Complexities of continuing medical education ignited a passion for research

You began your professional life as a community family physician. How did the transition to education leadership and research come about?

I was mostly unprepared for practice after 4 years of medical school, a rotating internship, and (long story) 2 years of pathology. I graduated in the Dark Ages of family medicine training, before residencies were established, at a time when you could hang your shingle out with minimal primary care exposure. As a result, my care of patients was less than adequate. To augment my learning I began attending traditional CME courses, all in lovely settings with nice food, but often impractical and useless for family medicine, a bit like the journals of the day. In both forms of CME, specialists talked (mostly down) to GPs, and there was little time or space [devoted to] practical application. That kind of learning pushed me to help develop and then study educational experiences in my own hospital (Joseph Brant Hospital in Burlington, Ontario) and ultimately at McMaster University [in Hamilton, Ontario], a relatively new and pretty innovative institution.

Frankly, much of that early educational planning was self-serving; any topic we discussed or presented represented my own learning needs—and there were a lot of them!

How did you acquire research knowledge and skills?

My grandfather taught me it was all right to “steal” with your eyes. And so, at the outset, it was mostly reading educational research articles, though the pickings were slim at the time. Later, when I became active at McMaster, I audited master’s level courses in research design and education theory, and I found other like-minded researchers and wrote papers with them. I learned a ton in the process.

What facilitated your research success? Did you face impediments?

I had a great time at McMaster in the early days—working in a fabulous atmosphere of curiosity and inquiry, a place where there was no fear of asking challenging questions (like, does CME work?). Later, colleagues in Toronto and across North America stimulated my research, supporting, encouraging, collaborating.

Impediments? Funding was always a challenge. So was the widespread feeling that CME was unimportant and not worthy of scholarship. As one researcher said, “There are no researchable questions in CME!” I forgave him; he was a basic science guy.

What part did mentorship play in your career?

Mentorship played a huge role. My mentors from the late ’70s to the early 2000s are too numerous to mention. Two played critical roles, both now gone, sadly: Jack Sibley, the dean of education at McMaster in the early days, and Paul Mazmanian of Virginia Commonwealth University [in Richmond], a true star in the relatively small firmament of CPD [(continuing professional development)] scholars. They were amazing, encouraging role models. In mentoring others I’ve tried to pass their spirit on—Jack’s enthusiasm for big ideas and unerring skill in finding talent, and Paul’s unobtrusive, supportive, thought-provoking mentoring.

What roles did career planning and serendipity play in your development as a researcher?

If the 2 were teams in the CFL [(the Canadian Football League), the score would be] planning 0, serendipity 50. There really was no career path for educational planners or scholars at the outset (especially in CME) and very little for academic educational research interests, though that’s different today in the post–Dark Ages era. So, mostly luck.

Your highly cited research focuses mainly on CME. Did you consider expanding your research program to areas beyond CME and knowledge translation?

Continuing medical education has, and I was able to study, its own complexities (age of the learner, experience, self-assessment ability, decision making, training, to name a few). However, it’s only the midpoint along a hugely important pathway, from the input of clinical information at one end to the output of clinical action and patient care outcomes at the other. From its input stage, I was heavily influenced by McMaster, where evidence-based medicine was the air we breathed. That morphed easily into a strong interest in creating and applying clinical practice guidelines to guide CME. Similarly, much of my later career has been occupied by the end product of CME—clinical performance and its impact on patient care. Writ large, this has evolved into interests in quality improvement and implementation science, called knowledge translation in Canada.

Looking back, which of your research initiatives was the most satisfying?

The inputs and outputs of CME are interests, though somewhat peripheral to my core and most satisfying focus on the process of continuing education—how knowledge is acquired and then applied in the clinical setting. In hindsight, though, the most satisfying research projects and initiatives? They’ve involved like-interested people and the relationships forged there, many of them lasting to this day.

Were there times when you felt disheartened about your research progress?

In the midst of a meta-analysis, or a knowledge translation or implementation study, or a QI [(quality improvement)] initiative, I’d become occasionally overwhelmed, honestly fearing I’d drown in the data or in the complexity of the work. Disheartened or pessimistic? No. Frustrated, standing back from a project to see the bigger picture, getting help, learning to be patient? Yes, for sure.

How has your research influenced clinical or CME practice?

I do see hints of change in course formats, in innovations like learning portfolios, and the emphasis on CME of professional associations like the College of Family Physicians of Canada and its specialty and American counterparts. There, CanMEDS and other competency frameworks now identify lifelong, practice-based learning.³ I can’t tell you whether this is from my and my colleagues’ efforts or from the sheer weight of evidence that didactic CME is unlikely to change clinical performance. I do like it when I see small group learning activities announced or hear people acknowledge that clinical practice and learning are inextricably linked. In my mind, they are 2 sides of the same coin.

What lessons did you learn from the interplay of your work and personal life?

Remember Robert Fulghum’s book All I Really Need to Know I Learned in Kindergarten?⁴ Share everything. Play fair. Don’t hit people. Look around you. Those are pretty much the lessons of research applied in personal life; mine, at least. Maybe research is just a kind of adult kindergarten. Except for Fulghum’s advice to take naps in the afternoon. [But] I’m retired now; I can do that.

In retirement you have taken up creative writing. Is that connected with your experience as a researcher, clinician, or administrator?

In a big way. First, I always felt constrained by the tight (but necessary) box of objectives, methods, results, interpretation—sticking close to, but often wanting to stray from, the facts or findings of a study. Creative writing allows me to colour outside the lines nicely. Second, it allows me to use and adapt patient stories. In 40 years there were a lot of them. Those patients (anonymized, of course) and the lessons they taught me—about bravery, loss and recovery, isolation and community, how to live and how to die—deserve to be memorialized.

Do you have any parting thoughts for would-be primary health care researchers?

I have 3. One: Find a mentor, or a bunch of them. Create a team, even a virtual one. Mentor others. Two: Don’t be afraid to challenge assumptions; ask provocative questions; fight the assumption that primary care, like CME, is somehow the hundred-pound weakling on a beach filled with those folks with PET [(positron emission tomography)] scanners, fancy endoscopes, and Big Pharma funding. Three: Never forget the patient. Just like education and clinical practice are inextricably linked, so should research and patient care [be intertwined].

Oh, I just thought of a fourth: Hang in there.