Guidelines to CME Organizers

Prepared by

Khaled Al-Jarallah, FRCPC, FACP, FACR, FRCP

I.G. Premadasa, BDS (Cey.), MA (Mich. State)

Published by Kuwait Institute for Medical Specialization, 10th Floor, Behbehani Complex, Al-Sharq, P.O. Box 1793, Kuwait 13018. © Kuwait Institute for Medical Specialization 2003. No part of this publication may be reprinted or reproduced, or stored in any form, with-out the prior permission of the copyright owner. Kuwait 2003.

Contents Preface Learning objectives

Part I – CME and its role in professional practice Mission statement of the CME Center ……………………………………………………. 5 Definition of CME …………………………………………………………………………... 6 Definition of CPD ………………………….…………………….…………………………. 6 Does CME/CPD work? ……………………………………………………………………. 7 Administration of CME Program ………………………………………………..…………. 8

Part II – Organization of CME activities CME activities and CME authorities ………………………………………………………. 13 Accreditation ………………………………………………………………………………… 13 CME Provider ……………………………………………………………………………….. 15 CME organizer ...………………….………………………………………………………… 16 Categorization of CME ..…...……..……………………………………………………….. 17 Credit points for CME organizers …………….…………………………………………… 19 Registration of CME activities under the CME Program ….……………………………. 20 Preliminary registration …………...……………………………………………………….. 23 Registration of ongoing activities …….……………………………………………………. 23 Renewal of registration of ongoing activities ..………………….……………………….. 23 Announcement and publicity ..……………………………….……………………………. 24 Completion of CME activity ..……………………………………………………………… 24 Verification of documentation by CME Center ……………...…………………………… 25 Sponsorship .……………………….……………………………………………………….. 26

Part III – Planning effective CME: educational considerations Needs assessment …………………..……………………………………………………… 32 Adult education …………………..………………………………………………………….. 33 Educational objectives in planning CME activities …………………………………… 34 Target audience ……………………….…………………………………………………….. 37 Effective CME strategies ………………..…………………………………………………. 38 e-Learning .………...………………………………………………………………………… 39 CME models ……….……………………………………………………………………….. 40 Instructional strategies ……….….…………………………………………………………. 41 Assessing effectiveness of CME ………….………...……………………………………. 48 Summary of important educational issues ….……………………………………………. 50

Part IV – Participation in CME Registration for participation …………………………………………...………………….. 53 Exemption from CME requirement ...……..…..…………………………………………… 55 Exclusion from credit ………………………….……………..……..……………………….. 55 Credit points granted by external agencies .…….……..………………………………….. 56 Reciprocity with external agencies ...…………...………………………………………….. 56

Appendix Evaluation of CME Program Bulletin of the Kuwait Institute for Medical Specialization Information on CME Program Communication with CME Center

Preface The Kuwait Institute for Medical Specialization (KIMS) of the Ministry of Health launched the CME Program in September 2000, and the majority of the medical and dental practitioners in Kuwait are now registered in it. Steps have already been taken to expand the program so that other categories of health professionals would benefit from it.

To ensure that the CME program runs smoothly and that practitioners receive optimum opportunities for participating in CME activities, the CME Center has stipulated some ad-ministrative requirements to be met by CME organizers. Fur-thermore, CME organizers need to consider relevant educa-tional issues when planning and conducting CME activities so that the participants find the activities beneficial. Guidelines to CME Organizers deals specifically with these and other top-ics that should be of interest to those who wish to plan and conduct CME activities. The short section on how the CME program affects the practitioners illustrates the link between CME organization and CME participation and the obligations of CME organizers as far as the participants are concerned.

The past publications of the CME Center have been used by practitioners in Kuwait as well as those in the other GCC countries. We feel that a wide readership of CME organizers in the region would find the Guidelines similarly beneficial.

The CME Officers who have been appointed by KIMS to represent the different specialties would be in a position to clarify matters regarding the routine administration of the program. Details supplied by the CME organizers regarding CME activities, and updates of CME program implementation appear in the CME Center website www.kims.org.kw/cme. Ad-ditional copies of the Guidelines, too, can be downloaded from the site. Khaled Al-Jarallah FRCPC, FACP, FACR, FRCP Secretary General Kuwait Institute for Medical Specialization I.G. Premadasa, BDS (Cey.), MA (Mich. State) Director, CME Center Kuwait Institute for Medical Specialization Kuwait, 2003.

Learning Objectives

Guidelines to CME Organizers has been prepared so that the reader would:

1. Be able to state the organizational and administrative structure of the CME Program;

2. Be able to describe the roles and responsibilities of CME Providers and the CME organizers;

3. Be aware of the procedure adopted in accrediting CME activities;

4. Be able to outline how the resources offered by private commercial establishments be properly used in the organization of CME activities;

5. Appreciate the importance of clearly-defined learning objectives in selecting target audiences, identifying subject content, and choosing teaching methods for CME activities;

6. Be aware of the methods that could be used for determining the effectiveness of CME activities;

7. Be able to outline the basic aspects of the CME Program that would be of interest to health professionals who wish to participate in CME activities conducted in Kuwait.

Part I

CME and its role in professional practice

Learning objectives 4 Mission statement of the CME Center 5 Definition of CME 6 Definition of CPD 6 Does CME/CPD work? 7 Administration of the CME Program 8 CME Center, CME Officer

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Learning Objectives for Part I - CME and its Role in Professional Practice By the end of this section the reader should:

1. Be able to state the overall aims of implementing CME schemes;

2. Be able to state the general objectives of the CME Program in Kuwait;

3. Be able to define CME and CPD, and outline justifications for the use of the latter term;

4. Be able to state the factors that contribute to the effectiveness of CME, as reported in the literature;

5. Be able to state the essential elements in the administrative structure of the CME Program in Kuwait, and outline their roles and functions.

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CME AND ITS ROLE IN PROFESSIONAL PRACTICE MISSION STATEMENT OF THE CME CENTER The CME Center aims to assist health professionals to keep abreast of the developments in their specialties and in fields that have a bearing on their practices. The competencies that practitioners would gain from the opportunities provided un-der the CME Program would improve their performances, and ultimately raise the quality of health care that patients and the community receive. The CME Program has the following main objectives:

• To ensure that health professionals participate in accred-ited educational programs so that the care provided to the community is of high standard;

• To demonstrate to patients, the public and peers that health professionals are committed to participating in ac-credited educational activities throughout their careers;

• To improve the performances of all health professionals, instead of limiting educational opportunities to those who may be identified as under-performing;

• To provide a standardized and easily-accessible mecha-nism to health professionals for documenting their partici-pation in accredited continuing medical education and con-tinuing professional development activities.

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Definition of CME Continuing Medical Education (CME) represents the educa-tion of medical and dental practitioners after they complete formal training. It comprises all education related directly to professional responsibilities and is aimed at assisting them to carry out their professional duties more effectively.

Three phases can be identified in the education of health professionals: undergraduate, postgraduate and continuing. CME comprises all educational activities that practitioners undertake after they complete the training that qualifies them to engage in practice in the fields of their choice. In the case of many practitioners, the pre-CME training would be an under-graduate course of studies, followed by an internship. A small proportion would go for additional, postgraduate training after this phase. There is an increasing emphasis today, however, on the need to start CME during the undergraduate phase it-self, and for medical schools to play a greater role than in the past in providing CME opportunities to the practitioners.

CME therefore consists of any educational activity that helps to maintain, develop or increase knowledge, problem-solving, technical skills or professional performance standards so that physicians and other health professionals are in a posi-tion to provide better health care. CME includes formal courses, conferences and workshops, as well as self-directed activities such as preceptorship and directed reading.

Definition of CPD Continuing professional development (CPD) is a term that of-ten comes up when discussing CME. It is generally understood to cover the development of a wider range of professional skills than learning in medical subjects.

Both terms CME and CPD are in use today, often synony-mously. The broad aim of CME as well as CPD, however, is to equip the practitioner to perform more effectively so that the patient and the community receive optimum care.

It is important that patient care improves as a result of the CME activities undertaken by the health professionals. There-fore, when assessing the effectiveness of CME, the emphasis should be on the outcome of participation, rather than on whether the participants were satisfied with how the individ-ual activities were organized and presented.

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DOES CME/CPD WORK? Today, a number of institutions use CME as evidence of com-petence for medical practice when granting re-licensure, hos-pital privileges, specialty recertification, professional society membership and recognition for other professional activities.1

An extensive review of the literature, coupled with opin-ions of recognized experts in the field of CME, by Davis et al showed that the majority of the interventions studied were associated with an improvement in physician performance or health care outcome.2,3

Three aspects that contribute to the effectiveness of CME activities have been described:4,5,6

• Predisposing features, which influence individuals to change. One way in which this may be achieved is by providing relevant information;

• Enabling features help practitioners to apply the new competencies in the practice setting. Equipment and other resources required may be made available to the practitioner to introduce new procedures;

• Reinforcing features would confirm the positive outcomes of any changes implemented. This may be undertaken by providing appropriate feedback and with reminders. E.g. Compliance with guideline recommendations by hyper-tension patients may be improved with reminders to practitioners.7

Predisposing features alone are moderately successful in improving performance. When either enabling or reinforcing features were combined with predisposing factors, the effec-tiveness of the activities is markedly increased. When CME/CPD activities are planned after an adequate needs assess-ment and are directly related to practice they tend to be more effective. The effectiveness is further enhanced if the predis-posing, enabling and reinforcing strategies are incorporated.

