Is experience enough?

Within the realm of continuing professional development there is no factor more influential than experience. Strong theoretical knowledge and years of application are a formidable combination. There can be no surprise that senior clinicians make fewer diagnostic errors. However, even experienced clinicians make mistakes. Errors made by clinicians are frequent and result in unnecessary patient morbidity and mortality. Unfortunately many of the errors are related to lack of knowledge. Although it is commonly known that during formal education better learners are self-reflective and selfassessing, this may not extend to the professional years. Despite professional commitment to self-directed learning, frequently mandated and quantified through continuing professional development (CPD) programmes, physicians’ knowledge declines with time. This decline in knowledge is particularly evident 15 years after specialist qualifications are gained. It would seem CPD strategies such as educational material, conferences and audit are not effective at improving physicians’ knowledge and performance. How can we know if we are making the right decisions for our patients? How can we ensure our next decision is indeed better than our last? Clinicians have significant confidence fuelled by the observation that their patients generally respond favourably to the provided treatment. Most would also believe that there are fewer diagnostic challenges as years in practice increases. Unfortunately there is little correlation between self-belief and performance, in fact, in the novice it is inversely related to skill level. Of concern is the observation that physicians do not accurately self-assess compared with external observations of their competence. Also, the least competent are the least able to self-assess. Subjective self-assessment is not providing satisfactory evidence that we are on target with our clinical judgement and that our knowledge is evidence based. Despite its limitations, self-directed learning remains a potentially valuable tool for lifelong learning in medicine. Its effectiveness increases markedly if the physician is given an indication of learning needs via objective feedback. In recent years, there has been the emergence of systems which provide objective feedback to the clinician and trainee. One such tool is CUSUM (cumulative sum). A CUSUM chart can be applied to any situation where quality control is required. It continually monitors performance against a benchmark. If the chart line is flat, benchmark is achieved, if there is an upslope, there is a loss of performance and action can be initiated. CUSUM has been investigated and revealed as a useful tool in monitoring competency in cataract surgery. Another such tool is online skill assessment. In this issue, Kong et al. present the results of a project evaluating the optic disc assessment skills of nearly 200 participants. The GONE (glaucomatous optic neuropathy evaluation) system assesses and then gives rapid feedback to each participant. Even though the system has limitations, such as lack of stereo images, the quality and detail of the images is quite good. The real crowd pleaser is the detail in the feedback. The online participant is given a breakdown of errors made. In this way, knowledge strengths and limiters are identified and the participant can get on with targeted learning. The observed decline in knowledge and performance will not be welcome news, like no other the medical profession shows continued commitment to self-development. The emergence of tools and systems to aid self-assessment and self-directed learning will be met with the greatest of enthusiasm.