SPECIAL ARTICLE

PHILOSOPHICAL CONSIDERATIONS IN HEALTH PROFESSIONS CONTINUING EDUCATION Craig L. Scanlan, Ed.D., R.R.T.

Health professions continuing education is in a state of sprawling disarray Much of this chaos can be attributed to a lack of clarity regarding its goals and purposes. A historicalphilosophical analysis of the aims of continuing education for the health pro fessions provides the basis for clar- thing its major goal orientations. Application of this paradigm to practice he@ emlain under- lying variations in the values, beliefs andprem- bes currently characterizing health professions continuing education and can provide sound direction to those responsible for programmatic and policy-making decisions.

he state of continuing education in the health T professions has been rightly categorized as chaotic.’ Both within and across its many disci- plines, wide variations exist in the focus, content and methods of delively.2,3 Such diversity is due, in part, to the wide range of purposes, goals and objectives ascribed to health professions contin- uing education. Indeed, like continuing educa- tion in general, there exists no single underlying paradigm, no single set of basic assumptions and principles from which all involved can view the field.4-6

Much of this diversity of educational purpose reflects the pluralism of our society as a whole.’ Moreover, intrinsic differences among the pro- fessions themselves accentuate this diversity. Al- though Houle has identified commonalities in educational needs, resources and methods across professional groups, he acknowledges occupa- tional claims to unique expertise and distinctive

traditions.8 Indeeci, various health professional groups exhibit su xtantial diversity in both the settings characterizing their practice and in the point of view, outlook or assumptions underly- ing such practice.

Compounding the effects of societal pluralism and professional differences is the pragmatic orientation characterizing most continuing edu- cation for the heal h professions. Like continuing educators in genei al, those responsible for health professions contiiiuing education are too often concerned with what to do without sufficient examination of m,hy they do it. Overemphasis on skills rather t ian principles, means rather than ends, and details rather than the “big pic- ture” probably accentuates existing confusion over the goals and purposes of continuing edu- cation for health xofessionals.

Without a clea- perspective on the aims of continuing education, it is little wonder that providers and participants alike are often con- fused regarding tlie nature of their r0les.4~6 Lack of clarity on the ::oak and purposes of contin- uing education can also create artificial barriers to cooperation be ween and among professional groups.* Lastly, in the absence of a coherent goals framework, many of the major issues and questions surrour ding the continuing education of health profess onals are destined to remain muddled and uni esolved.

Identifying the various goals characterizing continuing education can help place “what is,” “why it is,” and “what should be” questions in proper perspecthe, thereby giving sound and

Q 1986 by The Regents of the University of California For MOBIUS Vol. 6, No. 3, July 1986

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purposeful direction to continuing education practice.9 Moreover, reflective consideration of what we d o and why we do it can provide the necessary framework for examining our key assumptions regarding the learner, provider, content and process of continuing education.10 Finally, inquiry into the purposes of continuing education can help clarify many of its major issues and, ultimately, provide the basis for more rational and coherent policy-making.” If, as some have charged, the field of continuing edu- cation is in a state of “sprawling disarray,”l2 the solution might well lie in infusing its various institutions with a better sense of purpose.

Values, Beliefs and Principles in Educational Practice

The purposes that an individual o r institution ascribes to continuing education activities rep- resent an outgrowth of the various values, beliefs and principles underlying educational practice. Clearly, the need to incorporate philosophical consideration within the health professions con- tinuing education planning process has long been recognized,13 and most continuing edu- cators make their decisions and fulfill their roles in ways that presuppose certain values and be- liefs. Nonetheless, the field has generally failed to grapple with the assumptions underlying its practice and has yet to fully elaborate a working philosophy or paradigm.%”J

General perspectives Fortunately, the general continuing education

literature provides direction. In contrast to that in the health professions, the general continuing education literature has exhibited a long tradi- tion of philosophical inquiry.14 -19 Given the close relationship between continuing education in general and that applied to the health profes- sions, such inquiry provides a useful foundation for reflective consideration of its underlying goals, purposes and assumptions.

Apps’ synthesis of extant educational philoso- phies provided a framework for analysis of the various values, beliefs and principles underlying continuing education practice.9 Applying the as- sumptions characterizing the major movements in educational philosophy, Apps derived a typ- ology of three continuing education learning models, each oriented toward a different goal (see Figure 1). As is evident, assumptions re- garding the roles of the learner and the provider and purpose of the content differ according to the educational goal being espoused.

