational strategies aimed at general practitioners working in ambulatory settings. The study outcome was change in prescribing behaviour of physicians through prescribing indicators. The following data were extracted: study design, target drugs, type of intervention, follow-up period of the prescription trends, type of data analysis, type of statistical analysis and reported results. We found 3233 articles that met the search criteria. Of these, 51 met the inclusion criteria and 43 studied the efficacy/effectiveness of one or various interventions as compared to no intervention. Among seven studies evaluating active strategies, four reported positive results (57%), as opposed to three of the eight studies assessing passive strategies (38%). Among the 28 studies that tested reinforced active strategies, 16 reported positive results for all variables (57%). Eight studies were classified as a high degree of evidence (16%). We concluded that the results of our review suggest that the more personalized, the more effective the strategies are. We observe that combining active and passive strategies results in a decrease of the failure rate. Finally, better studies are still needed to enhance the efficacy and efficiency of prescribing practices. Publication Types: Review; Review Literature

11: Cochrane Database Syst Rev. 2000;(2):CD000172. Printed educational materials: effects on professional practice and health care outcomes. Freemantle N, Harvey EL, Wolf F, Grimshaw JM, Grilli R, Bero LA. Centre for Health Economics, University of York, Heslington, York, Yorkshire, UK, Y01 5DD. nf2@york.ac.uk

BACKGROUND: It is often assumed that merely providing information in an accessible form will influence practice. Although such a strategy is still widely used in an attempt to change behaviour, there is a growing awareness that simply providing information may not lead to appropriate changes in the practice of health care professionals.
OBJECTIVES: To assess the effects of printed educational materials in improving the behaviour of health care professionals and patient outcomes.
SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, reference lists of articles, and contacted content area experts.
SELECTION CRITERIA: Randomised trials, interrupted time series analyses and non equivalent group designs with pre-post measures of interventions comparing 1. Printed educational materials versus a non-intervention control; and 2. Printed educational materials plus additional implementation strategies versus printed educational materials alone. The participants were any health care professionals provided with printed educational materials aimed at improving their practice and/or patient outcomes.
DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality.
MAIN RESULTS: Eleven studies were included involving more than 1848 physicians. It proved impractical to examine the impact of interventions quantitatively because of poor reporting of results and inappropriate primary analyses. Nine studies examined comparison 1. Estimates of the benefit from printed educational materials ranged from -3% to 243.4% for provider outcomes, and from -16.1% to 175.6% for patient outcomes, although the practical importance of these changes is, at best, small. Six studies (seven comparisons) examined comparison 2. Benefits attributable to additional interventions ranged from -11.8% to 92.7% for professional behaviour, and -24.4% to 74.5% for patient outcomes. Two of the 14 estimates of professional behaviour, and two of the 11 estimates of patient outcomes were statistically significant.
REVIEWER'S CONCLUSIONS: The effects of printed educational materials compared with no active intervention appear small and of uncertain clinical significance. These conclusions should be viewed as tentative due to the poor reporting of results and inappropriate primary analyses. The additional impact of more active interventions produced mixed results. Audit and feedback and conferences/workshops did not appear to produce substantial changes in practice; the effects in the evaluations of educational outreach visits and opinion leaders were larger and likely to be of practical importance. None of the studies included full economic analyses, and thus it is unclear to what extent the effects of any of the interventions may be worth the costs involved. Publication Types: Review; Review, Academic

12: BMC Fam Pract. 2002 Aug 20;3(1):15. Increasing the satisfaction of general practitioners with continuing medical education programs: a method for quality improvement through increasing teacher-learner interaction. Gercenshtein L, Fogelman Y, Yaphe J. Department of Family Medicine, Rabin Medical Centre and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. leonidw@zahav.net.il

BACKGROUND: Continuing medical education (CME) for general practitioners relies on specialist-based teaching methods in many settings. Formal lectures by specialists may not meet the learning needs of practitioners and may cause dissatisfaction with traditional CME. Increasing learner involvement in teaching programs may improve learner satisfaction.
METHODS: A quality improvement program for CME for 18 general practitioners in the Tel Aviv region was designed as a result of dissatisfaction with traditional CME activities. A two-step strategy for change was developed. The CME participants first selected the study topics relevant to them from a needs assessment and prepared background material on the topics. In the second step, specialist teachers were invited to answer questions arising from the preparation of selected topics. Satisfaction with the traditional lecture program and the new participatory program were assessed by a questionnaire. The quality criteria included the relevance, importance and applicability of the CME topic chosen to the participant's practice, the clarity of the presentation and the effective use of teaching aids by the lecturer and the potential of the lecturer to serve as a consultant to the participant.
RESULTS: The participatory model of CME significantly increased satisfaction with relevance, applicability and interest in CME topics compared to the traditional lecture format.
CONCLUSIONS: Increased learner participation in the selection and preparation of CME topics, and increased interaction between CME teachers and learners results in increased satisfaction with teaching programs. Future study of the effect of this model on physician performance is required.

