Choosing the audience and designing for more than one profession

A continuing-education activity is now aimed at many groups beyond physicians, and its audience decides what goes into it: the learning objectives each profession needs given its scope of practice, whether the professions learn side by side or together as a team, and how teamwork is practised inside the activity rather than only named in its objectives.

Who continuing education is aimed at

In oncology, the way medical education is targeted, designed and delivered has had to evolve with the changes in the field. ¹ Physicians have historically been the primary target of medical education, but by 2012 the changing healthcare environment meant that other important targets were emerging, such as specialist nurses, pharmacists, patients, carers and even payors, and pharmaceutical and device companies were therefore increasingly investing in medical education for these groups, particularly in oncology. ² Specialist nurses play a key part in patient management in many countries and are often best placed to monitor and manage side effects. ² Pharmacists often play a key part in deciding which treatments can be prescribed, and they reconstitute drugs for intravenous administration. ² Patients are encouraged to take an active part in decisions about their treatment, and carers often need advice on how best to support the patient during and after it. ² Payors influence which treatments are available to a particular patient. ² All these stakeholders need to be educated for a treatment advance or a shift in thinking to emerge in clinical practice. ² By 2016 the participants in medical education included nurses, midwives and various allied health professionals, and patients increasingly sought access to sophisticated medical information. ³

Educational programmes that help patients understand their diagnosis, treatment options, possible side effects and the importance of adherence, directly or through their nurses or carers, can strengthen the partnership between healthcare professionals and patients and so promote better care and outcomes. ² Peer-reviewed publications and scientific symposia at key congresses, the traditional channels to physicians, do not suit nurses, patients or carers, so they have been joined by approaches that reach these audiences, such as electronic side-effect management toolkits for nurses and support websites or information booklets for patients and carers. ² An effective programme evaluates which stakeholders influence treatment decisions and sends each of them specific educational messages through the most appropriate channels. ² Effective medical education acknowledges that numerous healthcare professionals are involved in patient care, so its messages need to reach nurses and pharmacists as well as physicians. ⁴

In 2010 physician participation in accredited continuing medical education (CME) rose to 11.5 million, up 6% on 2009, and 7.8 million non-physicians took part in CME activities, up 16%, bringing the total to over 19 million. ⁵ Pharmacists, nurses and physician assistants are among the health professionals who must also earn CME credit to maintain licensure. ⁵ In 2021 accredited US continuing education had an estimated 28 million learner interactions, about 75% of them by physicians, and despite that share medical writers will still be asked to create content for other clinicians. ⁶

In May 2011, shortly after two reports from leading health associations and foundations recommended core competencies for interprofessional collaborative care, the administrator of the US Health Resources and Services Administration stressed the importance of interprofessional education: rather than being educated in silos, health professionals need to be educated in ways that model and promote effective care coordination and team-based care, which are among the important underpinnings of the Affordable Care Act's delivery-system reforms. ⁵ CME providers took up the challenge with programmes for a variety of health professions, including therapists, nurses, physician assistants and pharmacists. ⁵ So CME providers need writers who can create content for the needs of several professional audiences, and the content is becoming multidimensional, expanding to include other clinicians and to teach organisational process and team communication skills. ⁵

Scope of practice and learning objectives

Physicians, nurse practitioners, physician assistants, pharmacists, nurses, clinical psychologists and dietitians are examples of professions that often require continuing education (CE) to maintain licensure. ⁷ Many medical writers belong to a health profession, and many others come from nonclinical backgrounds such as basic science, communication or journalism; either may be asked to write educational content, accredited or not, and needs to know how to adapt it to the needs of the target clinician audience. ⁷

Understanding a clinician audience rests on knowing its scope of practice and role in the health care team. ⁸ A nurse practitioner's role, for example, is very different from a registered nurse's: an activity for registered nurses should not include a learning objective on prescribing treatments or making a diagnosis, while objectives on monitoring vital signs and symptoms or on administering medicines would be reasonable for them. ⁸ The general responsibilities of selected professions are as follows: ⁸

• Physicians screen for, diagnose and treat injury and illness, examine patients, take histories, order and interpret tests, counsel on prevention and lifestyle, and perform surgery and procedures.
• Nurse practitioners have similar responsibilities, practising independently in many US states and under a physician's supervision in others.
• Physician assistants have similar responsibilities but must practise under a physician's supervision.
• Pharmacists advise on the safe and effective use of medicines, fill and dispense prescriptions, educate patients and give vaccines, and in some states prescribe under a physician's supervision.
• Nurses provide and coordinate care, assess patients and monitor vital signs, administer the treatments a prescriber orders, operate equipment and educate patients.
• Medical assistants record vital signs, assist nurses and practitioners, give vaccines and schedule appointments.
• Clinical social workers assist with diagnosing, treating and managing behavioural, mental and emotional disorders and provide therapy.
• Clinical psychologists screen for, diagnose and treat those disorders, and in some states prescribe.
• Registered dietitians use food and nutrition to manage disease and promote health.

