Shifting the culture of continuing medical education: what needs to happen and why is it so difficult?

A revolution in health care is occurring as a result of changes in the practice of medicine and in society. These include changing demographics and the pattern of disease; new technologies; changes in health care delivery; increasing consumerism, patient empowerment, and autonomy; an emphasis on effectiveness and efficiency; and changing professional roles. The issues raised by these changes present challenges for the content and delivery of the whole continuum of medical education. The ways in which continuing medical education (CME) needs to respond to these challenges are outlined. The Informed Shared Decision Making (ISDM) Project at the University of British Columbia is used as a case study to illustrate some of the practical problems in providing CME that address these current trends in health care, is effective, and is attractive to physicians. Two particular problems are posed: how to respond to a demonstrated need when there is no perceived need on the part of physicians and how to enable change agents on the margins to develop allies and get ownership from stakeholders and opinion leaders on the inside. Two strategies for change are discussed: the substantive incorporation of CME into the continuum of medical education and the involvement of patients in the planning and delivery of CME. A final challenge is raised for the leaders of CME to define and agree what "shifting the culture of CME" means and to make a commitment of time and energy into making it happen.