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ADMINISTRATION OF CME PROGRAM The Kuwait Institute for Medical Specialization (KIMS) is designated by the Ministry of Health of the State of Kuwait as the authority that is responsible for planning and imple-menting the CME program. The scheme was introduced in September 2000, and at present covers medical and dental practitioners attached to government institutions as well as those serving in the private sector. Steps have already been taken to expand the program to include other categories of health professionals. CME CENTER

KIMS oversees the organization of formal CME activities through the CME Program, which is administered by its CME Center. Institutions and organizations that have the necessary resources are accredited as CME Providers for presenting indi-vidual events. The CME activities may take the form of courses, symposia, conferences, workshops etc. The CME Pro-viders accredited at present are the Faculties and Scientific Committees of KIMS, the specialty divisions of the Ministry of Health, the Faculties of the Health Sciences Centre of Kuwait University, and professional organizations and specialist socie-ties in the health care disciplines.

The Director of the CME Center is responsible for the day-to-day running of the CME Program, under the overall super-vision of the Secretary General of KIMS. The CME Center functions in consultation with the CME Council and the Ac-creditation Committee of KIMS. The CME Council is consti-tuted by the CME Officers appointed by KIMS to represent the different medical and dental specialties.

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CME OFFICER

The CME Officers of KIMS coordinate all CME/CPD activities in the respective specialties. While some subspecialties have a CME Officer who is a specialist in the same subspecialty, others have their CME activities coordinated by a CME Offi-cer appointed for a related specialty.

The main functions of the CME Officers are to: 1. Serve as the link between the CME Center of KIMS and

the Faculty/specialty concerned, with respect to the im-plementation of the CME Program;

2. Be a member of the CME Council of KIMS, and collabo-rate with the Director of the CME Center in developing the overall plan for implementing the CME program in the specialty concerned;

3. Prepare an annual program of CME activities that the Faculty/specialty concerned wishes to undertake during the KIMS Academic Year, and forward it to the CME Center of KIMS in time so that the Scientific Calendar of the following year could be prepared in advance;

4. Participate actively in assisting the CME Center of KIMS to give adequate publicity to CME/CPD programs that are organized by the accredited CME Providers;

5. Assist the CME Center in CME credit validation and validation of documentation maintained by practitioners registered in the CME Program;

6. Assist the CME Center and the CME Council in monitor-ing the implementation of the CME Program of KIMS.

The CME Officer would be familiar with the CME activities in the specialty that comes within his or her purview. Organ-izers of CME activities as well as practitioners registered in the CME Program are advised to contact the CME Officer for details of accredited CME activities or for clarifications on any aspect of the CME Program. A list of the CME Officers is available at www.kims.org.kw/cme, the web site of the CME Center.

Health care institutions, and academic and scientific estab-lishments may appoint their own CME Coordinators to facili-tate the organization of CME activities within the respective institutions. These CME Coordinators would also be able to liaise with the CME Officers of KIMS, and with the CME Center where necessary, to assist in the smooth running of the CME Program.

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Part II

Organization of CME activities

Learning objectives 12 CME activities and CME authorities 13 Accreditation 13 Accreditation of CME activities by CME Center CME Provider 15 CME organizer 16 Categorization of CME 17 Category 1 CME, Category 2 CME Credit points for CME organizers 19 Registration of CME activities under the CME Program 20 Application procedure, Drawing up session

schedules, Advance notice of application, Application forms Preliminary registration 23 Registration of ongoing activities 23 Renewal of registration of ongoing activities 23 Announcement and publicity 24 Completion of CME activity 24 Evaluation of CME activities Verification of documentation by CME Center 25 Sponsorship 26

Sponsorship of CME programs by private commercial establishments

Learning Objectives for Part II - Organization of CME Activities By the end of this section the reader should: 1. Be able to state the requirements that need to be satisfied

for proposed CME activities to be accredited; 2. Be able to state the basis for accrediting CME Providers and

name the CME Providers currently accredited; 3. Be able to state the roles and functions of the CME

organizer with regard to planning and conducting CME activities;

4. Be able to describe the system used for categorizing CME activities and the basis of the classification;

5. Be able to state the steps that CME organizers need to follow for getting CME activities accredited;

6. Be able to indicate the administrative obligations of the CME organizer prior to, during, and on completion of accredited CME activities;

7. Be able to outline the professional and ethical issues that need to be taken into account when using the resources supplied by private commercial establishments. O

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ORGANIZATION OF CME ACTIVITIES CME ACTIVITIES AND CME AUTHORITIES CME activities would fall into one of two major groups: for-mal CME activities organized and presented by an accredited CME Provider and its CME organizer, or CME activities in topic areas identified and undertaken by individual practitio-ners. Part II of the Guidelines deals specifically with activi-ties of the former group, i.e. those organized by an accredited CME Organizer.

For many years CME activities of varying degrees of so-phistication and academic and scientific standards have been conducted by educational or scientific institutions, profes-sional organizations and commercial establishments. Practi-tioners attended them depending on their background, exper-tise, interest and availability. However, until formal CME schemes were started, the strategies used to assess the qual-ity of the activities varied considerably. Often there was no mechanism to monitor the progress of the practitioners in CME. This section of the Guidelines describes the CME Pro-gram in Kuwait, and deals with points of special interest to those who wish to organize accredited CME activities.

ACCREDITATION Accreditation is the system used by the CME Center to ensure that CME activities meet the accepted standards of education and scientific merit. Accreditation constitutes registering the proposed CME activity by the CME Center, based on the infor-mation received regarding the aims and objectives, content covered, scheduling of sessions, expertise of the resource per-sons, target audience, and the intended approach to evalua-tion.

CME authorities, in general, require that the proposed program satisfies the following requirements:8,9

• Presents clear aims to potential participants; • Demonstrates the relevance of the aims to educational

needs of practitioners; • Is structured and includes varied learning approaches; • Is able to cater to the varying needs of participants, and

provide individual feedback; • Gives details of the evaluation of the program.

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ACCREDITATION OF CME ACTIVITIES BY CME CENTER

The CME Center adopts an approach essentially similar to that listed previously in accrediting CME activities that are conducted locally. The criteria it uses are that:

• The target audience of the activity is clearly identified; • The activity is planned on the basis of identified needs

(perceived and/or objective); • The objectives of the activity are clearly stated; • The educational methods selected allow the objectives

listed by the organizer to be achieved; • The audience is able to actively participate in the ses-

sions, where relevant; • The participants receive an opportunity to evaluate the

activity at its conclusion; • The activity, if funded by an external body, is organized

adhering to an approved code of ethics and responsibili-ties with regard to sponsorship of CME activities.

For a CME activity to be accredited, the organizer of the program has to submit all the relevant documents to the CME Center. On receipt of the information requested, the activity is assigned a Registration Number, and is classified into one of two groups: Category 1 or Category 2. Taking the duration of contact hours of education into consideration, a credit point value, too, is allotted. These details are then con-veyed to the organizer, who is expected to indicate the cate-gory to which the CME activity belongs and the number of credits assigned to it in all announcements and in the certifi-cates that would be issued to participants. It is essential that formal and structured CME events such as conferences, sym-posia, seminars and workshops receive prior CME accredita-tion, if participants are to claim CME credits under the CME Program.

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CME PROVIDER A number of institutions and organizations that possess ex-pertise for conducting CME activities at a national level have been recognized as CME Providers. They are eligible to plan conferences, courses, symposia, seminars and other educa-tional activities for CME. The following have been accredited at present:

• Faculties and Scientific Committees of KIMS; • Health Sciences Faculties of Kuwait University; • Specialty divisions of the Ministry of Health; • Health professions associations, e.g. Kuwait Medical As-

sociation, Kuwait Dental Association and their specialty societies, Kuwait Pharmaceutical Association, and Ku-wait Nursing Association.

Institutions that possess expertise and adequate resources for conducting activities, but not included under the above may contact the CME Center of KIMS to inquire whether they qualify for accreditation, and if so, to obtain details of the procedure adopted.

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CME ORGANIZER Depending on the subject area of a given CME/CPD activity, an appropriate content specialist would function as the CME organizer on behalf of the CME Provider. He or she takes im-mediate responsibility for the different aspects of the CME ac-tivity, which include:

• Initiating, planning, and developing the program; • Identifying overall goals and specific objectives, subject

content, target group, resource persons, financial re-sources and logistical support, plan of program evalua-tion, venue, scheduling etc.

• Applying to the CME Center to get the activity registered and, after registration, announcing it among the prospec-tive participants;

• Coordinating the presentation of the activity, carrying out an evaluation, maintaining the participant list, and pro-viding certificates of attendance.

Scientific or educational events that CME Providers organ-ize for enhancing professional competencies qualify to be regis-tered under the CME Program. Activities that are primarily for patient care, or promotional displays of medical or dental equipment and materials, therefore, may not be included as CME. Pharmaceutical firms and other private establishments could, however, contribute to the CME Program by way of pro-viding resources for conducting activities. The scientific and educational content included in those events, though, comes within the purview of the accredited CME Provider and its CME organizer.

