Legal, Ethical, and Professional Issues in Psychoanalysis and Psychotherapy
Knowledge and techniques in the health field are rapidly expanding. According to Carl Lindsay, James Morrison, and E. James Kelley, it is estimated that the half-life of knowledge acquired in medical school is approximately five years. (1) Therefore, in just five years, half of what a doctor learns in medical school will be obsolete. With such a vast increase in the knowledge base, it is essential that health professionals, particularly doctors, dentists and nurses, constantly update their skills. In fact, their patients' lives and well-being often depend on health professionals keeping current on the latest advances.
One way this can be done is through "continuing education," a common synonym for adult education, where adults pursue education beyond formal schooling. Most frequently, colleges, universities and professional organizations use the term to describe programs designed to assist practicing professionals.
In an effort to insure quality, many health professions now require continuing professional education (CPE) for relicensure. Massachusetts is typical and will be discussed here. In Massachusetts, licensed practical nurses and registered nurses are required to take 15 contact hours (equivalent to approximately three, one-day workshops); registered dental hygienists, 20 hours; and dentists, 40 hours -- in each case, every two years. Physicians must take even more: 150 hours every three years, if they report to the Medical Society, and 100 hours every two years, if they report to the Medical Board of Registration.
Dentists, dental hygienists, physicians and nurses are free to choose whatever educational offerings interest them. However, pharmacists must, as of January 1, 1991, devote at least two out of the 15 hours required annually to the study of pharmacy law.
Other professionals who may have an effect on the health of the public may or may not be certified or required to participate in continuing education. For example, while the National Certification Agency for Medical Laboratory Personnel requires 40 contact hours every two years, technicians certified through the Board of Registry have no continuing education obligations. Moreover, medical laboratory technicians decide which agency certifies them.
Putting aside the question of whether and how additional professional groups should be credentialed, this article will discuss the extent to which mandatory continuing education, as currently required, may be effective to protect society from incompetent health care professionals.
While the literature is discussed, this article will also be based on experience at the Southeastern Massachusetts Area Health Education Center (SMAHEC). SMAHEC is a nonprofit regional organization governed by a consortium of both academic and service institutions including Boston University, Bridgewater State College, Bristol Community College, Cape Cod Community College, Erna Yaffe Foundation, Massasoit Community College, Southeastern Massachusetts Hospital Council (representing 21 area hospitals in the region), University of Massachusetts Medical Center and the New Bedford Area Center for Human Services, Inc. SMAHEC serves the counties of Bristol, Plymouth and Barnstable which consists of 69 cities and towns totaling approximately 1,735 square miles and has a population of over one million. One important purpose of the organization is to promote the development of continuing education for physicians, dentists, dental hygienists, nurses and other health professionals to enhance the professional atmosphere for practitioners. SMAHEC accomplishes this through contracting with consortium members and other agencies, and its staff implements the programming with advice from its Program Development and Planning Committee and users. Over the past nine years nearly 18,000 health care professionals have attended an SMAHEC sponsored program.
The Objectives of Continuing Professional Education
For Jarvis, "the aims of the educational process are about the learners rather than about the profession or wide society" and the "aims of continuing professional education may relate intrinsically to the needs of the profession or to those of the wide society."(2)
However, as Singh and Rice point out:(3) Continuing professional education philosophy and practice should be learner centered, and accomplished in a climate wherein the professional begins to realize the value of continuing professional education and engages in this type of professional development voluntarily.
Houle identifies several objectives of CPE, including clarifying the professions' functions, mastery of theoretical knowledge, self-enhancement, formal training, credentialing, creation of a subculture, legal reinforcement, public acceptance, ethical practice, penalties, and relations to users of services. (4) He believes that the ultimate aim of continuing education is to prepare practitioners not only "to use the best ideas and techniques of the moment but also to expect that they will be modified or replaced."(5) He also believes that:(6)
1) The primary responsibility for learning should rest with the individual.
2) The goals of CPE should be concerned with the entire process of professionalization.
3) CPE should be considered part of a process which continues throughout life.
4) The patterns and methods of CPE should be planned and conducted in terms of one of three modes of education: inquiry, instruction, performance.
5) The provision of CPE should be expanded to pervade all aspects of professional life.
6) Professions should collaborate in planning and providing continuing professional education.
7) The process of recredentialing should be thoroughly rethought to determine the appropriate role of CPE.