Elaborating upon the framework of Apps and of other s~holars,19~20 Darkenwald and Merriam identified five major aims of adult and contin- uing education: 1) to cultivate the intellect; 2) to facilitate individual self-fulfillment; 3) to pro- mote personal and societal improvement; 4 ) to catalyze social transformation; and 5 ) to ad- vance organizational effectiveness.” & with

Figure 1 Apps’ typography of continuing education learning methods. Adapted fiom J. W. Apps, Toward a Working Philosophy of Adult Education. Syracuse: Syracuse University Publications in Continuing Education, 1973.

Essentialist- Pmgressizu3t- Perennialkt Reconstructionkt Mtentialist

Goal Acquiring Content Problem Solving Self-Actualization Role of Learner Recipient of Content Problem Solver Self-searching Role of Provider

Function of Content An End A Means A Means

Translator, Helper, Guide and Counselor Communication Link Knowledge Source

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Apps’ framework, Darkenwald and Merriam in- sist that one’s perceptions regarding the learner, provider, content and process of education are necessarily contingent upon the goal orienta- tion(s) one supports.

Application to health professions continuing education

These various philosophical perspectives, al- though not fully generalizable, do help explain current ambiguities over the purposes and methods of continuing education for the health professions. Diversity of putpose is explained, in part, by the recognition that the selection of educational goals is a normative process, i.e., that the goals one ascribes to continuing educa- tion for health professions, like those chosen for continuing education in general, are dependent upon one’s underlying values and beliefs. Di- versity of method, moreover, is acknowledged as the logical extension of differing purposes.

Bringing order out of chaos, however, requires more than simply acknowledging diversity. In addition to helping explain the eclectic nature of continuing education for the health profes- sions, the literature does much to help clarify its various purposes. Among the most important insights emerging from the philosophical liter- ature are the means-ends distinction and the differentiation of purpose according to intended beneficiaries.

The means-ends distinction differentiates be- tween the instrumental and intrinsic values ascribed to continuing education. The instru- mental perspective views continuing education as a means to a particular end, e.g., remediation, growth or change. This utilitarian focus is most evident in Progressivist and Reconstructionist thought, as described by Apps.

In contrast to this viewpoint is the intrinsic orientation, which values education as an end unto itself Based, in part, upon Essentialist and Perennialist philosophies, the intrinsic values orientation seeks no pragmatic justification for learning; indeed, cultivation of the intellect is

valued for its own sake and considered inde- pendent of any individual, organizational, or social goals.

Further clarifyin,; variations in both the meth- ods and purposes ascribed to continuing educa- tion is the literature’s differentiation of intended beneficiaries. Whereas the individual orienta- tion has long pervaded continuing education, increased attention is now being given to its potential role will hin otganizutions and t h e social system. This expanded conception of pur- pose is attributatsle, in part, to the growing acceptance of the utilitarian perspective as the dominant ideolojy of continuing education. These changing orientations are clearly evident in the evolution of health professions continuing education.

Evolution of :IPurpose in Health Professions Continuing Education

The emergence of various goal orientations in the continuing education of health profes- sionals tends to 3arallel the general develop- ment of the profasions themselves. Although the actual timelint,s vary according to the devel- opmental stage of the professions involved, the trends are remark ibly similar. Variations that do occur are based tr ainly upon differences in pro- fessionals’ practicc: settings and in the point of view, outlook, or assumptions underlying such practice.

Intrinsic values orlentation The priests of primitive society, the guild

members of medi -Val times, and those entering the “learned occupations” after study in the post-Renaissance miversities of Europe all took for granted the need for continuing learnings The knowledge underlying the practice of these original “professionals,” albeit rudimentary by today’s standards, was heavily founded upon then extant theories in the basic arts and sci- ences. Implicit in :he elaboration of such theory was the ongoing search for basic truths, i.e., knowledge for it: own sake. As the traditional

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professions established their collective identity, intellectual inquiry became firmly entrenched as both an intrinsic occupational value and a de- sired characteristic of those aspiring to profes- sional status. That our modern conception of professionalism still embodies the value of on- going inquiry attests to the persistence of this early orientation toward continuing learning. Felch has emphasized the importance of this tradition: “Physicians having the right mindset - the unremitting attitude of intellectual curiosity -practice medical education that is truly con- tinuing.”21 Although the intrinsic values orienta- tion, with its emphasis on rigorous self-directed inquiry and the development and synthesis of basic knowledge (often spanning many discipli- nary areas) lives on among the more innovative practitioners of our modern health professions, its influence is apparently waning. Sir George Pickering has decried the loss of these scholarly habits as the central tragedy of contemporary medical education - “such habits have made medicine into a highly respected learned pro- fession and only the possession of such habits will keep it ~ 0 . ~ ~ 2 2