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CATEGORIZATION OF CME The primary aim of CME is improving the health profession-als’ competencies by assisting them to keep abreast of the de-velopments that would affect professional practice. Some form of yardstick is needed for use in keeping track of CME involvement, and quantifying it. The CME program relies on a relatively imprecise measuring tool – CME credit points – for this task.

All CME activities that come under the CME Program have been categorized into two groups, Category 1 and Cate-gory 2. Some CME schemes outside Kuwait have a higher number of categories: the KIMS program has opted for two, to allow it to be easily understood by the practitioners while cov-ering both structured as well as self-learning educational op-portunities.

The category under which a given CME event gets classified and the amount of credit allotted to it are related to a number of factors which include:

• Type of CME Provider; • Extent to which the activity is structured; • Organizational resources required for planning and con-

ducting the program; • Degree of involvement of the participants in the learning

opportunities; • Choice of scheduling and the venue. An important consideration in the categorization is

whether all those in the appropriate target group have the opportunity to participate.

On an average, Category 1 activities allow the participants to claim 1 credit point for every hour of participation, while Category 2 events give 0.5 point for the same period. Some events in either group receive different credit ratings.

CATEGORY 1 CME

Category 1 CME activities comprise formal and structured learning opportunities provided by recognized educational or scientific institutions or professional bodies. They are usually scheduled and held at venues that would allow all concerned practitioners to participate. Symposia, conferences, work-shops, seminars and lecture series would normally receive reg-istration under Category 1. While lectures and formal presen-

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tations in this category entitle the participants to claim 1 credit point of CME per hour of educational activity, practical/clinical training sessions are valued at 0.5 credit point per con-tact hour.

For participants to claim CME credit points, all CME ac-tivities under Category 1 need to be registered in advance with the CME Center. The responsibility for taking steps to register them lies with the respective CME organizers.

CATEGORY 2 CME

Category 2 activities are those that are essentially of a self-learning nature, or are planned and conducted with a local participant group in mind. Many self-instructional formats, reading scientific papers in journals, and research and profes-sional publications would be included under this category. Category 2 also includes a wide variety of activities that are ongoing at health care, educational or scientific institutions. Examples of activities falling under Category 2 are:

i. Participation in patient care review activities ii. Teaching of medical and other health professionals iii. Writing questions for use in examinations iv. Journal clubs Case conferences Morbidity/mortality meetings v. Use of self-assessment examinations and reviews vi. Use of approved self-instructional material, including

computer assisted instruction vii. Use of distance learning programs viii. Reading scientific papers in journals and other related

professional publications ix. Conducting research in health-related disciplines x. Publication of medical/dental books or articles, books

and exhibits in medicine/dentistry, which target health professionals

xi. Self-directed study undertaken as preparation for ex-aminations

Some conferences, symposia, group learning sessions, seminars etc., too, may be classified under Category 2, based on the information that is available to the CME Center.

Participants qualify for 0.5 credit point of CME for every hour of education for involvement in activities such as scien-tific meetings in Category 2. Publication of scientific papers or

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review articles in the area of specialization in refereed jour-nals qualify the authors for variable amounts of CME credit: 1st (or single) author 5 credits, 2nd author 3 credits, 3rd author (and beyond) 2 credits. Writing a chapter in a book in the area of specialization would also enable the authors to claim credit in a similar fashion, while writing a book or monograph in the area of specialization gives the author 10 credits.

Calculating the credit values for some of the Category 2 ac-tivities could be difficult. The organizer responsible for the ac-tivity, where applicable, should estimate the time that the av-erage practitioner would require to complete it. This estimate is used in arriving at the maximum amount of credit that could be claimed. For self-directed education such as reading scientific papers, the amount of credit claimed should match the hours that an average practitioner would spend on compa-rable tasks.

CREDIT POINTS FOR CME ORGANIZERS The resource persons who play a major role in the planning and organization of CME activities are entitled to claim CME credit for their contribution. Purely administrative functions such as attending to correspondence needed for communica-tion with speakers or funding agencies, or secretarial duties are not classified as CME. In addition to the speakers or dem-onstrators in CME activities, chairpersons, moderators and rapporteurs who make an important academic or scientific contribution are included under resource persons. The organ-izer of the CME activity and the resource persons responsible for the individual sessions would decide on who is eligible to claim CME credit.

The quantum of CME credit that could be claimed depends on the category under which the activity was registered by the CME Center. The resource person may claim twice the amount of credit that the session participants are entitled to claim. If a session has been allocated 1 credit point, giving the partici-pants the opportunity of claiming 1 credit point, the resource person responsible for it, therefore, may claim 2 points.

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REGISTRATION OF CME ACTIVITIES UNDER THE CME PROGRAM All CME activities such as symposia, conferences, workshops and other similar events conducted within Kuwait need to be registered with the CME Center, if the participants who would attend them are to claim CME credits. APPLICATION PROCEDURE

Organizers of CME programs and CME Providers who wish to obtain accreditation of the proposed activities are required to apply to the CME Center, well in advance of the scheduled events, for them to be registered. Two forms (Form I – Appli-cation for Accreditation, and Form II – Information on Pro-posed Program) need to be completed and submitted.

It is essential that the organizer indicates the duration (in hours) of each session, as this information is used in calculat-ing credit points. A quarter of an hour is used as the unit in the calculation. When sessions last for periods of time that cannot be converted to credit points on this basis, a rough ap-proximation is used by the CME Center.

One of the requirements in the CME scheme is that practi-tioners registered in the CME Program should send their CME credit details to the CME Center. At the stage when this is undertaken, the CME Center would accept credits only from CME activities that have received prior registration un-der the CME Program. If a conference or a seminar had not been registered for whatever reason, practitioners who at-tended it may include the credits under self-instruction or as Category 2 symposia, workshops or seminars.

DRAWING UP SESSION SCHEDULES

When planning the program, it is important that program organizers bear in mind the needs of the participants and their attention span. Excessively long sessions as well as many presentations coming one after another are not likely to benefit most CME participants. (Details of educational issues that have a bearing on planning of sessions appear in Part III of the Guidelines.)

If the schedule submitted to the CME Center does not indi-cate an appropriate recess or a break within a session, the

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credit points allotted would be adjusted. For a two-hour ses-sion presented by the same resource person, credit points would be calculated with 15 minutes deducted from the total duration. An option the organizer may use is to include a 15-minute break within the session, unless there is a strong practical reason that prevents it. For a three-hour session, or for three one-hour sessions scheduled one after another, the duration of a break is taken as 30 minutes, the academic ac-tivity being taken as running for 2 hours and 30 minutes.

ADVANCE NOTICE OF APPLICATION

The application for registration of proposed activities needs to reach the CME Center at least three weeks before the scheduled starting date. This period of advance notice has been decided mainly in response to requests made by the practitioners themselves. Additionally, such advance notice is necessary for the CME Center to confirm that the relevant information has been submitted, and to attend to the admin-istrative formalities. It also gives the organizer adequate time to prepare the announcements indicating credit point details, and have them circulated for the benefit of the prospective participants. The practitioners would then be able to choose those activities that they wish to attend, and make appropri-ate arrangements to ensure that their routine duties are car-ried out without disruption. We hope that the advance notice requirement would prevent the occurrence of situations where interested practitioners were unable to attend CME activities because the notices did not reach them in time. APPLICATION FORMS

Two forms, Form I and Form II, are available at the CME Center website www.kims.org.kw/cme, for online registration. They can also be printed from the site using MS Word, to be completed and sent to the CME Center by fax or other means. Online registration, though, is the preferred option.

Form I of the application deals mainly with the administra-tive aspects of the activity, while Form II is concerned with academic matters, which are used in reviewing the proposed activities before they can be accredited. Information is called for under the following headings:

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• CME/CPD Provider • Title of program • Frequency of conducting program • Aims and objectives • Content outline • Scheduling of sessions • Target audience - number and background • Resource persons (lecturers, demonstrators, instructors,

tutors etc.) • Plans for assessment of outcome and for follow-up • Plans for program evaluation For activities classified under Category 1, the above infor-

mation is needed in nearly all the situations. With respect to ongoing scientific meetings and other frequent activities that come under Category 2, some of this information may not be applicable.

The organizer is not expected to calculate the credit points for the CME event. The CME Center would undertake this task based on the information supplied by the organizer and the criteria that have been announced.

Once the CME Center receives the application, it classifies the proposed activity under either Category 1 or Category 2. It then assigns a credit value to the program considering the information available on objectives, content covered, educa-tional contact hours of the activity, target audience, resource persons, venue and scheduling of sessions.

The maximum number of CME points that would be allot-ted to a single CME activity (e.g. symposium, workshop, semi-nar, training program etc.) is 25 CME credits.

When the information supplied regarding a prospective activity is incomplete, there is bound to be delay in registra-tion. If the CME Center does not receive all the information requested, it may not register the program as an accredited CME activity. Therefore, it remains the responsibility of the CME organizer to ensure that all relevant information is in-cluded when the application is submitted.

