The Journal ofcontinuing Educarion in the Health Projessions. Volume 10. pp. 367-372. Printed in the U.S.A. All rights reserved. Copyright 0 1990 The Alliance for Continuing Medical Education and the Society of Medical College Directors of Continuing Medical Education.

Case Report

The Case of Pam DAVE DAVIS, M.D. Chairman, Continuing Education Faculty of Health Sciences Professor, Department of Family Medicine McMaster University

Adapted from an address to the Third Conference on International CME,

Annenherg Center, Palm Springs, California, Dec. 16,1989

A Case History I propose to present a case to you. As I do so, ask yourself this question: “Would CME have changed the outcome of this case?” If so, what kind of CME?

Pam first presented to me in 1970, somewhere in my first year of prac- tice. She was 24 years of age, divorced, and living with a young man whom I’ll call Ben. She had three children aged six, three, and two years; the first two were by her ex-husband, the third by another man, not Ben. Early in 1972 she conceived and was seen by me at six weeks. She wanted an abortion, but while arrangements were being made to see the three phy- sicians required at that time to confirm that an abortion was required, she changed her mind. In March, about 10 weeks into her pregnancy, she pre- sented to me with a red, swollen right calf and a positive Homan’s sign. I diagnosed a deep vein thrombosis of her right leg. Heparin was the drug of choice indicated as immediate treatment and we admitted her to hospital for 10 days of therapy.

We knew that following her hospitalization she would require at least three months of either Heparin by injection or Warfarin by pills to contin- ue her anti-coagulation treatment, and so, at the end of her hospital stay, I paid a quick visit to her. As it turned out, this was an extremely important encounter, a “critical incident,” we would say today. It went something like this:

I said: “Pam, you’ll have to go on several months of something to thin your blood.” She replied, “Well, Doctor, I hope it’s not needles, I hate needles and shots!”

“No, Pam,” I said, “it could be pills if you want - they’re almost as safe as Heparin shots.’’

“Well, if you’re sure they’re safe, Doctor - I’ll take the pills. Just let me out of here!”

And so, I prescribed the pills, stopped them after three months, and de-

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livered her without any difficulty in August. While the delivery was fine, the baby was slightly under 5 lbs. He didn’t do very well. He gained only a bit of weight at a time, didn’t suck very well, and his mother didn’t bond with him at all, saying, “Something’s wrong, Doctor!” She was right: his head size was small, and didn’t grow much; his nose was strangely “flat”; he failed to meet his milestones. He didn’t roll or sit at all. A child devel- opment consultant specialist saw him in June, and confirmed that the baby was retarded, and that he fit the picture of what he knew about a Warfarin- induced fetal anomaly.

Well, you can appreciate the fallout from all of this - both for Pam, who had few coping skills at the best of times - and for her doctor. You can also perhaps appreciate the last part of the case. Pam became de- pressed, was at risk to herself, and so was put in hospital early in ’74. The baby was placed in the care of the Children’s Aid Society, and finally in a home for the retarded. Ben, tired of looking after Pam’s children, left the scene. Pam left town, running off with another man she met on the psychi- atric ward. She and her children have been lost to follow-up; and so I’m unsure of their outcomes today.

Certainly a sad, even tragic, case.

Questions and Models I suspect, as you heard this story, that you may have thought of a case like it in your own experience and perhaps recalled my questions, “Would CME have helped?,” and “If so, what kind of CME?” Let me take you through three approaches to CME to see which, if any, might make a change in the outcome of Pam’s case.

The Delivery Approach (Model 1) The first type of, or approach to, CME I’ll call the delivery model. Recent- ly Nowlenl has termed it the update model, in his book, A New Approach to Continuing Education for Business and the Professions. Whatever we call it, it really is the “projector bulb syndrome” - an overemphasis on the tools of the CME trade, not that they’re not important. It’s analogous to the questions “How long do we make a slide tape show?” or, “Should we have a debate or panel discussion?” It’s also analogous to the over con- cern that undergraduate curriculum deans have as they decide what depart- ment gets to give what percent of the lectures to what class and with what slides.