⁸

The education company will likely set the audience from the educational need and the supporter's interest, and the audience determines the approach to every deliverable, the needs assessment included: if a provider educates only pharmacists, the needs assessment should not identify gaps for physicians. ⁸ A writer unsure of the audience's role should always ask; sometimes the client or employer is relying on the writer to determine it, and in many cases a key opinion leader in the profession can supply more information, as can the many clinician writers of the AMWA community. ⁸ Writers familiar with creating CE content should need only small adjustments to their approach: much of the material will be similar, and the audience dictates where to go into detail. ⁸ Given differences in scope of practice, writing for pharmacists or nurses is not always the same as writing for physicians, and physician audiences may have different specialties too: content on dementia for primary care practitioners needs a different approach from content on dementia for neurologists. ⁶ Writing for interprofessional education often needs its own approach as well, since such initiatives may focus more on communication and collaboration among team members than on detailed medical or scientific content. ⁶

In a worked case, an education company wants slides for a multidisciplinary oncology programme on non-small cell lung cancer, for physicians, midlevel practitioners, pharmacists, nurses and other support staff, with four learning objectives: describing the role of molecular testing in diagnosis and classification; applying best practice in choosing targeted therapies by genetic alteration and immune checkpoint target; managing adverse events; and taking a multidisciplinary approach to educating patients, families and caregivers. ⁹ A first step might be to consider which objectives are relevant to each group. ⁹ All four apply to oncologists, who test, diagnose and treat and oversee patient education and the whole patient experience, and to nurse practitioners and physician assistants, who diagnose and treat under a physician's supervision, except nurse practitioners in states that do not require one. ⁹ The second, third and fourth are relevant to pharmacists, who in many settings help select and monitor treatment and educate patients but are generally less involved in initial testing and diagnosis. ⁹ The third and fourth are relevant to nurses, who might administer medicines in the clinic, call patients to assess their response to treatment, handle questions or concerns and provide education. ⁹ The fourth is relevant to other support staff, who may not be directly involved in managing the disease but are still part of the multidisciplinary team and help educate and support patients, their families and caregivers throughout treatment. ⁹ A writer should consider whether a programme will be multidisciplinary or focused on one profession, and a working knowledge of the clinicians' roles in the team helps a writer create the right content for the audience. ¹⁰

Teamwork in patient care

Effective patient care requires specialised approaches that teams often provide more effectively than a single physician; for example, a growing body of literature supports outpatient multidisciplinary interventions as an effective treatment for obesity in children and adolescents. ¹¹ Until shortly before 2012 the health care system supported the assumption that each clinical specialty owned a distinct area of care and delivery, and inside those silos practitioners were further divided by hierarchical job descriptions. ¹¹ Research on teamwork found that even clinicians of different professions and titles working together often worked individually beside each other rather than collaboratively as a team. ¹¹ Communication and interaction between medical professionals have become so vital to patient care that the American Board of Medical Specialties' six core competencies for quality patient care set out evidence of competency in them, under interpersonal and communication skills and systems-based practice. ¹² By 2012 medical education providers were beginning to develop interventions that enhance teamwork, and a growing literature showed these programmes result in positive outcomes including enhanced learner knowledge, skills, attitudes and behaviours and improved patient outcomes in specific disease conditions. ¹³

By 2012 the multidisciplinary team's role in decision-making had received increasing focus. ² In oncology, effective treatment often requires close collaboration between specialties with different mind-sets. ² Prostate cancer management, for example, was traditionally led by urologists because surgical and hormonal treatment had long been its mainstay. ² Once new chemotherapy regimens offering a survival benefit in hormone-refractory prostate cancer were launched, it became increasingly important to involve oncologists at the earliest possible stage, so that the treatment plan incorporates surgery, hormonal therapy, chemotherapy and supportive care where appropriate. ² Medical education can play a key part in facilitating dialogue between such specialties by creating opportunities to discuss common issues and challenges, so sometimes it is merely about bringing people together to learn from each other. ² Effective medical education takes into account that collaboration between disciplines is critical to effective patient care, and it provides forums for dialogue between them. ⁴

Patient care often involves more than one professional. ¹² Sometimes the team works together, and sometimes a patient is referred to a specialist who must collaborate with the patient's primary care clinician, not necessarily a doctor, on results, diagnosis, next steps, recommended care and follow-up. ¹² Since patient care is a coordinated collaboration, it is logical for education of the patient care team to move beyond uniprofessional approaches to include multidisciplinary and interprofessional formats. ¹²

Multidisciplinary, interprofessional and team-based designs

In a multidisciplinary format, several disciplines within the target audience contribute to and take part in one activity. ¹⁴ Its objectives may focus on knowledge or competence for the audience as a whole, and it may address new diagnosis and treatment protocols, communication skills and disease management as they bear on the different roles and on how those roles interact. ¹⁴