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PRELIMINARY REGISTRATION Some CME activities such as major international conferences often involve communication between the organizer and a number of different parties. Therefore the organizers may need a considerable amount of time before complete schedules and programs can be prepared. While the CME Center is un-able to allocate credit points to an activity until scheduling details are received, the sponsors or the administrative au-thority may want to ensure that the program would be an ac-credited CME activity before an offer of funds etc. is con-firmed. To deal with this situation, the CME Center provides a scheme of preliminary registration. The organizer may for-ward the available information to the CME Center although planning is not complete, and the activity could be considered for registration on a preliminary basis. With details received in due course, registration is confirmed and credit points are assigned. Preliminary registration also enables the organizer to announce “CME accreditation applied for” even in a First Announcement of a seminar or a conference.

REGISTRATION OF ONGOING ACTIVITIES Ongoing educational activities at health care institutions such as patient care review meetings, journal clubs, and mor-bidity/mortality meetings are accepted for credit under Cate-gory 2. For this, the institution has to appoint a suitable prac-titioner to function as the organizer. He or she would submit an application in advance to the CME Center for registration. The application could cover events that are to be conducted over an extended period (6 months or 1 year).

RENEWAL OF REGISTRATION OF ONGOING ACTIVITIES Ongoing educational activities that have already been regis-tered under the CME Program need renewal of registration if they are to be repeated beyond the period of initial registra-tion. A written request by the organizer, before the activities are held, would be sufficient for this unless there is a major change in the format of the activity.

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ANNOUNCEMENT AND PUBLICITY Preparing the announcements and brochures, and taking steps to circulate them among the potential participants re-mains the responsibility of the organizer. The Illustrations Unit of KIMS could assist in these tasks, provided the organ-izer submits the text of the material well in advance to the Unit. Additionally, the Office of the Secretary General of KIMS would make some of the resources at its disposal avail-able for distributing the announcements among the various health care facilities and other institutions.

It is essential that the Registration Number and the Cate-gory of CME and credit points are clearly stated in all an-nouncements. A program should not be announced as a CME activity, with details of CME credits accredited by the CME Center, until the organizer has received a letter of registra-tion from the CME Center.

COMPLETION OF CME ACTIVITY When a CME activity is completed, the organizer is expected to maintain relevant documentation, and to issue each par-ticipant a certificate of attendance. The documentation re-quired is:

i. A list of the participants who completed the activity sat-isfactorily;

ii. An evaluation report. The ‘certificate’ that the organizer of the CME activity is

required to issue is only an official document, which may be printed on office stationery using standard office equipment. Professional artwork and page designs, and printing at a com-mercial establishment are not needed to satisfy the require-ments of the CME Program. The CME Registration Number, the Category of CME and the number of CME credit points the participant may claim should clearly be stated in the docu-ment issued. Each physician or dentist is entitled to claim only those hours of credit that he or she actually spent in the edu-cational activity.

In the case of some Category 2 activities, a number of events conducted over a specified period may be included in the same certificate. The organizer would decide where such an approach is appropriate after considering the practicality issues.

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EVALUATION OF CME ACTIVITIES

The main purpose of the evaluation is to give feedback to the course organizer and the instructors on the strengths and weaknesses of the activity. This would help to introduce ap-propriate modifications if similar programs are to be con-ducted in the future.

When preparing an Evaluation Report a series of compara-ble events that are held routinely and frequently may be grouped. Thus journal clubs, morbidity/mortality meeting or patient care review meetings conducted over a specified pe-riod may be included in a single report.

The website of the CME Center (www.kims.org.kw/cme) provides sample forms for documenting participation and for use in evaluation (Form III - Attendance at CME Program; Forms IVa and IVb for evaluation; Form V - Letter of Atten-dance). These may be modified to meet the specific needs of individual CME events.

During the periodic review of the CME Program, the CME Center would ask the organizers of past CME activities to submit copies of relevant documentation pertaining to them.

VERIFICATION OF DOCUMENTATION BY CME CENTER The documentation maintained by the organizers of CME ac-tivities will be reviewed on a regular basis to ensure that the implementation of the program proceeds satisfactorily. The organizers would be contacted by the CME Center for this purpose. The organizers are then expected to forward copies of the Attendance Lists and of the Evaluation Reports to the CME Center or to the CME Officers of KIMS, as requested. The CME Officers would also assist the CME Center in the verification of the documentation.

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SPONSORSHIP Most major CME activities need financial and other forms of sponsorship. Prior to the commencement of planning activi-ties, the organizer would estimate the expenses likely to be incurred and identify the potential sponsors. When an appli-cation for registration of a CME activity is received by the CME Center, it is taken for granted that the organizer had already dealt with the issue of resources, and has received the necessary assurances from the concerned parties, if rele-vant. The CME Center is not a sponsoring agency in any way, and inquiries regarding budgetary estimates or allocation should be directed to the appropriate authority at KIMS or other institution. Additionally, by the time an application is submitted for registration, substantive planning is expected to be in place to conduct the program so that the organizer could supply details of program objectives, scheduling etc. to the CME Center without difficulty.

Organizers of CME activities are welcome to use the re-sources offered by private commercial establishments in orga-nizing CME activities. Guidelines for making use of these op-portunities are listed in detail overleaf.

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SPONSORSHIPS OF CME PROGRAMS BY PRIVATE COMMERCIAL ESTABLISHMENTS

The CME Center of KIMS has received many inquiries from CME organizers about how sponsorship by pharmaceutical firms and other private establishments could be used to sup-port CME activities organized under the CME Program. CME Providers and organizers are requested to ensure that CME activities that receive financial or other forms of sponsorship from such institutions meet the following guidelines: Academic and Scientific Content The CME Provider is responsible for the scientific and aca-demic merit of the CME activities approved under the CME Program. Therefore, the course director, course organizer or the planning committee of the activity would take the overall responsibility for the subject content and the choice of speak-ers for conferences, symposia, workshops and other similar events.

Activities that are primarily of a promotional nature such as displays of medical or dental equipment and materials are not considered as CME. Choice of Topics The activities should focus on topics that would assist in the development of expertise in one or more areas of professional competence. Even if a formal needs analysis may not be possi-ble prior to planning, the organizers should consider at least the perceived needs of the participants when defining the ob-jectives and identifying the content for the proposed activity. This would help to ensure relevance to professional practice, promoting interest and involvement of the participants in the sessions. Generic Names of Drugs As a general principle, the use of generic names of drugs is preferred in presentations and discussions. Appropriate Ethical and Professional Standards During planning and implementing the program, issues deal-ing with ethics and professional standards should receive ap-propriate consideration. Patients’ rights and informed con-sent need to be given their due place by the organizers and the presenters of the sessions.

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Evaluation of Activity An essential component of the activity is its evaluation by the participants. This may be undertaken at conclusion of the sessions, or within a few days/weeks of completion if some post-program action was expected. Many workshop evalua-tion forms are available for this purpose. The CME Center has supplied its own formats considering the activities that would be conducted under the CME Program. The CME or-ganizer may modify these forms as required for the specific activity. Social Events Social events may be arranged as part of the activity. How-ever, the main emphasis in the program should be on its aca-demic or scientific aspects. Travel and Accommodation Arrangements for travel and accommodation of speakers or participants of the CME activities should be comparable to those that would normally be made if assistance from the sponsor was not available. Acknowledgement of Support Support provided by the sponsor may be acknowledged in the course brochures or other documents as appropriate. Identifi-cation or endorsement of the products marketed by the spon-sor should not appear in the material circulated by the pro-gram organizer. Additionally, promotional displays should not be held in the same room where the educational activity is conducted.

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Part III

Planning effective CME: educational considerations

Learning objectives 30 Needs assessment 32

Types of educational needs, Methods of identifying needs

Adult education 33 CME and adult learning 33 Educational objectives in planning CME activities 34

What is a learning objective?, Knowledge, Procedural skills, Values and attitudes

Target audience 37 Effective CME strategies 38 e-Learning 39 CME models 40 Instructional strategies 41 Small group teaching and discussions,

Practicals/demonstrations, Clinical teaching, Lecturing

Assessing effectiveness of CME activities 48 Assessing short-term effectiveness, Assessing effectiveness on a medium-term basis and a long-term basis

Summary of important educational issues 50

CM

E AND

EDU

CATIO

NAL ISSU

ES

By the end of this section the reader should: 1. Appreciate the importance of needs assessment prior to

planning CME, and be able to state the types of educational needs;

2. Be able to define adult education and show its application in planning and organizing CME;

3. Be able to define learning objectives and classify them so that the classification could become useful in planning CME;

4. Appreciate the importance of clearly identifying the target audience, for CME activities to be conducted effectively;

5. Be able to list strategies that would be effective in achieving the learning objectives of CME activities;

6. Be able to describe e-Learning and state its current and potential uses in CME;

7. Be able to state the teaching methods that could be used for different types of learning in CME, and indicate measures available to the instructor to facilitate learning by the participants;

8. Be able to indicate the approaches for planning the evaluation of effectiveness of CME, and list strategies of evaluation.