In brief, this model values or places the basic sciences at its apex as its main item of business, followed by the applied sciences and, at the bottom of this hierarchy, problem solving. Would this approach have helped Pam? As it was, this was about the only kind of CME available in the 1970’s, and so it is ideal for us to look at.

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My undergraduate/postgraduate training indicated that Warfarin had been used in prenatal cases of deep vein thrombosis in the first and second trimester, relatively safely. The 1971 CPS, or Canadian Compendium of Pharmaceuticals and Specialties, indicated that Heparin was quite safe in pregnancy, but that Warfarin had not been sufficiently studied. So the risk and benefit of prescribing it in pregnancy had to be carefully weighed - not much help. Two review articles subsequently appeared, although there had been other sporadic reports of fetal anomalies with Warfarin use. The first of these was in a specialist journal, therefore not one I read, but which the consultant recalled. The second of these appeared in the Canadian Family Physician, which I did read, but too late to help Pam or her baby. Finally, two CME events - a refresher day and a local rounds on fetal anomalies with Warfarin: informative - but too late to effect a change in outcomes.

Could we, by manipulating the delivery of CME, have changed the outcome? There are two ways we could have done this and perhaps im- proved the rate of diffusion of information. In fact, there were sporadic re- ports when I read the CPS in 1971, and comprehensive review articles could not have appeared much before they did. Further, could we have im- proved the delivery of CME? I think not, the rounds and meetings were well planned, the articles well conceived. In point of fact, CME - seen as update or delivery, was and probably is incapable of changing the outcome for Pam. Perhaps computers will change the speed of delivery, but even they do not address issues of competence or performance.

The Competence Approach (Model 2) The second model I’d like to explore with you has to do with competence, traditionally divided into knowledge; skills, including interpersonal, com- munication, record keeping; CME i.e. self-directed learning and critical appraisal skills; and attitudes. When we compare this model against our “case,” it begins to become clear where, and in what ways, things went wrong. The question occurs to me - “At what points would a considera- tion of competency affect the the outcome?”

I had formed a fairly unsupportive, negative attitude about Pam from my first encounter with her. I saw her as not very responsible, not very mature; a nice kid, but not very bright; and not well equipped to cope with problems, yet leading a lifestyle that constantly produced them. All of this probably had considerable truth to it, but it did affect and color my judg- ment later on to a greater extent than necessary.

I’d like to turn to a consideration of skills next. My physical exam skills were pretty hot in those days. That was a deep vein clot, I’m sure, though there were no investigations we could use back in the early 1970s to confirm that impression. My interviewing skills, however, were defi-

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cient. I only gave information only; received none or very little, and closed the interview off abruptly, discouraging free discussion about treatment of the deep vein thrombosis. Had I listened, I might have been able to probe Pam’s dislike of needles and perhaps persuaded her to take the Heparin in- jections. Instead, my mind was made up that she couldn’t or wouldn’t take injections twice a day for three months, and I had some other concerns that I’ll return to shortly. My management and problem-solving skills were also somewhat deficient. I might have been able, for example, to suggest a home or visiting nurse to give the injections; or perhaps a homemaker to help her with the children. I didn’t know of such things, nor if her insu- rance plan would pay for them, and so my knowledge - a key factor un- derlying many, but not all, competency-based decisions - was inade- quate. Finally, my CME skills. What of them? Had I determined best my own learning needs, set up a coherent, cohesive, systematic plan to meet those needs, or evaluated my performance? I’ll ask you to be the judge.

There is a further component of competence that I would like to ad- dress - a sense of self or self-concept. I saw myself then in the mode of physician-as-executive, prepared to make decisions like “The Boss” would without much input from his patient. Today, post-Pam, I see myself as a somewhat flawed and certainly more reflective physician following Schon’s2 concept of reflection-in-action. I wonder, “How often do we con- sider self-concept in CME?”

