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Lawrence Sherman, FACEHP, FRSM, CHCP: If it's not designed, developed and based on a needs assessment of gaps of the learners in the geographies,then it's not going to be effective.

Don Harting, MA, MS, ELS, CHCP: So welcome back to continuing conversations the Alliance Podcast. In case you didn't recognize it, the voice you heard just now belongs to Lawrence Sherman, a longtime member of the alliance who has achieved the distinction of being named an alliance fellow. You may have heard him speak about mentorship at our 2025 annual meeting in Orlando, Florida. Lawrence lives just outside Tampa, and his company is called meducate Global LLC. He specializes in designing, developing, implementing and evaluating continuing education programs for health professionals around the world. In this episode, I'm delighted to be able to share with you a conversation we had recently, Lawrence and I share a common perspective on the importance of a strong needs assessment to build the foundation for a quality continuing education program. Lawrence has also amassed an impressive list of peer reviewed publication credits on a topic that's becoming increasingly relevant to American medical education companies, as well as their employees and contractors. That topic is the growth of accredited CME, CPD around the world. Lawrence has become quite an authority, and we'll have more to say about that in a few minutes. Tell me why you accepted this invitation, and I'll tell you a little bit why I extended it.

LS: Sure. Well, one, I always like talking to you so that that was an easy one.

DH: Thank you. But I think it's important that we address the topic of CME and CPD around the world, and share the information that we know and try to make it better. I mean, I spent a long time working as a provider, both in the U.S. and outside the U.S. delivering education, and that led into this more scholarly work that I've done of late, and I'm just happy to have a platform to share the information with our large educational community of practice. Lawrence, I just want to thank you for joining me here today, and one of the reasons why I invited you, and so much look forward to speaking with you, is because of the scholarly approach that you've taken recently by taking an interest in CME, CPD around the world, and then publishing what you found out about it, and going to the effort of getting grant support, to support your efforts, to find out what CME/CPD around the world is like today, and then to take it to the next step, which is to recommend suggestions for improvement. And I very much look forward to sharing some of your insights with our podcast listeners on this episode, congrats on having three more journal articles published just late last year on the topic of what I'm calling global CME/CPD. Could you please start us off by just giving our listeners a quick update on this multi-year Capacity Building Initiative that you've been working on, and what makes it special?

LS: Sure. Well, you know, what makes it special, Don is it's a passion project for me, right? I've been doing CME and CPD for over 30 years, the first 25 years as a provider, the last 15 years of that, mostly as a non-U.S. provider. So it really is, as I said, a passion project. In 2019, I approached Pfizer with the idea of doing a capacity building project in multiple phases. And I approached IME, the International Association of Health Professions Education to be a collaborative partner. The goal here was to assess the status of CPD around the world, get a sense of where the gaps were, and try to figure out a way to close those gaps. And what we learned was published in all of those papers, okay, and there were a lot of gaps, but one of the things that we learned was there's a big gap in the perception of and the delivery of CME and CPD around the world, and there was a lack of really well trained CPD educators in Some parts of the world, and there was a lack of awareness of frameworks and best practices in CPD that perhaps you and I take for granted. So Pfizer, since 2019 has funded our efforts. And not only did we assess the CME and CPD systems in over 40 countries around the world, we developed a six module, 60 hour course as part of the IME essential skills and medical education curriculum, six modules covering all of CPD for educators and other stakeholders. And just over the last year, we've implemented five communities of practice across five Sub Saharan African countries, and we have upskilled 75 CPD educators in those five communities of practice in Botswana, Lesotho, Kenya, Malawi and Rwanda. So this is really, it's a big deal, Don it's a big deal.

DH: I did a literature review last night. I was on PubMed searching for articles with your name on them that had to do with CME CPD around the world. And as you know, I sent you my my reference list, and I think I found eight of them all together. And the first, the very first one, was dated 2018, you teamed up with Kathy Chapel from the American Nurses Credentialing Center, I think it was, and you published an article in Asia Pacific scholar on global perspectives on continuing professional development. Is that kind of how and where it all got started, though?