Learning Objectives for Part III - Planning Effective CME: Educational

Considerations

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PLANNING EFFECTIVE CME: EDUCATIONAL CONSIDERATIONS When planning any CME activity, it is important that the CME organizer pays attention to the relevant educational is-sues. In this section, the following topics are dealt with:

i. Needs assessment; ii. Educational objectives in planning CME activities; iii. Target audience; iv. Approaches to CME; v. Assessing the effectiveness of CME. The term effective CME would signify learning activities

that enable the participants to reach the educational objec-tives for which the sessions are being planned. It is more im-portant, however, to assess whether the widely used types of CME such as conferences, seminars or workshops ultimately result in the individual patient and the community receiving an improved level of health care services. Some of the factors that could contribute to the success of CME activities are:

• Examples of good practice getting established as the norm among colleagues;10

• Ensuring that speakers at formal presentations are ex-perts in their fields;11

• A person of authority taking responsibility for educational programs;

• Where institutions collaborate, one person at each institu-tion being responsible for the management of the inter-vention;12

• Promoting good interpersonal relationships between the participants.13

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NEEDS ASSESSMENT Before planning CME activities, the CME organizer should consider the educational needs of the prospective participants. Identifying these needs would help in selecting the subject content and the appropriate method of teaching. TYPES OF EDUCATIONAL NEEDS Perceived Needs Perceived needs reflect a gap between the knowledge and skills the practitioner feels that he already possesses and those that he would like to acquire.8 The practitioner himself identifies these needs through self-reflection. Objective Needs Objective needs reflect a gap that has been shown to exist be-tween a practitioner’s current level of skills and knowledge and the level recommended by experts. Informal meetings, questionnaires, peer review, reports of assessment commit-tees, and feedback from peers or patients may be used to gather data on objective needs. Normative Needs Normative needs are a type of objective need. They are related to advances in research and development in the medical sci-ences. They are defined by experts in training or research in-stitutions or professional societies. Institutional Needs Institutional needs are derived from the goals that a health care facility or any other institution wishes to achieve. They are influenced by the mission of the organization. METHODS OF IDENTIFYING NEEDS

Examples of formal methods used for identifying needs are focus groups, the nominal group technique, evaluation of past activities, meetings between colleagues, survey of participants’ expectations, and analysis of patient records. Some of these methods of needs assessment may be limited in scope, and of-ten are not practically feasible for use by the average CME organizer. Therefore, relatively informal methods, based on professional judgment and organizational development could be used.14,15

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ADULT EDUCATION A concept that is relevant when dealing with the topic of orga-nizing effective CME is adult education. A related issue that also warrants attention is whether the education of adults dif-fers from adult education?

All learning activities created by one agency for another group of people may be referred to as education. Some may view education as consisting of programs having wide rather than narrow goals, thus excluding training and indoctrination from education.16

The education of adults is often described as all forms of education for those above a specified age that identifies adult-hood. This cutoff point may be 16, 18 or 20 years of age. The term adult education is restricted to what can best be learned as adults because they rely on experience or relate to adult roles. These definitions would still leave some subjects such as literacy, sports, art and languages falling under one or the other.

The difference between the education of adults and adult education may lie more with the approach to learning than with what is being learned. Therefore adult education could consist of all forms of education that treat the student partici-pants as adults—capable, experienced, responsible, mature and balanced people.

CME AND ADULT LEARNING CME is likely to be effective when the activities that are being planned are based on the principles of adult education. The main factors that have an influence on planning effective edu-cation for health care practitioners are listed below:14 1. Adults learn best when actively engaged in the learning

process and where the learning builds upon their prior knowledge and experience.

2. The subject content that adults learn must be relevant to the practice or some other aspects of the work.

3. Adults learn best when they feel that the learning is neces-sary to solve a practical problem related to their profes-sional performance.

4. Adult learners tend to be independent and to maintain re-sponsibility for their learning.

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EDUCATIONAL OBJECTIVES IN PLANNING CME ACTIVITIES WHAT IS A LEARNING OBJECTIVE?

A learning objective is a description of an observable change in the performance that results from a learning activity. There-fore, a learning objective is not a theme to be discussed or the way a topic is to be dealt with during a learning session. Ob-jectives can be general (e.g. at the level of the overall program) or specific, referring to the outcome expected from a narrower activity (e.g. a short lecture).

If learning objectives are to become useful, they need to state the abilities that the participants are expected to gain from the sessions. Most of the time the objectives that we see have been written to describe what the course planners or in-structors wish to deal with. The emphasis instead should shift from the intent of the teacher to the outcome expected in the learner. In other words, what would the participants be able to ‘do’ as a result of the proposed interaction? Such learner-centered objectives enable the prospective participants to as-sess beforehand whether a given CME activity is likely to benefit them. They also help the resource person to select the most appropriate teaching method to be employed.

As a means of analyzing objectives, it is useful to classify them into categories, often called domains. Though the groups overlap to varying degrees in many situations, such an analy-sis helps to emphasize the different facets of learning.

A classification that is widely accepted in educational cir-cles lists three domains:

• cognitive domain • psychomotor domain • affective domain

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KNOWLEDGE

Learning objectives that are related to knowledge are grouped under the cognitive domain. Within it, they are often divided into a hierarchy—tasks or concepts that move stepwise from a lower level to a higher level. The outcomes, thus, may range from recall/recognition (e.g. stating signs and symptoms of a disease, or naming appropriate antibiotics for a given condi-tion), through data interpretation (e.g. interpreting a labora-tory report or identifying a lesion in a radiograph) to problem-solving (e.g. arriving at a diagnosis, or assessing the progress of a patient). Problem-solving involves making judgments, and the learner who can carry it out would obviously be able to re-call or interpret data. This is because recall or data interpre-tion are pre-requisite abilities, which come at a lower level in the hierarchy.

For achieving objectives in the cognitive domain, which in-volves the acquisition of information, some learning methods that may be used are lecture, discussion and reading assign-ments. Each of these has its advantages and disadvantages, and the course instructors would choose one or more in a given situation.

When opting for lecturing it should be kept in mind that the attention span of the average learner sitting in a lecture hall is 15 to 20 minutes. Ensuring that the subject matter is rele-vant and interesting, and that the instructor is skilled in pres-entation would help to overcome these difficulties.

One approach in planning effective CME sessions is to opt for smaller groups than traditionally done. This would give the participants an opportunity for interaction. Additionally, the presentation itself could deal with highlights of the topic or one or two of its important aspects, leaving the rest of the sub-ject content to be discussed in a well-written handout.

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PROCEDURAL SKILLS

The psychomotor domain is concerned with performance of skills, which involve doing manual procedures. Common exam-ples are measuring the blood pressure of a patient, setting up an intravenous drip or doing a lumbar puncture.

None of the tasks mentioned above can satisfactorily be completed unless the learner has the required knowledge base. But knowledge alone is no guarantee that the skill has been mastered. The implication of this argument is that it is not sufficient if the learner states how to do a task: it is essential that he or she performs it.

When learning objectives state that the CME activity is to enable the participants to perform specific procedures, lectur-ing is an inappropriate teaching method. The procedures have to be demonstrated, and the participants need to be given an opportunity to practice, initially under supervision, if neces-sary. The extent to which the different phases have to be em-phasized would naturally vary depending on the complexity of the skills. With today’s technology, a demonstration may be given even to a large group, but for the second, of practice un-der supervision, smaller groups are essential. VALUES AND ATTITUDES

Practitioners in the health professions are expected to possess many desirable attitudes, which fall within the affective do-main. These attitudes may be influenced by many factors, one of which is knowledge in the related topics. However, knowl-edge by itself does not lead to the desired attitudes towards the attitudinal object. A student or a practitioner may give all the correct answers when questioned (because he or she has the knowledge), but the performance on a long term basis is the only indicator of the presence of the attitude. Therefore, lecturing or giving reading material aimed at increasing the participant’s knowledge is unlikely to achieve the desired goal. Role modeling, role playing, discussion of issues in small groups or undertaking specific assignments are preferred in-stead.

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TARGET AUDIENCE

The background of the participants who are to attend the CME activity would have an overriding influence on the learn-ing objectives that would be defined for a course or a session, and on the subject content that is to be dealt with. This pre-requisite level of the participant could be analyzed as regards the educational level in the subject area, prior experience in the specialty or sub-specialty, and the relevance of the content of the program to the participant’s own needs and to practice in the clinic, hospital, laboratory or field setting.

In most situations, large groups of participants, running into hundreds, are unlikely to benefit were they to attend the same presentation. Furthermore, such excessive numbers would prevent the participants from being involved in any use-ful form of interaction. Many of those who attend may feel dis-pleased with the presentation, and may later complain that they did not gain anything worthwhile.

The CME organizer who desires to ensure that those who attend the activity get the maximum benefit would clearly in-dicate the type of target audience selected for the program. Occasionally, especially when the topic is of major interest to many, more than one session may have to be conducted cater-ing to the needs of different groups of practitioners. Some of these sessions may repeat the subject content with groups who have the same ability levels. In others, the content may be dealt with to different depths as they would target, for in-stance, general practitioners, specialists or sub-specialists in different settings.