Arguments Against Mandatory Continuing Education
Mattran indicates that effective compulsory continuing education requires that programs originate within the profession, provide a wide range of alternatives and be found appealing.(7) Yet, even if these criteria are met, would CPE automatically result in health care professionals being more competent? For example, a geriatric nurse may select a series of courses in parenting education or assertiveness training that would not update the nurse's knowledge or skills in gerontology. Thus, professionals may be able to select interesting courses that may, in fact, be irrelevant.
Many of the health care providers who have attended the continuing education workshops that SMAHEC has sponsored have fallen in this category. They have participated in continuing education offerings which were not directly related to their jobs. The participants' course selections depended upon several other factors such as cost and timing. Sometimes the participants took any course that was available just to meet requirements before their license expired.
Many arguments have been raised against current continuing education requirements. Rockhill opposes them because she believes it limits individual freedom, places efficiency before ethical considerations, has negative social consequences as well as negative effects for adult education, and does not solve the problem it is designed to address.(8)
This is echoed by Darkenwald and Merriam, who point out that the public has a right to be protected from incompetent practitioners, but mandatory continuing education is neither necessary nor sufficient to insure that result.(9) They suggest mandating "competent performance through periodic evaluations and to deny relicensure to those who fail to demonstrate continued proficiency."(10)
Darkenwald and Merriam believe that "educational offerings do not guarantee learning and the acquisition of knowledge and skills does not insure that they will be applied to improve performance."(11) This is reinforced by Houle, who believes that the issue is not whether the professionals know something but whether they do it.(12)
Rockhill points out that education may only partially contribute to competence.(13) What may seem like a deficiency of knowledge or skills can be due to inadequate equipment, lack of supervision, conflicting expectations or regulations governing professional performance and many other factors that have little to do with deficiencies in knowledge or skill. She suggests that by assuring that education assures accountability, education becomes the end rather than the means to competence. Thus alternative ways of developing competence and accountability are looked to less and less.
Further, Rockhill argues that mandatory continuing education, in fact, may prevent the problem from being resolved.(14) There is no evidence that present requirements for continuing education improve the performance of health care professionals. She notes that less than 0.5 percent of the estimated 16,000 incompetent physicians in the U.S. have had their licenses revoked. Yet, New Mexico suspended 127 of 2,500 registered physicians for not participating in mandatory continuing education. While most of the latter were retired or residing out of state, there was no evidence that the remaining 23 (mostly over 65 years of age) physicians were incompetent.
Rockhill asserts that mandatory continuing education is used for social control rather than for learning and may actually limit learning,(15) observing that "whereas initially education may have been considered a desirable activity, by mandating it becomes a necessary one and de facto becomes the sufficient condition for assuring competence."(16)
Cross also recognizes "that people who are motivated to learn are more likely to be better informed than people who are merely serving time in class."(17) Further, Brookfield argues that:(18) When adults are forced to learn against their own inclinations and desires the resulting resentment is likely to become a major block to any kind of meaningful learning. Consequently, participation in compulsory continuing professional education might lead to increased statistics of adult participation but be characterized by mental absenteeism.
Knowles, too, believes that learning is more effective when learners feel a need to learn.(19)
Rockhill fears that education suffers when there is a captive audience (20) because less effort may be given to developing a challenging and exciting educational experience. Rockhill is also concerned about discrimination. If health care professionals must participate in a certain number of courses in order to maintain their licenses, what happens to the professional who cannot afford to pay the ever-increasing cost of these educational offerings?
Arguments to Support Mandatory Continuing Education
Arguments in support of current mandatory continuing education are based on the assumption that: health care professionals need to continue their education in order to be competent; the health care that the public receives is in jeopardy, if health care professionals fail to remain current in their field; health care providers can increase their competency through education; most health care professionals would not engage in formal learning within their own discipline unless required to do so; and increased knowledge will result in improved performance of health care professionals.
Houle asserts that it is the inherent responsibility of all professionals to remain current,(21) and Cross believes that even though voluntary education is preferable, required learning is better than none.(22)
Many health care professionals would not voluntarily attend continuing education programs. According to the registration lists from approximately 120 of SMAHEC educational offerings, rarely did people not requiring CPE for relicensure attend any of these workshops. Therefore, regulations are necessary in order to insure that health care professionals update their skills.