Approaching Pam’s case with this paradigm or model might well have changed the outcome.

The Health Outcome Approach (Model 3) Many of the uncertainties in Pam’s case lie in factors outside the realm of what the physician traditionally does or doesn’t do, and what kind of CME he or she takes part in. They lie for the most part in a model I’d call the Health Outcome Model. It is a third way of looking at the role of CME; and a bit of a stretch for those of us interested in projector bulbs. This model builds sequentially on the other two. It also builds on the concepts derived from the work of Fox and his colleagues3 on factors producing change. Considerations in this model would include the following issues:

First among these is the availability of resources. Had abortion been a procedure more easily or readily available in 1971 in my community, I have no doubt that Pam would have selected that option or, had the labs made house calls in those days, Pam might have agreed to select a treat- ment that would have required repeated lab tests. The second set of issues arise from patient factors. What about Pam’s compliance? What about her lifestyle? Would these have permitted her to take needles or to keep the baby? To what extent could we have changed her lifestyle? Third is the professional environment or milieu. Supposing the small group I worked in then had done chart review, or had encouraged discussion more? Sup-

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posing there were hospital regulations regarding prenatal care and drugs? Fourth are factors related to the health care insurance system. For exam- ple, what would have happened if it could have paid for treatment of her infections, home assistance, or the extra time required to support her?

I think, considering this approach, that we could have changed Pam’s outcomes. However, these are all conjectural considerations at this point: they are only of polite academic interest to Pam or her son. Clearly, how- ever, they are of real impact on how we view CME, how we deliver it, and how we link competency assessment, CME, and health care outcomes.

Summary/Conclusion Let me offer a few words to conclude this discussion. First, there’s no one answer to the question I raised at the start. We’ve seen that the update ap- proach may not be, by itself, sufficient to change outcomes; that the com- petency approach is a more potent change agent; and that the health out- come model has more teeth still. The truth is that while each of these can stand alone, each adds to the next, and their sum is greater than its parts.

Second, CME divisions and departments in medical schools or profes- sional associations or hospitals aren’t new. And, most often, they’re entire- ly distinct operations from quality assurance, professional review organi- zations, or health service research groups. They’re often up the hallway, but quite distinct entities. A notion I’ve tried to capture is that each by it- self is about as effective as the sound of one hand clapping; it’s better to use both hands. And, I’d call for the formation of joint CME/Peer Review, departments, divisions, offices, etc., wherever we work.

Third, while these aren’t new concepts, their linkages are. A group of us met in Banff, Alberta4 to explore what we called the frontiers of CME research and development. Among other things, what we said there was this: If we’re interested in improved health care, and if to achieve that goal, we recognize we must improve physician performance, then our area of interest lies at the overlap or junction of three separate fields:

1) the area of continuing education delivery; 2) the realm of adult education, educational psychology, the black

3) the domain of the professional environment. It’s in this last realm that Kerr Whites says the task of physicians lies

in the next decade or century, that task impinging on aspects of the health outcome approach we’ve discussed. And if the task of physicians lies in this domain, so does ours - as CME providers, researchers, and developers.

Let me conclude with one final point. I’m grateful for the challenge and opportunity that Pam has presented to me - and for this chance to share her case with you. The case of Pam has compelled me to think of

box; and

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myself and of CME in new ways. If it’s done that for you as well, then I’ve met my objective.

References 1. Nowlen P. A New Approach to Continuing Education for

Business and the Professions. 2. Schon D. The Reflective Practitioner. 3. Fox RD, Mazmanian PE, Putnam RW, eds., Changing and

Learning in the Lives of Physicians. New York: Praeger Publishers, 1989.

4. The Banff Conference: the Frontiers of CME. McMaster University Publications, Hamilton, Ontario, 1990.

5. White K, ed. Dialogue at Wickenberg: the Task of Medicine.

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