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EFFECTIVE CME STRATEGIES Strategies of CME that produce positive changes in perform-ance are outlined below:2,3

• Highly effective strategies - Strategies linked to practice: E.g. When it has been

observed that there is a need for a change in referral rates or diagnostic tests ordered, the practitioner would undertake specific measures to introduce the changes;

- Academic outreach: E.g. Specially trained academic or scientific experts could work jointly on-site with local practitioners for promotion of rational prescribing be-havior;

• Moderately effective strategies - Audit/feedback: E.g. The information is presented by a

person of authority or the strategy is especially de-signed to meet the needs of the individual practitioner

- Opinion leaders: E.g. Meetings between practitioners and recognized, respected experts in the disciplines are arranged at which solutions to specific queries are ar-rived at;

• Less effective strategies - Educational materials (especially unsolicited, printed

material sent via the mail) - Formal CME (especially didactic courses)

Short educational meetings with both didactic and interac-tive components could be considered as a strategy having some degree of effectiveness.

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e-LEARNING e-Learning may be defined as the use of new multimedia tech-nologies and the Internet to improve the quality of learning by facilitating access to resources and services as well as remote exchanges and collaboration.

The vast strides that have occurred in developments in the field of information technology have opened many new ave-nues to the health professional for continuing education and professional development. The learning process can be im-proved through more autonomous, individualized learning than was possible in the past, learning material of a higher quality may be developed, and access to learning resources and services could be broadened. In addition, advanced facili-ties could be made available for distance virtual learning, and greater opportunities could be provided for interaction be-tween tutors and learners.

e-Learning appears especially suited for the adult and life-long learner. The health professional interested in continued professional development would find that the medium offers innovative learning opportunities with improved availability, accessibility and quality. Additionally, the learning may be undertaken within a formal or a non-formal learning frame-work.

Among the extensive features of the Internet, which is widely available today, are two that would be of major interest to the health professional. Firstly, there are web addresses of institutions or organizations that function as CME providers with schedules of proposed CME events. Secondly, some Inter-net sites provide access to lessons on selected topics, so that the interaction becomes an effective distance learning experi-ence. The opportunities provided by the Internet would be-come especially useful to those in specialties that do not have a sufficient number of activities organized locally.

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CME MODELS Three models of CME are commonly identified:14

• Update models, which aim to communicate or disseminate information;

• Competence models, which aim to ensure at least the mini-mum standards of knowledge, skills and attitudes and val-ues are attained;

• Performance models, which aim to help doctors overcome barriers to successful changes in practice and also to re-solve clinical concerns.

An analysis of the type given above becomes important be-cause the mere acquisition of knowledge may not translate into improvements in practice. Additionally, ensuring that the minimum standards of competency are gained may not neces-sarily result in optimum patient care. It is essential to bear in mind, though, that effective CME need not always produce changes in practice: some may merely confirm good practices that the health professional already uses.

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INSTRUCTIONAL STRATEGIES The methods of instruction that the resource persons would select should be determined by the specific learning objectives that would be defined for the individual sessions.

The following analysis highlights the important features of: • Small group teaching and discussions • Practicals/demonstrations • Clinical teaching • Lecturing

SMALL GROUP TEACHING AND DISCUSSIONS

Three essential elements of small group teaching are:17 • active participation • face-to-face interaction • purposeful activity. Within limits, the size of the group is not critical in deter-

mining the effectiveness of small group teaching. Active Participation The most important feature in small group teaching is discus-sion among all present. Though an ideal size for effective par-ticipation is between five to eight members, groups of about twenty participants can still use the standard techniques quite effectively. Face-to-face Interaction To allow for face-to-face interaction, the members need to see one another when they are seated. Communication is both ver-bal and non-verbal, and sitting in a circle is essential to facili-tate it. Purposeful Activity The meeting needs to have one or more definitive purposes and has to proceed in an orderly fashion. While most group learning may be concerned with medical subject content, oth-ers can be used to influence attitudes or to develop skills of critical thinking and problem-solving.

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Managing a Small Group How a group develops and operates should be understood clearly. The instructor need not constantly intervene to ensure that the group moves purposefully. The overall task should be clearly defined and steps taken to maintain the group involved in reaching the pre-defined goal. Some examples of the actions that are often needed are clarifying the roles of the instructor and of the participants in advance, and dealing appropriately with the dominating or the quiet members. PRACTICALS/DEMONSTRATIONS

Some of the essential elements of the teaching of practical skills (a few of which are also applicable when learning other competencies) are: i. Identifying the background of the learner; ii. Clarifying the learning objectives; iii. Giving information about the task:

The learner needs to be given information before, during and after completing the task. In guiding the learner be-fore doing the task, the standards are set at a relatively low level, and a brief overview of how an expert performs it may be given. While the task is being done, the learner receives help in identifying critical cues—the factors that affect the level or the validity of the performance. When the task is completed, feedback is provided as soon as pos-sible. Negative comments should be avoided (as they would be unnecessary, and may be harmful), and an op-portunity is given for repeating the task at an early stage.

iv. Stating the conditions of practice Defining the conditions of practice involves describing what is to be practiced (whether the whole task or sub-tasks), and clarifying how it should be practiced (Should a number of trials be done each closely following another or with breaks interposed in between?).

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CLINICAL TEACHING

A competent clinician needs to posses many technical skills to deal with patients’ problems effectively. These include being able to collect relevant data about the problem, to arrive at an appropriate differential/definitive diagnosis, to develop a suit-able management plan, and to carry out management. Non-technical abilities such as knowledge and understanding of the patient, interpersonal attributes, problem-solving skills and clinical judgment have an equally important role to play in the performance of the clinician. Competent Clinical Teacher The competent clinician need not necessarily be an effective clinical teacher. The competencies that the effective clinical teacher should possess are:

• Providing feedback and positive reinforcement to the learner;

• Correcting the learner without making him or her feel inadequate or incompetent;

• Showing personal interest in the learner; • Being dynamic and energetic, and enjoying teaching; • Communicating knowledge and what is expected to be

learned, explaining clearly, and emphasizing the impor-tant;

• Showing knowledge of physical diagnosis and the current state in the specialty;

• Reviewing histories and case notes; • Demonstrating/supervising physical examinations and

procedures. It has been reported that clinical teachers who are consid-

ered as excellent have knowledge of the patients, the context, and the learners, are aware of the general principles of teach-ing and use case-based teaching scripts. Some of the principles that could contribute to effective clinical teaching are:18

• Actively involving the learners; • Capturing attention and having fun; • Connecting the case to broader concepts; • Going to bedside; • Meeting individual needs; • Being practical and relevant; • Being selective and realistic.

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Feedback Many types of feedback play an important role in clinical teaching.

Positive feedback is information which confirms appropriate actions. Negative feedback, on the other hand, confirms inap-propriate actions.

Negative comments are of no benefit. They provide little in-formation, and do not tell the learner how to perform correctly. They are often redundant as the learner already knows that he is doing something wrong. They would also generate anxi-ety.

Constructive feedback is information that motivates indi-viduals to repeat appropriate actions and to eliminate inappro-priate actions. They are descriptive and precise.

Sub-skills and Mastery In learning clinical skills, the learner needs to master sub-skills before overall mastery can be achieved. An expert may not have to pay attention to minor details as some of these would have become almost second nature to him on account of continued practice. It is also desirable to get the learner to un-derstand the relevance and the applicability of a hierarchy of acquiring clinical competence: prerequisites, component abili-ties; composite performance and competent practice, in that order, from entry level to mastery. Clinical Decision Analysis and Instruction Extensive research in the field of clinical decision analysis pro-vides approaches that differ markedly from the traditional model of clinical teaching (which emphasizes complete data collection, data interpretation, and developing a management plan, in that sequence). These alternative strategies encourage the learner to begin with limited data (cue acquisition) and to generate hypotheses at an early stage (cue interpretation). Further data are collected to reject or accept each diagnosis (hypothesis) generated. It is also now known that there is no correlation between the thoroughness of data collection and the accuracy of data interpretation.

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LECTURING

The lecture is one of the most widely used instructional meth-ods. However, it is often seen that lecturers do not pay suffi-cient attention to factors that affect learning from lectures, and therefore, the members of the audience do not get the op-portunity of getting optimum benefit from them. Retention and Recall A point of major concern about lectures and lecturing is that retention of information presented at lectures and the ability to recall it later are quite low.

Attention fluctuates considerably during a lecture. During a one-hour session, attention declines markedly after about 20 minutes, and it increases just before the lecture ends. The fall in attention is less likely if the lecture includes some brief ac-tivities for the audience; in fact, the change will renew atten-tion. Some of the techniques available to the lecturer to achieve this are:

• Involving the learners by asking them questions • Asking for examples • Involving the learners in exercises or simulations • Teaming with a colleague • Offering quizzes, puzzles or paradoxes It is worth recalling how information is processed by the

average individual. Messages that are received are temporar-ily stored in the short-term memory. If they cannot be re-hearsed or transferred to the long-term memory, they are lost after about 30 seconds. Messages entering the long-term mem-ory get related to concepts and facts that are already there: those that cannot be understood are most likely to be forgot-ten.

Note-taking and recall of information from lectures are not very efficient. Note-taking can amount to 10% of what was presented. About 60% of the lecture is forgotten within 24 hours, unless some action is taken.

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Some Hints on Lecturing To assist the learners, the lecturer should ensure that the in-formation presented:

• is well structured, • is meaningful and interesting, and • may easily be added on to existing knowledge. The subject matter needs to be well organized, and the or-

ganization made clear to the learners at the beginning of the presentation:

1. Three cardinal principles of lecturing are: • First, tell them what you are going to tell them. • Then, tell them. • Lastly, tell them what you have told them.