LS: Well, that's where the scholarly part of this whole thing got started. I mean, what we realized is that there was a need to get a better understanding of what CME and CPD looked like around the world. And as I said, I've been working as a provider and implement education on six continents, and it was really a trial by fire every time I went to a new place. So what we tried to do is we tried to start to establish a little bit of research and a little bit of scholarly activity around what do we know about CME and CPD around the world? What are the perspectives of the experts, but also, what are the perspectives and expectations of the learners, and really get a sense of what that environment looks like and and I will tell you that we in the US and Western Europe really take CME and CPD for granted. I mean, we have it really good. Our learners have it good. Our faculty have it good. Our supporters have it good. Everybody has it good. When you go to places outside of those general geographic areas and even some within those geographic areas, the definition of CME, the availability of CME, what CME even means, is very, very different, and I think we need to sort of embrace that and and understand that before we go someplace to try to implement education in in other cultures and environments.

DH: Okay. Great, great. Thank you, Lawrence. And one more question on your work before we move on to some of the findings from your work, and that is when you were explaining to me your passion project, you use the word gaps, and that you were looking to find the gaps in all these various countries around the world. And that made me think I mean, that kind of warmed the cockles of my heart Lawrence, because, as you know, I love to write needs assessments. And what is a needs assessment but a gap analysis, right?

LS: Well, you know what it is. It's a global gap analysis, at least, right? So, but, but limited to those countries and regions in which we've had the opportunity and and honor to do these assessments, but we can sort of extrapolate beyond, and we hope to do more assessments in other regions around the world, but we did, and as you said, we'll get to the findings. But there are a lot of common themes and and I think it's important that we remember again, the environment that we come from is very different from the environment that the majority of the rest of the world is living what is, what is the perceived value of accredited or non promotional education to the physician audience in countries outside the United States and Europe? Right? So we have to sort of level set the playing field here, the language that we use in the US and in Western Europe and in industry supported CME is completely foreign to the majority of the world. Okay, so, so there's not this. There's a need to discuss the need for independence. And the International Academy of CPD accreditation is doing a great job of helping accrediting bodies around the world where they exist to understand and implement the importance of independence. But the reality is that the question that you asked me is impossible to answer in the broad sense, because it's really a country by country and sometimes region by region-specific answer. So so we had to in our research and in the surveys that we did, and all surveys were in local languages, we had to define what independent CME and CPD was. We had to define what industry supported CME and CPD is because it's intrinsic to our system, but it's extrinsic to systems in other places around the world. So we had to ask the questions differently. So we had to ask the questions about whether they felt the pharmaceutical industry was involved in the development of CME and CPD around the world, and whether the education that they were able to access was free from industry influence or bias. So it's a little different than having an expectation of independence in CME. In fact, in some places around the world, the only structured CME and CPD that's available to learners is is that that is provided by the pharmaceutical industry? So again, you know, it's a great question. Don The problem is getting to the answer is really challenging, because it's, it's a whole different world.

DH: Yeah, it reminds me of a conversation that I had with Eugene posniak Not long ago, when I was using the term accredited to mean non promotional and kind of bearing the the this the stamp of a third party, a stamp of approval by a third party. And Eugene Posniak said, "Well, over in Europe, accredited, can accredited education, can be company sponsored and and therefore promotional." And so I'm thinking, oh my gosh, we really have to use we have to find different words at different vocabulary, right?

LS: And you know, Eugene's a good friend of mine, and he and I, we talk about this a lot. You also have to think about who's doing the accreditation, who's providing that credit, and what's the reason why they're providing that credit. So I'm not naming names, and I'm not picking on any one accreditor versus another, but there are debates within the accreditation community as to whether it's appropriate to provide credit for industry, developed, company led, education or not. So that's a whole other issue. What is the best way for potential collaborators in the United States to find host country collaboration partners, say in Asia or Latin America or Africa, it really needs to be a collaboration. And if it's a U.S. or European based provider that wants to design, develop, implement and assess education in another geography, the collaborative partner has to be involved from the beginning. And this is going to warm the cockles of your heart again, Don because, because they have to be involved from the needs assessment, but it's so true, but, but I've seen and heard and talked to my industry friends where that's not what they're seeing, and you and I have had this discussion totally separately, Right? But, but the reality is, you can't implement education that was developed for a U.S. audience, for non-U.S. providers without first considering what the environment that the learners practice in. And so the gaps may be different. The practice environment is different, the journey of the patient is different. So that's where you have to pull in the collaborative partner early on. And here's a big one, if you're a U.S. or European based provider and you want to implement continuing education in other geographies, if you're not a known entity, it's incredibly difficult. And if you're going in and thinking, Oh, the learners are going to break down the doors to participate in our education, because it's the best thing that they've ever seen, you're probably mistaken, because they don't know who you are. And what's the why? What's the incentive for them to participate again? And it goes back to the question you asked. You need to find the right collaborative partner, but you also need to understand who the right collaborative partner is, what what environment they come from. So in some places, there are really great digital platforms that already have hundreds, thousands in China, millions of learners that visit their platforms every week. So you need to know, okay, well, if that's going to be my partner, how should I approach them? To say, Where would you like? Be involved. How can you help me? And here's the world and opportunity that I'm coming from. How do we make it work in your environment? The biggest mistake I've heard from my colleagues outside the U.S. is when a U.S. or Western European based provider comes in and says, "We've got this great education, we just need you to disseminate it." A collaborative partner is not only for examination.