In interprofessional education, several types of health care professional learn in a cooperative environment, purposely created to address specific goals of the interprofessional team in the systems it works in. ¹⁴ The Centre for the Advancement of Interprofessional Education defines it as occurring when two or more professions learn with, from and about each other to improve collaboration and the quality of care. ¹⁴ Such activities focus on enhancing the collaborative skills of the whole team, resulting in improved patient outcomes. ¹⁴

Team-based learning is an active, learner-centred instructional design strategy built on small-group learning, typically made up of individual assignments, group assignments and interaction, and immediate team feedback. ¹⁴ It acknowledges individual roles and responsibilities and also helps evaluate the system itself for the team's cohesiveness and functions. ¹⁴ It is only one type of group-learning design, and it is recognised as falling within the realm of interprofessional designs. ¹⁴ Interprofessional team-based learning proper focuses on authentic teams in specified environments, so the systems in that environment may also be assessed for improvement, further supporting the team's evolution. ¹⁴

By 2023 interprofessional continuing education had emerged as a framework in which two or more professions, such as nursing, medicine and pharmacy, share a common learning process to learn with, from and about each other, with the goal of fostering interprofessional communication and teamwork and the effective coordination of patient care. ¹⁵ Multidisciplinary education, by contrast, has health professionals learning separately about patient needs within their own professional roles and responsibilities. ¹⁵

Choosing a design

The professional practice gap analysis and the identified needs may warrant a multidisciplinary or interprofessional design, and these are key considerations in deciding whether one is appropriate rather than traditional siloed learning: ¹⁴

• Did the needs assessment identify more than one professional type with the same professional practice gap?
• Is the identified problem occurring in more than one institution?
• If only one discipline were educated and those clinicians made a practice improvement, would that be enough to close the gap and so improve patient care?
• If two or more disciplines were educated and made practice changes, would that be enough to address the gap?
• Based on the educational focus, would individual team members benefit, or would the whole team benefit more?

¹⁴

If siloed learning is ruled out, these questions help determine whether a multidisciplinary or an interprofessional design would be more beneficial: ¹⁴

• Are the learning objectives appropriate across all learner types?
• Based on learner roles, should different objectives be developed for each learner type?
• Does the content speak specifically to the various learner types targeted?
• Is the identified practice gap specific to individuals, or is it a problem of the team system or its functioning?
• Are the issues underlying the gap more knowledge-oriented or more systems-oriented?

¹⁴

An interprofessional activity requires more than adding multiple certifications and listing several groups in the target audience. ¹⁴ It has to take account of the roles of the entire team and of how each member's responsibilities are linked to the others', and it may require customised objectives based on function-dependent roles. ¹⁴ Its learners, planners and faculty may have little experience of interprofessional formats, because their own professional training did not involve them. ¹⁴ Barriers to changing practice behaviour may have a significant impact, so the planner or medical writer needs to address them within the activity itself. ¹⁴ Designing education for the individual learner or for the team requires planning with the end result in mind. ¹⁴

Teamwork practised within the activity

As of 2012, CME was still largely centred on diagnosing and treating specific conditions rather than on the process of practising medicine, especially in multidisciplinary teams, and few medical education programmes included team training. ¹⁶ In the view of one team-training researcher, any well-designed training, in any industry, involves four elements: information about the topic, demonstration, practice and feedback. ¹⁶ People learn best, and adults especially, when they can practise what they are taught and get direct feedback. ¹⁶ The researcher would design a CME programme around teamwork so that participants practise working in teams and get as much feedback on their performance as possible: information about why teamwork matters in patient care, demonstrations of team interaction in patient care, and then simulations such as role play in which participants practise communication, exchange of information and group decision-making and receive direct feedback from experts and educators. ¹⁶

In the researcher's view, one reason few programmes include team training is that they are often created by clinicians unfamiliar with the science of learning, who do not consider that they need to teach teamwork. ¹⁶ In the researcher's experience of consulting in manufacturing, oil, aviation and the military, the problem is not unique to medical education: good teamwork is wanted, but training does not usually include ways to improve team functioning. ¹⁶ It is easy to get bogged down in clinical content, but some learning objectives have to go beyond diagnosis and treatment to coordination, cooperation and communication, each a requisite competency expected of the individual clinician and vital to patient care. ¹⁶

The same researcher advises that the CME writer needs to start with teamwork in mind. ¹⁶ Even condition-focused CME should include some discussion of the interdependencies between the people managing the patient and of how care is to be implemented, such as when coordination begins or what communication has to happen for good cooperation to occur. ¹⁶ The writer should then try to create scenarios in which clinicians can practise elements of teamwork and get feedback during the session. ¹⁶