In a carefully reasoned paper, Donald Moore and his associates have reminded us once again of the past failures in continuing medical education, but more importantly of the challenges, as well as the opportunities, that the contemporary health care revolution may provide. By highlighting the current forces for change and the facilitating factors that could now be embraced, they have offered a "new paradigm" to guide us toward a better future. It would be hard to quarrel with their message. The real problem is the difficulty of translating an intellectually persuasive argument into a practically acceptable program.
As the authors have recognized, over the decades since Williamson's Rockford study and Brown's Bi-Cycle experience more than a few explorers have mined the field that merges quality care assessment with continuing medical education, using physician performance data for diagnosis of need, and measurement of success, in a program of educational therapy. But as they also note, "It has been difficult to implement these largely researchoriented approaches in routine CME." And there is the rub: it is so much easier both to deliver and to receive routine CME.
If real improvement in health care is to occur through the continuing education of physicians, several additional considerations may be necessary. The first is forthright recognition that not all health care problems can be solved through medical education; some demand system changes. Physicians are not alone in resisting change, but their central role in the delivery of health services will surely require them to learn, with others, new ways of addressing those issues, A concerted interdisciplinary effort to achieve consensus on what needs to be done, and who is in the best position to do those things, should certainly precede the development of physician education programs dealing with either purely medical or essentially management matters.
Second is the inescapable truth that behavior will change only if knowledge is used. Episodic instruction is no more likely to change physician performance than periodic affirmation of the danger of tobacco is likely to change the behavior of teenagers. That fact is presumably the reason for the word "continuing" in CME. Madison Avenue long ago learned the importance of this principle, as all those who watch painfully repetitive television commercials will testify. But educators seem strangely reluctant to embrace the idea that if the behavioral objectives of an educational program have not been achieved, then follow-up, through repetition or modification of in-