DH: And I think that's what our listeners that's a nugget that our listeners can take away, and I thank you for offering that.

LS: Now, in some cases, maybe it's okay if it's just information, if it's just basic, you know, background information, maybe that's okay, but if it's not designed, developed and based on a needs assessment of gaps of the learners in the geographies, then it's not going to be effective. You know that because you spent your life finding those gaps and those root causes, and you can only have my life, but you can imagine that a root cause analysis in a health system in the United States is probably not relevant to a health system or a group of hospitals, or even one hospital or community based practitioners in Vietnam, it's just not going to be relevant. So so to get back to where do you find the partners? You need to have a library of partners before you decide that you're going to try to pursue the education and the funding to develop the education or to develop a global dissemination strategy so some provider organizations acquire organizations in other countries and regions. Some provider organizations establish collaborative relationships. That's how I did it, and that's how I've been able to build up that CADRE. There's probably not a region in the world where I don't have someone that I can call to say, is there someone that I could work with in Estonia, in oncology to to develop an educational activity? But again, it's gotta start from before that RFP hits your desk and you say, Oh, this is great. It's a global one. We're going to build in five countries, right? Because it's just not going to work. And and if you only do your needs assessment in English and you don't search local language literature, you're going to miss information. And if you deliver your education in only English. The majority of participants will not participate. Now you can break it into two groups. There's the top world leading expert, key opinion leaders who go to the big international conferences. All of the conferences are in English. That's one group of learners. But if that's what you think, all learners outside the U.S. are like, that's another big mistake. If you're looking for community based learners, if you're looking for non academic learners, if you're looking for non department chairman, if you're looking for the practitioners who really have the gaps and need to make the changes you need to be working in their language.

DH: So Lawrence, now that you have published peer reviewed journal articles about CME/CPD all around the world, do you still think a well written needs assessment is important?

LS: Why not? No, no, I again, it's a setup, but, but you and I have talked about this before. Education and CME needs to be needs based, but let me, let me caveat that a little bit, because we know we're working with adult learners, and where do the needs and questions and challenges come up? They come up at the point of care. So, so we know that point of care has become the point of education. The point of care has also become the point of need. So we know that there are huge needs that happen all over the place. I think we need to embrace that when we're conducting needs assessments and get a sense of not only what the needs are, but what are the challenges of accessing education on that level. What other what's an environmental analysis? Where are they going to get their education? What's missing from their education? So, so when we say well, structured needs assessment. To me, all of those need to be components of it, especially if we're going into a new geography. Because if I'm someone who, let's say that the needs assessment is part of a proposal where you're asking for support of grant, I want to review this and say, okay, they know this environment. They know where the gaps exist. They know where people are going to get their education, and therefore the rationale for the education not only based on the clinical and professional practice gaps, but the recommended format is substantiated by that needs assessment. One of the things is, if you're recommending, if you're a provider, and you're recommending an educational methodology, delivery, format, platform, etc, why is that the right one? And how do we know the learners will go there? So if you have your own, and let's take the big, mega sites out of it. But let's say you're a small to mid size provider, and you host your own digital CME activities. It is not always the case that people will connect to your platform because you're offering them this education. And by the way, if it's English language with subtitles, they're not going to connect to your platform, and a sub question in terms of finding the right collaborator.

