Should doctors get CME points for reading?

“To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go sea at all.” William Osler¹

Practising medicine without reading is unthinkable, and reading is extensively used in searching for information to solve clinical problems.²,³ Moreover, lack of time for reading is often perceived as a threat to professional practice and has a negative impact on perceived level of coping.⁴ Yet most programmes of continuing medical education give little credit for reading: what evidence do we have that it is an effective way of learning?

Scanning journals for articles of interest is probably what first comes to mind when thinking of doctors' reading. Reading is also often used for re-examining one's clinical practice (How should I manage patients with osteoporosis?) or finding information to solve more focused problems (What is the best treatment for tick bites?). As computers become part of doctors' office equipment, access to databases should enable doctors quickly to find the most updated and reliable answers to their clinical problems. In essence this is no different from reading journals, books, or self produced notes.

The United States has the longest tradition of formal continuing medical education, and, as knowledge has grown about how doctors learn, an increasing number of learning formats have begun to attract credits within education programmes. The American Medical Association issues two forms of continuing medical education diplomas—a standard certificate and a “certificate with commendation for self directed learning” (www.ama-assn.org). Each is based on participation in a category of learning activities: formally organised and planned meetings (category 1) and less structured learning experiences (category 2). Reading as a required activity was introduced as late as 1990 and is defined as reading “authoritative” medical literature—that is, peer reviewed journals or textbooks. Self selected reading is a creditable activity only for the standard certificate. Reading is not a creditable activity for the certificate with commendation, though it presupposes that the candidate reads for at least two hours a week. For the past two years, however, doctors have been able to earn category 1 credits for reading articles specially designated for doctors' continuing medical education, structured as a learning experience and following specific rules.⁵

While formal continuing medical education based on collecting credit points has been practised in the United States and Canada for 30 years these activities are relatively new in Europe. Now, however, continuing medical education is on the agenda of virtually all national medical associations, medical societies, and royal colleges, and many have established continuing medical education standards for their members. From last year the Swiss Medical Association has required each active member to do at least 80 hours of continuing medical education annually—30 hours of self directed learning (such as reading) and 50 hours of documented educational activity (R Salzberg, personal communication). The Netherlands is the first, and so far the only, country in the European Union where failing to meet specified continuing medical education requirements may lead to loss of licence. Reading is, however, not included in the formal requirements (Royal Dutch Medical Association, personal communication). In the United Kingdom the General Medical Council has appointed a steering group to devise a system for revalidation of doctors⁶; next year we may know its view on reading.

Medical societies are also drawing up continuing medical education policies and programmes. The European Board of Urology has recently launched its internet based continuing medical education registration system for European urologists. Credit points are awarded in six categories, with reading included in category six (www.ebu.org). So far none of the United Kingdom royal colleges seems to include reading as a creditable activity in its standards, but when surveyed anaesthesists responded positively to making journal reading eligible for credit points.⁷

Reading clearly has a rather modest place among these developing continuing education requirements, at least in Europe. Measuring and controlling underpin the credit point system, and that does not fit with individuals' self directed learning. Arguments that doctors read anyway, and therefore giving them credits for it is unnecessary, are also voiced. However, it is well known from quality improvement work that it is what you measure that gets people's attention (irrespective of its importance), and that should warn us not to exclude reading from credit point systems.

The important role of reading in doctors' learning is well documented in data collected from the Canadian MOCOMP system. The most frequent stimulus for learning is reading the medical literature, followed by management of a current patient or problem.⁸ The study also provides evidence that reading has the same likelihood of leading doctors to a commitment to change their practice as attending group educational activities and completing self assessment programmes.

A system honouring the “good guys” and paying less attention to the “bad apples”—that is, less focus on control and more on learning—should be the way forward. Awarding credit points for reading may very well be based on self declaration, allowing readers to select any format they feel appropriate to meet their needs and also valuing non-medical literature. A written statement describing the format, time taken, reflection on, and evaluation of, the outcome—that is, did the reading have any impact on practice or spur any further action?—may serve as control measures and enhance learning outcome as well.

If we take into account the pivotal role that reading has in a doctor's continuous learning then reading should be generously honoured, allowing doctors to meet at least half of any set annual standard of credit points by reporting their reading and its perceived influence on their practice. A more relaxed approach to documenting doctors' continuing educational activities does not imply a less rigorous attitude to accountability. After all, meeting certain requirements for continuing medical education is not itself a measure of accountability. That can be demonstrated only through actual performance, irrespective of how competence is attained and nurtured.

See also p 432