Writers such as Rockhill (23) and Day (24) are opposed to mandating continuing education on the basis that it limits learning and freedom. However, society often limits individual freedom when necessary for the public good. Restricting the speed at which one can drive a car or restricting the use of drugs are examples. Certainly, protecting the public from unknowledgeable doctors and nurses is necessary for the public good.
Furthermore, as Mattran points out, when a person decides to pursue a career in a field that traditionally requires licensure, that person also decides to abide by the canons of the chosen profession -- and continuing education is not an infringement of individual freedom.(25) He argues that "since the professions are not static but dynamic, individual members of the professions cannot retain their integrity if they themselves remain static."(26)
Mattran believes that the real issue is the manner in which mass mandatory continuing education becomes institutionalized and sustained. (27) He feels that if a (28) state, in response to the desire of a professional body to improve through continuing education the services offered to the public, uses its power of licensure to ordain into law standards and procedures recommended by the professional body, the state's authority is legitimate.
Currently, the mandate and requirements for continuing education are coming from within the professional groups; therefore it is appropriate and does not violate this criteria. Moreover, many health care professionals prefer continuing education to, e.g., periodic examinations.
Most health care professionals enjoy and receive several benefits from participating in continuing education programs. In a study based on a needs assessment of continuing health professional education it was found "that 98.3 percent of physicians surveyed said that continuing education was important to them professionally." (29) These offerings can stimulate and enhance the abilities of health care professionals. CPE courses provide an opportunity to get away from normal routines and be exposed to new ideas. They can also help prevent burnout and allow networking with professional colleagues.
Rockhill's argument that less effort is made to develop a challenging and exciting educational experience when there is a captive audience is not the situation in health professional continuing education. (30) Since the competition for continuing education clients is usually keen, the planners have an incentive to make their programs appealing.
Further, under current requirements, health care professionals have an extremely wide range of educational alternatives. They can select workshops from a large listing of continuing education programs. Even home study offerings are available. Therefore, the health care professionals can meet requirements with little effort. Since there is so much variety and flexibility, they can also choose courses most stimulating to them and educational settings which best fit their individual preferences.
Finally, CPE programs can also serve as a catalyst for more formal programs. For example, programs sponsored by Boston University, School of Social Work sparked such interest that they led to a part-time M.S.W. graduate satellite program. Also, the Family Beginnings program, offered by St. Anne's Hospital in Fall River, Massachusetts was met with such enthusiasm by social workers and hospital pediatricians that it paved the way for discussion of a pediatric mental health residency program.
Recommendations and Conclusions
There is no question that, if the public is to receive the best quality of care, health care professionals need to continue to learn. However, as Houle states, "participation in organized activities is only one mode of continuing learning and not necessarily the most effective or appropriate under all circumstances." (31) The ideal situation would be, as Darkenwald and Merriam suggest, mandating "competent performance through periodic evaluations and to deny relicensing to those who fail to demonstrate continued proficiency." (32)
Periodic evaluations may be more effective than mandatory continuing education programs, but health care professionals are apt to resist them vigorously. Mandating continuing education is a feasible alternative, being relatively easy to administer and acceptable to most professionals. Yet, shortcomings have gone unnoticed.
Professional boards should pay more attention to credit hour and content requirements. For example, 15 contact hours every three years may be insufficient for nurses. Many are now employed as nurse practitioners and have much more responsibility for direct patient care than they did in the past. The number of required hours for nurses should probably be increased.
With regard to course content, Brookfield suggests: (33) Since doctors, pharmacists, dentists, nurses and lawyers regularly encounter real life instances in which agonizing choices between different courses of action have to be made, serious ethical dilemmas are experienced, the neat prescriptions of textbooks and case histories are inappropriate and contextual factors such as personality, political climate or budgetary change significantly alter practice. In staff development exercises for such groups, it is much more meaningful to build curricula and organize workshops that take these experiences as their starting point, engage participants in a collaborative analysis and exploration of experiences and encourage professionals to reflect continually on their interpretation of correct practice in actual work settings.
Also, newer technologies such as VCRs and computers should be used to expand the reach of continuing professional education into homes, work places and even automobiles. Peer critiques and team learning should be considered too.