DH: Lawrence, and forgive me if you've already said this, but here's a chance to say it amplify your previous comments. How do you find collaboration partners in a host country who have the necessary education expertise?

LS: Well, so that's sort of a trick question, because you have to find the providers that are educators, because providers, like we define them in the US and Western Europe, in most places around the world, don't exist. So, so it's not like you're looking to find a mech in Estonia, you're not going to it's not like you're looking to find a mech in Thailand, it doesn't exist. So you're looking for a different type of educational collaborative partner, whether it's a platform where you have to be the educator, or it's an academic or professional society, where they have the educational and subject matter expertise and you become true, even level collaborative partner. But every country is different, and that's why you need to be doing this research as a provider or as a medical writer. Long before the opportunity comes up, it's best and probably ideal not to wait till an RFP crosses your desk to decide that you want to be a global CME provider. You've got to make that decision long before that RFP hits your desk, and you have to put together your network. You have to decide where you want to have that expertise. You have to choose the countries or regions that you think you'll be able to design and develop education together with a collaborative partner. Now it may wind up being that you you're in search of collaborative partners, and you develop your network based on who's willing to work with you. So you really need to be able to make a prospective decision that you want to be dip your toe in that global CME/CPD space, and then you have to jump in the deep end of the into the deep end of the pool.

DH: Do other countries besides the United States, try to make this distinction between promotional and non promotional continuing education for health professionals that is funded by commercial interests? And if so, how do they? How do they make that distinction?

LS: So whether we call them commercial interests or an ineligible companies, etc. That definition is very specific to the U.S. Now the International Academy of CPD accreditation has done a good job of helping to share that definition in that model with the 30 or 40 countries that have accreditation systems that are participating in the International Academy, and so in those places, at least, the accreditors are familiar with those terms. But what we've learned is that the learners and that the educators are not necessarily as familiar with those terms, with some notable exceptions. So in Japan, what we learned in our research was that any time the pharmaceutical industry is involved in any form in a continuing education activity, it is deemed promotional. So even if it's designed to develop through an independent grant from an ineligible company, and they follow all of the processes in the local regulatory environment, it's considered promotional. Now remember, in Japan, at least as far as the research date that we published, CME participation is not mandatory, and although the head of the CME promotion committee at the time on the Japan Medical Association wanted to make it mandatory, it wasn't yet mandatory, and this is true in a lot of other places. Again, we have to remember the environment. So the focus that we have on the independence and the the commercial support and all the other things that are very specific to our system are very foreign in other places.

DH: So Lawrence, how can we tailor educational content to meet the specific healthcare challenges faced by healthcare providers in low and middle income countries?

LS: Well, it's all a matter of collaboration and finding the right organizations with whom to collaborate. There are great ones out there that are working in many of these regions, and there are the local educational providers. You know, many rely on the medical schools, hospitals and health systems in their countries to be the the owner of continuing education. But we also have to remember that the needs that they have are often very different than the needs that we have. I just came back from a trip to Africa, and I was in elder at Kenya, and I was, I had the pleasure of working with a group of CPD educators that we've put through this capacity building course, and and others who want to go through this capacity building course, who were starved for just how do you develop good, solid education, and those who went through the course were saying that they want to make sure that they are now more focused on needs based education. They want to make sure that they're focused on education that has measurable objectives and that they're measuring learning outcomes. So yeah, so what we take for granted is not necessarily the case in many places. So So your question is one that has sort of two answers. One, we have to start to make this help the people who are doing the CME and CPD there without us, do it better and and more efficiently, and then we have to find ways to collaborate with them, if we have opportunities and funding to develop education for these learners, to make sure that those needs that You ask about are identified and met, and are met through formats that work in those regions, in those places, for those learners and not assume that what we do here will work there. You know, Don there's a lot of places in the world that CME is still they ask the chairman of the department of, you know, endocrinology, to give a lecture on diabetes, and they have the their slides, and they give the lecture, and everybody's in attendance. So they call it inter professional. But it's not. It's interprofessional by recruitment, not inter professional by design, and there's no no needs assessment. It's based on what they think is important at that moment. And what our research showed was there are some places more than others, where the education that's available is not necessarily meeting the needs of the practicing clinicians.

DH: Right? What are the most effective methods that you've found to reach healthcare professionals in these regions, whether live meetings or virtual sessions or asynchronous?