2. Clearly identify each major point. Each point when listed allows the learner to attach the

details to it. Listing also indicates to the learners when a fresh point is to be dealt with.

3. Build-up a Story Building up a ‘story’ as the presentation progresses is

helpful to the learner in many ways. It differentiates the points, showing their relative importance. New concepts can be clearly identified. Additionally, the learners usu-ally believe that what is written is important. The tech-nique is valuable for emphasis and to take stock and sum-marize.

With today’s computer facilities, high quality buildups can be done by the average lecturer, if adequate planning and designing are undertaken beforehand. The illustra-tion (page 47) shows the relatively simple ideas of ‘doing in the head’, ‘doing with hands’ and ‘doing in the heart’ being used to build up (1→2→3→4) the three concepts of cognitive, psychomotor and affective domains respectively in performance (previously described).

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DOMAINS PERFORMANCE

ILLUSTRATION OF BUILDUP OF CONCEPTS

‘DOING’

in head

with hands

in heart

1

with hands

‘DOING’

in head

‘DOING’

in heart 2

KNOWLEDGE

in head with hands

in heart

SKILLS

ATTITUDES

3

skills knowledge

attitudes

PSYCHO-MOTOR

COGNITIVE

AFFECTIVE

4

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ASSESSING EFFECTIVENESS OF CME ACTIVITIES The literature on CME, shows that continuing education is effective when the practitioner identifies the need and under-takes the CME. The subject matter, learning methods, and learning resources need to be selected specifically to improve the knowledge, skills, and attitudes that practitioners require in their daily professional lives for improved patient care.

It is essential that CME is evaluated in relation to improve-ment in the performance of the practitioner. There is also con-cern that the current CME strategies do not meet the needs of the individual physician-learner.1 Additionally, practitioners often state that they are unable to take time off from routine duties and that this prevents them from participating in CME activities. CME organizers need to pay adequate attention to these issues when planning and organizing CME if the activi-ties are to have an impact on patient care. ASSESSING SHORT-TERM EFFECTIVENESS

Many variables and practical difficulties make the objective measurement of the outcome of CME a difficult task.14

Whether a CME activity helped the participants to achieve the learning objectives could be assessed at the end of a ses-sion or activity, or within a few days of concluding the pro-gram. The assessment of the level of achievement could be un-dertaken using tests of knowledge or of performance of skills. However, CME organizers need to weigh the likely benefits of the exercise against the practical difficulties that would be met and the implications of the three models outlined under CME Models previously. Self-assessment questionnaires One of the most convenient and widely used ways of assessing effectiveness of CME is using questionnaires answered by the participants. Questionnaires, specially designed or modified from those already available, may be used to ask for opinions about the processes. Opinions are surveyed on whether:

• They acquired new knowledge or skills; • What they learned would be useful in practice; • They will be able to apply the new knowledge and skills in

their practice; • What they learned would have an impact on their prac-

tices.

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The results of such surveys do not indicate that the new competencies would be used in their own practices or whether they would have any desired effect on the health services out-comes. The data only serve as a measure of the participants’ perceptions.9

ASSESSING EFFECTIVENESS ON A MEDIUM-TERM BASIS AND A LONG-TERM BASIS

Assessment of the long-term impact would be carried out after a few months of completing the program, or later on. The insti-tution in which the health professional practices would be the appropriate setting for this to be undertaken. The aim of the assessment would be to review whether the newly gained com-petencies are retained and are being used continually.

Although assessing effectiveness of CME and its impact on practice is not as convenient as administering post-session questionnaires, CME organizers need to aim for this approach wherever feasible. If the participants are a homogenous group, a review of medical records in an institution or direct observa-tion of practice could be considered. Epidemiological data, quality assurance studies, and prescribing patterns are addi-tional parameters that would be useful as indicators of CME effectiveness.

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SUMMARY OF IMPORTANT EDUCATIONAL ISSUES The following points are extracts based on a review of litera-ture published by Janet Grant and Frances Stanton:14 • Most CME would be initiated, organized, controlled and

evaluated by the individual, and formal inputs play only a supporting role.

• Self-directed learning implies only that the learners are in a position to decide what needs they have, and what benefit has been derived from CME/CPD. CME/CPD can take any acceptable form ranging from relatively traditional and for-mal to innovative and informal methods.

• Three models of CME are commonly seen: ‘Update models, Competence models, and Performance models’.

• Credit accumulation schemes of CME may not address the issue of patient care outcomes, and there is the risk that the primary goal of CME may shift from learning itself to at-tending CME programs.

• To ensure optimal patient care outcomes, locally managed systems based on developmental needs of particular units and of doctors may be more appropriate than systems based on accumulation of credits.

• Many CME/CPD activities are not credit bearing, and there-fore, difficult to be recognized or rewarded.

• It is not essential that CME/CPD always results in changes or improvements in practice: CME/CPD might only demon-strate that the doctors are already up to date and that they are fully competent in given areas.

• Given the unreliability, limited scope and the practical diffi-culties of using formal methods of needs assessment, rela-tively informal methods, based on professional judgment and organizational development could be used, and would still be effective.

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Part IV

Participation in CME

Learning objectives 52 Registration for participation 53

Notice about CME activities, Documentation of CME status, Minimum requirement of credit points, CME certificate

Exemption from CME requirement 55 Exclusion from credit 55 Credit points granted by external agencies 56 Reciprocity with external agencies 56

Learning Objectives for Part IV - Participation in CME By the end of this section the reader should be able to:

1. Indicate the categories of health personnel expected to reg-ister in the CME Program and state their responsibilities as regards documentation of CME participation;

2. State the minimum requirements of credits stipulated un-der the CME Program and outline how credits from differ-ent types of CME activities may be recorded ;

3. Indicate the procedure that practitioners are required to adopt for submitting CME credits;

4. State the categories of practitioners who would be eligible to claim exemption from fulfilling the CME credit require-ment;

5. Outline the approach used by the KIMS CME Program for accepting credits claimed under external CME authorities;

6. Name external CME authorities that accept local CME credits within their own CME/CPD programs.

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PARTICIPATION IN CME The main points that are relevant with respect to participating in CME activities are outlined in this section. Detailed infor-mation about the subject is available in CME Program, pub-lished by KIMS,19 and at www.kims.org.kw/cme, the website of the CME Center.20

REGISTRATION FOR PARTICIPATION CME is today regarded as a necessary component of competent practice, and all medical and dental practitioners in Kuwait have been requested by the Ministry of Health to register in the CME Program. In addition, for satisfying some of the ad-ministrative requirements of the Ministry and for serving as tutors in the KIMS training programs, registration in the CME Program is essential.

The CME Center web site, www.kims.org.kw/cme, gives a form for online registration in the CME Program. NOTICE ABOUT CME ACTIVITIES

Announcements regarding the scheduled CME activities are made by the respective CME organizers. The CME Center provides basic information about the proposed and registered activities in its website and in the Bulletin of the Kuwait In-stitute for Medical Specialization. Prospective participants should contact the organizer of the event for updated informa-tion on scheduling, venue, registration procedure etc. DOCUMENTATION OF CME STATUS

Every practitioner registered in the CME Program is respon-sible for maintaining records pertaining to his or her CME status. It is also the practitioner’s responsibility to submit credit details annually and copies of the relevant documents as evidence of involvement in CME to the CME Center when requested. A portfolio (logbook) is available to facilitate docu-mentation, for use as evidence of CME participation.

MINIMUM REQUIREMENT OF CREDIT POINTS

Credit points may be accumulated during a five-year cycle. The minimum requirement of CME within a five-year cycle is 250 credit points. The CME Year follows the calendar year (January to December).

The first CME cycle runs from 2001 to 2006. Credits accu-mulated commencing September 2000, when the CME Pro-gram was introduced, may be included within the total men-tioned above.

The CME Center does not stipulate a minimum number of CME credits that should be acquired every year. However, it is desirable that practitioners gain an average of 50 points annu-ally, so that they would not have to compensate for a large shortfall before a deadline. The Ministry of Health or the em-ployer concerned, on the other hand, may require a specific number of credits to be acquired within a given period for vari-ous administrative purposes. Combining credit points from Category 1 and Category 2 The total number of 250 credit points required within the five-year cycle may be acquired based solely on activities falling within Category 1, or by a combination of Category 1 and Category 2 activities. However, Category 2 activities may be cited for credit only up to a maximum of 100 credit points (40% of the total requirement) in the five-year cycle. CME CERTIFICATE

Health professionals who acquire 250 CME credit points dur-ing the five-year cycle would receive a Certificate of Satisfac-tory Completion of CME from KIMS. For processing the infor-mation pertaining to participation in CME and updating the records, the practitioner is expected to forward the requisite information to the CME Center at the end of every calendar year in the format provided. The form for submitting credit data is available at www.kims.org.kw/cme. The certificate to be awarded would remain valid for a five-year cycle from the date of issue.

Any practitioner who needs to obtain a certificate of the CME status to satisfy administrative requirements although the five-year cycle is not completed, or those terminating their services in Kuwait, may do so by contacting the CME Center.