13: Pharm World Sci. 1999 Aug;21(4):158-67. Changing doctor prescribing behaviour. Gill PS, Makela M, Vermeulen KM, Freemantle N, Ryan G, Bond C, Thorsen T, Haaijer-Ruskamp FM. Department of Primary Care and General Practice, University of Birmingham, UK. p.s.gill@bham.ac.uk

The aim of this overview was to identify interventions that change doctor prescribing behaviour and to derive conclusions for practice and further research. Relevant studies (indicating prescribing as a behaviour change) were located from a database of studies maintained by the Cochrane Collaboration on Effective Professional Practice. This register is kept up to date by searching the following databases for reports of relevant research: DHSS-DATA; EMBASE; MEDLINE; SIGLE; Resource Database in Continuing Medical Education (1975-1994), along with bibliographies of related topics, hand searching of key journals and personal contact with content area experts. Randomised controlled trials and non-equivalent group designs with pre- and post-intervention measures were included. Outcome measures were those used by the study authors. For each study we determined whether these were positive, negative or inconclusive. Positive studies (+) were those that demonstrated a statistically significant change in the majority of outcomes measured at level of p < or = 0.05 between the intervention and control groups. Negative studies (-) showed a significant change in the opposite direction and inconclusive studies (approximately) showed no significant change compared to control or no overall positive findings. We identified 79 eligible studies which described 96 separate interventions to change prescribing behaviour. Of these interventions, 49 (51%, 41%-61%) showed a positive significant change compared to the control group but interpretation of specific interventions is limited due to wide and overlapping confidence intervals. Publication Types: Multicenter Study

14: Acad Med. 2002 Aug;77(8):810-7. Domains-based outcomes assessment of continuing medical education: the VA's model. Gilman SC, Cullen RJ, Leist JC, Craft CA. Health Professions Accreditation, Department of Veterans Affairs Employee Education System, and associate clinical professor of medicine, University of California, Irvine, College of Medicine, Ca 90822, USA. stuart.silman@lrn.va.gov

Demonstrating outcomes of continuing medical education (CME) efforts has become increasingly important to CME providers, accrediting organizations, and licensing bodies. Many CME providers have difficulty defining the nature of the outcomes, much less documenting the outcomes for which they are responsible. The vague nature of the terms "outcome," "impact," or "result" in the complexity of health care and medical education environments is a particular obstacle to many education providers. To overcome these barriers, the VA's Employee Education System (EES), a large CME provider, created a model identifying five major domains of possible outcomes for CME interventions; these are the domains of individual participants, employee teams, the larger organization, patients, and the community. These domains are useful in either assessing a single CME activity's outcomes or comprehensively assessing a CME provider's outcomes-assessment strategy. The use of such a domains-based outcomes-management strategy links organizational mission, needs assessment, specific activity assessment, and assessment of the overall education program. This approach may be useful to CME providers, accrediting and licensing bodies, or others interested in the relationship of CME outcomes to the activities of CME providers.

15: Educ Health (Abingdon). 2003 Nov;16(3):328-38. General practitioners' perceptions of continuing medical education's role in changing behaviour. Goodyear-Smith F, Whitehorn M, McCormick R. Department of General Practice & Primary Health Care, Faculty of Medical & Health Sciences, University of Auckland, New Zealand. f.goodyear-smith@aukland.ac.nz

CONTEXT: The effectiveness of moving to compulsory, prescriptive continuing medical education (CME) for New Zealand general practitioners (GPs) is questioned. Motivational interviewing theory suggests that a series of interventions gradually increase awareness of the need to change until change is finally actioned. This study aimed to explore GPs' views on their need for CME, experiences regarding its provision and perceptions on the effect of CME in changing their clinical behaviour.
METHOD: Qualitative study using semi-structured interviews of 24 GPs from Auckland and North Island rural areas assessing their CME experiences and preferences.
FINDINGS: All participants acknowledged that CME is a life-long process essential for GPs. Changing behaviour is generally seen as an incremental, evolutionary process with reinforcement of knowledge from different sources. Single events were perceived to effect change rarely. These were often high-impact, either punitive or incentive-based. GPs have a myriad of CME sources including reading, the internet, specialist letters, conversations with colleagues, quality assurance feedback, as well as traditional meetings. Credit-based quota requirements received mixed opinions but mostly were perceived negatively, discouraging needs-based approaches to learning. GPs' greatest barrier to obtaining CME is time.
DISCUSSION: GPs perform poorly in assessing