LS: Let's look at the buckets that I mentioned earlier. There's the top notch academic thought leader people, and there's everybody else. So the top notch academic thought leader folks are the ones who are reading journals on a regular basis, who are attending international congresses, who are participating in internationally available or are seeking out education from international providers that's one group. They have a very different set of needs and also learning expectations than everybody else. So the secret sauce is finding the right collaborative partner that knows about. To those others and knows where they're going to consume the content. So in some places, Don every one of those formats that you asked about works. In some places, it takes a live meeting to ensure engagement in education, whether it be grand rounds or something based in a hospital or a weekly Lecture Series or something like that, in some places, there's no opportunity to have archived versions of digital activities, synchronous activities or asynchronous activities, so there's no one correct answer. It's all environment specific. And there are people who are not waiting for the next invitation to the next CME or CPD activity because they don't have the time. And we asked about this in our research, we said, what are the biggest barriers? And the biggest barriers are time and money, and time is money. So so it may be that they are only participating in education at a time either when they have the ability to do it. So maybe it's offered in their city, in their setting, in their hospital, or when they have a challenge arise in clinical practice, and they seek out the education. But we shouldn't think that there's a there's an active audience that's waiting for the next invitation to the next online activity about obesity, oncology, diabetes, etc. And we also have to remember that there's a big difference between specialists and primary care, GP and their practice environment and their abilities, and actually how some countries view them. Some countries, CME is mandatory for specialists and not available for primary care. And I'd argue it probably needs to be at least as available for primary care, because they have to see more things than the specialists you mentioned. How time is money and vice versa. What is a reasonable lead time to expect when it comes to planning an in person or an online activity for healthcare professionals, you know, in Asia or Africa or Latin America, lead time is a little misleading, because it's it's how and where you're making the education available. And it may be that you want to make sure that you're delivering the education through a partner that, I like to say, owns the audience, so that there's not a ton of recruitment that's necessary. Promotion is necessary, but recruitment isn't because the learners know to go to this resource for education.

DH: So, the lead time may not be as important as a good awareness campaign about the education, and typically, your collaborative partner will know far better than I do what the best way to do it, what the best timing is, what best time of day, what time of year? You know, all of that comes to play. I mean, that's one of the things that I'm taking away here, is that it's very, very difficult to generalize.

LS: It is, and again, I think it ties back to something we said much earlier, which is, we can't expect the learners to behave in other places, the way our learners behave here. And I think that's probably the best nugget that I could give and and that's what you need to really get from your collaborative partners, is, what are the behaviors of the learners? What, where do they go? What? What? What what do they like? What do they not like? What are their expectations? What are the formats? All of these things. I remember the first time I did a digital project with a collaborative partner in Japan. I had my mind wrapped around what I thought would be a good format for the education. And the partner said, yeah, it's not gonna work here. And here's what works, and here's the three different formats that we would recommend, knowing the learners that participate on our platform all the time, and and so again, that goes into the needs assessment, and that becomes the justification for selecting that platform for the delivery of the education, and saying, Okay, well, here's what we can get as outcomes from that platform. What are the outcomes that can be done?

DH: I'm so glad you mentioned outcomes Lawrence, because that's a great segue into my next question, how do we measure the success or impact of CME/CPD initiatives in these international settings that may vary so widely from what we're used to?

LS: I don't think outcomes are geography dependent. Outcomes are learner dependent and educator dependent. So how you develop your education dictates how you could measure outcomes. Higher level outcomes, like levels five and six in our world, may be much easier to well, level five may be much easier to measure in a small country where you're working with an academic partner and you have access to patient level data, and you're not working with such a broad, vast number of potential learners. So it's very specific to where you are and how you design your education. And another factor is in some places, hierarchy can work in your favor. If your activity chairperson is a top opinion leader in that institution or in that country, and they say you will receive a survey in four weeks talking about the impact of this education. And you will your practice. You will fill it out, and you will return it. So again, you have to understand the environment in order to answer the question about outcomes other places, the second the activity is over, if not 10 minutes before they're gone. If you're relying on post activity questions, it's not going to happen. And here's another nugget, even if the activity is delivered in English, if you could ask the questions before, during and after the activity in the local languages of the learners, you will get a higher rate of response. And if you're doing a live activity, if you can do Q and A in local language, my experience was people are far more resistant to ask questions in English, if English is their second or third language?