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EXEMPTION FROM CME REQUIREMENT Residency, Fellowship, or Education for Advanced Degrees Trainees enrolled in approved postgraduate training pro-grams and practitioners registered in advanced degree pro-grams in the fields of medicine, dentistry or other related health professions are not required to collect the minimum number of CME credit points that has been stipulated. They may cite the above activities as evidence of involvement in CME. However, they are eligible to attend any relevant CME event for their own educational advancement. Additionally, practitioners coming within these groups may also register in the CME Program, mainly to enable them to participate in CME activities and to avail of benefits that may be made available only to those registered in the CME Program.

EXCLUSION FROM CREDIT Non-educational commitments such as service on a medical society or patient care activities may not be cited for claiming CME credit.

Events that are primarily of a promotional nature such as displays of medical or dental equipment and materials, too, are not considered as CME.

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CREDIT POINTS GRANTED BY EXTERNAL AGENCIES The CME Program in Kuwait has been put in place primarily to take into account CME activities held within Kuwait by the accredited CME providers. However, credit points ob-tained by participating in approved programs organized by institutions such as the Royal Colleges in the UK, Canada and Australia, the American College of Physicians, the American Medical Association, the British Medical Associa-tion, the Saudi Council for Health Specialties or CME au-thorities in other GCC countries, and other similar organiza-tions could be considered by KIMS as evidence of CME/CPD participation. Applicants are required to submit copies of the certificates issued by the respective CME providers at least six weeks prior to any applicable deadlines to claim such rec-ognition. The certificate should clearly indicate the number of credits that the practitioner is eligible to claim.

RECIPROCITY WITH EXTERNAL AGENCIES The CME Program in Kuwait has been approved by selected CME authorities abroad for satisfying the CME requirements by their Fellows. THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS OF CANADA (RCPSC)

CME credits gained by attending CME/CPD programs of the CME Center are accepted by The Royal College of Physicians and Surgeons of Canada in its Maintenance of Certification Program. Medical specialists possessing the Fellowship of the College who practice in Kuwait may submit credit points ac-quired through the local programs in satisfying the require-ments of the Maintenance of Certification Program of the Col-lege under Section 1 of the framework of CPD activities. THE ROYAL COLLEGE OF PATHOLOGISTS OF UK

The Royal College of Pathologists, UK has endorsed the CME Program as suitable for its members in Kuwait for their CME needs. Members and Fellows of the College practicing in Ku-wait may participate in the KIMS scheme and submit credits gained in satisfying the requirements of the Continuing Pro-fessional Development Program of the College.

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Appendix AUDIT AND EVALUATION OF CME PROGRAM The CME Center has carried out two types of evaluations of the CME Program during the past two years. The results have been used to introduce modifications to the scheme so that the benefit received by the practitioners could be en-hanced. External Review of Program by WHO Consultant The CME Program was reviewed by a WHO Short Term Con-sultant on two occasions, in 2000 and in 2002. The results were very positive, with the reviewer stating that the local program compared favorably with similar programs abroad. Special mention had been made that the program in Kuwait in its relatively short period of existence had managed to achieve a standard that many others had reached only after a considerably longer period. Internal Evaluation by KIMS An ongoing survey of opinions of practitioners is being under-taken at present. The analysis of the results indicate that the CME activities conducted had been in topic areas of relevance to practice and the subjects presented had enabled the par-ticipants to gain additional competencies. The material dis-tributed by the CME Center including its website had pro-vided the practitioners with useful information about the CME Program. BULLETIN OF THE KUWAIT INSTITUTE FOR MEDICAL SPECIALIZATION During 2002, KIMS launched its own peer-reviewed journal of postgraduate medical education, continuing medical educa-tion and clinical practice. CME is a main theme it deals with, and one of the special features carried in each issue is a series of articles that allow readers to claim CME credits under the CME Program.

As a companion publication, all the CME articles that ap-peared in one volume of the journal are published separately under the title CME in Clinical Practice.

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INFORMATION ON CME PROGRAM Physicians and dentists registered in the CME Program as well CME Organizers will be informed via the CME Center web site www.kims.org.kw/cme, or by circulars, about any fu-ture changes in the implementation or updates in the CME Program.

Detailed information about the CME Program is available in CME Program, a publication of the CME Center, KIMS. COMMUNICATION WITH CME CENTER CME Center Kuwait Institute for Medical Specialization 10th Floor, Behbehani Complex, Al-Sharq Tel.: 2410027, Ext. 107/159; Fax: 2467140 Email: cmecenter@kims.org.kw

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REFERENCES 1. Bennet NL, Davis DA, Easterling, Jr. WE, Friedman P,

Green JS, Koeppen BM, Mazmanian P, Waxman B. Con-tinuing medical education: A new vision of the profes-sional development of physicians Acad Med 2000;75:1167-72.

2. Davis DA, Thomson MA, Oxmon AD, Haynes RB. Evi-dence for the effectiveness of CME. A review of 50 ran-domized controled trials. JAMA 1992;268:1111-7.

3. Davis DA, Thomson MA, Oxmon MD, Haynes RB. Chang-ing physician performance: a systemic review of the effect of continuing medical education strategies. JAMA 1995;274:700-5.

4. Davis D, Thomson MA. Implications for undergraduate and graduate education derived from quantitative re-search in continuing medical education: lessons learned from an automobile. J Cont Educ Health Prof 1996;16:159-66.

5. Davis MH, Harden, Laidlaw JM, Pitts NB, Paterson RD, Watts A, Saunders WP. Continuing education for general dental practitioners using a printed distance learning pro-gramme. Med Educ 1992;26:378-83.

6. Grant J, Stanton F, Flood S, Mack J, Waring C. An evaluation of educational needs and provision for doctors within three years of completion of training. London: Joint Centre for Education in Medicine; 1998.

7. Tu K, Davis D. Can we alter physician behavior by educa-tional methods? Lessons learned from studies of the man-agement of hypertension. J Cont Educ Health Prof 2002;22:11-22.

8. British Postgraduate Medical Federation. The quality of continuing medical education for general practitioners. London: British Postgraduate Medical Federation; 1993.

9. Grant J. CME. Its validation and outcome, In: Mansfield A, editor. CME and the Royal College of Surgeons. Ab-stracts of the 1st Conference held at the Royal Society of Medicine: ‘British Continuing Medical Education: a Framework for the Future’ (4th and 5th July). 1994.

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10. Hadiyano JE, Suryawati S, Danu SS, Sunartono S. San-toso B. Interactional group discussion: results of a con-rolled trial using behavioral intervention to reduce the use of injections in public health facilties. Soc Sci Med 1996;42:1177-83.

11. Kushnir T, Vigiser D, Weisberg E, Ribak J. A graduate course in work site health promotion for occupational health practitioners. J Occup Environ Med 1996; 38:284-9.

12. Malenka DJ, O’Connor GT. A regional collaborative effort for CQI in cardiovascular disease. Northern New England Cardiovascular Study Group. Jt Comm J Qual Improv 1995;21:627-33.

13. De Buda Y, Woolf CR. Saturday at the university: a for-mat for success. J Cont Educ Health Prof 1990;10:279-84.

14. Grant J, Stanton F. The effectiveness of continuing profes-sional development: A report for the Chief Medical Officer’s review of continuing professional development in practice. Edinburgh: Association for the Study of Medical Educa-tion; 1999.

15. Fish D, Cole C. Learning through the Critical Appreciation of Practice. Massachusetts: Butterworth-Heinmann; 1998.

16. Rogers, A. Teaching of Adults, Milton Keys: Open Univer-sity; 1992.

17. Newble, D. A Handbook for Medical Teachers, Boston: MTP Press; 1981.

18. McLeod, P.J. & Harden, R.M. Clinical teaching strategies for physicians, Med Teach 1985;7:173-89.

19. Kuwait Institute for Medical Specialization. CME Pro-gram. Kuwait: Kuwait Institute for Medical Specializa-tion; 2001.

20. Kuwait Institute for Medical Specialization. Center for Medical Education. 2002. Available from URL:/http://www.kims.org.kw/cme.

FURTHER READING Goulet F, Snell L, editors. Handbook of Continuing Medical Education. Québec: Conseil de l‘éducation médicale continue du Québec; 2000.

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CME Center website: www.kims.org.kw/cme

KIMS The Kuwait Institute for Medical Specialization (KIMS) is engaged in a variety of activities aimed at achieving the following objectives:

• To formulate the general policy for training doctors and other health professionals in different fields of specialization, and supervise the implementation and the evaluation of the training programs;

• To design and monitor the implementation of professional training for graduates who have obtained basic medical qualifications;

• To initiate and coordinate the implementation of programs for specialty training at various levels for medical practitioners and other health professionals;

• To plan and conduct activities aimed at continuing professional development for health professionals in Kuwait;

• Award certificates for trainees who have successfully completed designated training programs in the specialties in medicine.

CME Center The CME Program of the CME Center has the following main objectives:

• To ensure that health professionals participate in accredited educational programs so that the care provided to the community is of high standard;

• To demonstrate to patients, the public and peers that health professionals are committed to participating in accredited educational activities throughout their careers;

• To improve the performances of all health professionals, instead of limiting educational opportunities to those who may be identified as under-performing;

• To provide a standardized and easily-accessible mechanism to health professionals for documenting their participation in accredited continuing medical education and continuing professional development activities.