Finally, additional evaluation is needed. Evaluating, e.g., the qualifications of the instructor, participants' opinions of instructor performance, or the goals and objectives of courses is not enough. Professionals are required only to attend a certain number of offerings. They need not be able or inclined to absorb the information or to apply it in practice. If they choose, they can sleep or daydream and still get credit. Thus, a sample of participants should be evaluated to determine whether or not there has been a successful learning experience.
Notwithstanding arguments against it, mandatory continuing education is useful in maintaining professional competence. With revisions in the present system, continuing education can play a significant role in enhancing the quality of health care as well as provide professionals with an enriching experience.
* The author thanks Drs. Franz Wurtz and Jack Mezirow for reviewing this article.
This article is reprinted by permission from the author and the publisher. Dr. McPartland's article was originally published in 1 RISK: Health & Safety 329 (1990). The journal, which has since changed its name to RISK: Health, Safety & Environment, is published by Franklin Pierce Law Center and is the official journal of the Risk Assessment & Policy Association.
Patricia Ann Mc Partland, Ed.D, CHES is the Executive Director of the Southeastern Massachusetts Area Health Education Center, Inc. and the Program Director and Founder of the Institute for Cross-Cultural Competence. She holds a Bachelor’s Degree in Political Science from the University of Missouri, Masters’ Degrees in Preventive Medicine and City & Regional Planning from Ohio State University and a Doctorate in Adult and Higher Education from Columbia University. Patricia is a Certified Health Education Specialist and Certified Grants Writer with over 15 years experience in education, training, marketing, development and management. She also received Certification in Distance Education from Texas A & M University.
Dr. Mc Partland is the author of the book Promoting Health in the Workplace along with numerous publications and the editor of a quarterly publication. She designed, implemented, administered and marketed over 800 programs and training materials that generated several million dollars for her service area. She presents lectures and provides consultation for national and international programs throughout the world. Dr. Mc Partland is listed in Who’s Who in America and Who’s Who in the World and has received five national awards for Excellence in Continuing Education.
1 Lindsay, Morrison, & Kelley, Professional Obsolescence Implications for Continuing Professional Education, 25 ADULT EDUCATION 3 (1974).
2 P. JARVIS, PROFESSIONAL EDUCATION 41 (1983).
3 Singh & Rice, Continuing Professional Education (1986) (Unpublished paper available from Columbia University Teachers College, Aegis Office, Dept. of Adult and Higher Education, New York).
4 C. HOULE, CONTINUING LEARNING IN THE PROFESSIONS 34-74 (1980).
5 Id. at 74.
6 Id. at 305-315.
7 Mattran, Mandatory Education Increases Professional Competence, in EXAMINING CONTROVERSIES IN ADULT EDUCATION 49 (B.W. Kreitlow & Associates, ed. 1981).
8 Rockhill, Professional Education Should Not Be Mandatory, in EXAMINING CONTROVERSIES IN ADULT EDUCATION 62 (B.W. Kreitlow & Associates, ed. 1981).
9 G.G. DARKENWALD & S. MERRIAM, ADULT EDUCATION: FOUNDATIONS OF PRACTICE 242 (1982).
10 Id. at 241-242.
11 Id. at 241.
12 HOULE, supra note 4, at 43.
13 Rockhill, supra note 8, at 53-54.
14 Id. at 65-66.
15 Id. at 63-64.
16 Id. at 54.
17 P.CROSS, ADULTS AS LEARNERS 43 (1981).
18 S. BROOKFIELD, UNDERSTANDING AND FACILITATING ADULT LEARNING 174 (1986).
19 M. KNOWLES, THE MODERN PRACTICE OF ADULT EDUCATION 57 (1984).
20 Rockhill, supra note 8, at 64.
21 HOULE, supra note 4, at 305-306.
22 CROSS, supra note 17.
23 Rockhill, supra note 8, at 62.
24 Day, On Behalf of Voluntary Adult Education, in TASK FORCE ON VOLUNTARY EDUCATION REPORT 5 (T.Heaney, ed. 1980).
25 Mattran, supra note 7, at 46.
26 Id. at 47.
28 Id. at 48.
29 Krugman, Tabak & Freyer, Effectiveness of the AHEC Concept in Colorado, 57 J. MED. EDUCATION 87 (1982).
30 Rockhill, supra note 8, at 64.
31 DARKENWALD & MERRIAM, supra note 9, at 242.
33 Brookfield, supra note 18, at 173.
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