DH: Oh, yeah, sure. Yeah, it's a much steeper hill to climb. You know, you're not only just translating a new medical concept or health concept, you're also translating into a foreign language. So yeah, sure.

LS: And people don't want to be embarrassed in front of their colleagues, or those who are their bosses and leaders and superiors, so, or anything else you think we should address. There's also another thing, sort of a negative story rather than a positive story. Well, we learn from our failures just as much as we learn from our successes. So, and it was, it was an organization that was trying to bring a new format of education outside the U.S., and it was one that required active participation by the faculty, and the faculty were not willing to be as active regardless of honoraria offered because they their role. Faculty around the world are often not trained in education, so they get into their comfort zone of delivering education in one format, in one style it the way they're most comfortable.

DH: We've all lived that reality for sure. Yeah. So if you take them out of their comfort zone, they don't want to risk losing face in front of the learners and others so. So what I learned was, before entering into an agreement where a format is going to be used for the first time, make sure that I've got the faculty who are willing to participate, who are willing to be trained, who are willing to do something in a new and innovative and unique format, and will it work in that setting?

LS: And and so it brings me to a point that that's another sort of passion point for me. Don, so thank you for asking me if there's anything else I want to talk about. Sure. Sure it is about faculty, okay, what is? What is it about faculty? So, so the core of the the education, after the needs assessment and after the design, is the delivery, yeah, amen, and, and I think we. Need to upskill the faculty that we work with delivering global educational activities, not argue even domestic in some cases, to take them from being and I hate the term KOL, but that's the term we hear all the time, the key opinion leader, and move them into being an educator and to helping them understand that being an educator has a lot of roles, and the biggest role is being a learning facilitator, because it's not about teaching the learners what you know. It's about helping them learn what they need to know. And that's a subtle but important difference, and I can tell you that there was never a proposal that I wrote when I was a provider that didn't have a section that addressed faculty selection and training, because it is so incredibly important. Sometimes we think that the faculty are better educators. Sometimes they are, don't get me wrong. They're intrinsically terrific educators. There are others that ask, What should I do? How can I do it? We need to find those others right and make sure that we're helping them to deliver the education in a way that we need them to deliver the education so that we achieve the outcomes that we're looking for. Often times, lower outcomes are not related to the quality of the education or the content, but how it's delivered.

DH: Sure. Sure, that reminds me when I was first getting started in this field back in 2010/11/12, there was something called the FEI the faculty education initiative, I think it was, and that was a thing maybe 10-12, years ago. It's not as much of a thing today, but, but that was in this country to train faculty in this country, right?

LS: But imagine that's that's us asking our faculty to part as a provider, to go and participate in an educational program on how to be a faculty. That's our job. We have to send them someplace. We should. We're educators. We should help them do that. And I can tell you that I just worked with a health system in the United States who asked me to work with their faculty on an initiative to help improve the outcomes of the education so, so it's possible to do, but I think, and I remember that the faculty education initiative, and I thought it was a great thing, but I also thought the challenge was getting people who are already time constrained to participate in something else. It made it already heavy lift even heavier. So, yeah, right, but, but I think we need to focus on faculty, domestic and international.

DH: Lawrence, hank you so much for meeting with me. It's been a real pleasure speaking with you and to our listeners out there. If you're interested in finding out more about this topic, please be sure to check out the latest issues of the Journal of CME, where you'll be able to find articles authored or co authored by Lawrence on CME?CPD in Middle East and North Africa, Europe, Latin America, East and Southeast Asia and China. And you may also be interested in the summative article that he wrote for a medical teacher, which gives kind of a overview of, I think it was four different regions. Lawrence, did you have any more that you wanted to say?

LS: No and listen, if people have specific questions, everybody knows how to find me. I'm happy to help folks try to find the right path to designing, delivering, implementing and evaluating CPD around the world, because we know the learners and the faculty need it.

DH: Thank you for joining us for another episode of the Alliance Podcast, continuing conversations. If you enjoyed this episode, remember to rate review and subscribe to stay updated on future releases. In the meantime, we invite you to access our wealth of continuing professional development content on the almanac@almanac.acehp.org. Until next time!