Instrumental perspective The eighteenth and nineteenth centuries rep-

resented a period of dramatic change for both society and the evolving professions. With the age of rationality came growing demands for pragmatic solutions to the many emerging social problems; with the industrial revolution came an increasing emphasis on applied technical knowl- edge and specialization. Within this milieu, the health professions strengthened their hold over their distinctive knowledge bases and increas- ingly emphasized the utility of content, skills and principles applied to practical ends.

Remediating deficiencies Ironically, the explosive growth of applied

knowledge itself posed a significant problem to the health professions - a problem to which continuing education was kst applied as a prac-

tical solution. In the early 20th century, formal programs of “postgraduate” continuing educa- tion were established to remediate the short- comings then characterizing medicine’s basic professional education system.23 This reparative orientation to continuing education is still evi- dent today among health professions that em- ploy “bridging-the-gap’’ courses to fill the void between theory-oriented basic education and its practical applications. As many of the health professions developed

mechanisms to strengthen their basic education- al preparation (e.g., practicums and internships) and better ensure that neophyte practitioners were indeed fit for the responsibilities of prac- tice (e.g., state licensure and/or professional credentialing), the focus of continuing education shifted from the remediation of deficiencies in prior education to the correction of the time- related gaps in knowledge and slulls. In many and diverse disciplines, “professional obsoles- cence” became an occupational hazard to which continuing education was again readily applied as the cure. The application of continuing edu- cation as a remedial treatment for knowledge and skills obsolescence still represents the dom- inant ideology of many health professions, par- ticularly those based primarily upon technology.

With the acknowledgment that professional knowledge and skills could be subject to time- related obsolescence came the recognition that not all practitioners were either willing or able to maintain the level of proficiency necessary to the delivery of competent services. In a presci- ent observation made some 50 years ago, the Commission on Medical Education concluded that:

The time may come when every physician may be required in the public interest to take continuation courses to insure that his practice will be kept abreast of current methods of diagnosis, treatment and prevention.23

It was not until the 1960s, however, that this predicted shift in the orientation toward contin-

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uing education actually occurred. During this period, labeled by Houle as the “second era” of continuing professional education? a con- fluence of public pressure, governmental inter- vention and professional acquiescence served to transform a relatively simple system intended to facilitate professional updating into a com- plex mechanism designed to provide assurance of professionals’ competence. The impact of this orientation was clearly evident in the develop- ment of the Regional Medical Programs and, ultimately, in the proliferation of state statutes linking a health professional’s right to practice with mandated participation in continuing edu- cation activities.

Although representing an exponential leap in expectations, the competency assurance ide- ology shares much in common with earlier remedial orientations to continuing education. All tend to emphasize gaps between existing and desired performance standards, translating these normative “needs” into remedial-behav- ioral approaches to learning. The most notable difference among these approaches is in regard to content. Whereas earlier remedial orienta- tions focused mainly on knowledge deficiencies, the professional updating and competency as- surance approaches have increasingly empha- sized gaps in proficiency (the ability to perform) or actual performance deficits.

Fostering growth Early dissatisfaction and, more recently, dis-

illusionment with the limitations of the remedial approach to continuing education have prompted some leaders in the field to reconceptualize its role. This reassessment is based upon the grow- ing recognition that a modern professional’s career path is no longer linear and stable, but marked by frequent and often complex changes in responsibilities and/or direction.8 From this perspective, continuing education based solely upon the remedial goals of updating knowledge or assuring minimal competence is clearly insuf- ficient; accommodations must be made to facil-

itate both professional and personal growth and development.

This growth orientation toward continuing education is most evident among health profes- sionals working n collective or hierarchical settings, such as iiurses and allied health per- sonnel. In such sc ttings, shifts in specialization, assumption of supervisory responsibilities and promotion to hig her levels of administrative authority represent common transitions in a professional’s career line - transitions that re- quire mastery of concepts and skills different from those previously necessary to fulfill the practice role.

In addition to professional development, the growth orientation toward continuing education has increasingly recognized the need for per- sonal self-enhanct-ment through the pursuit o f knowledge, skills and sensitivities not directly related to one’s occupational role.8 This per- sonal development perspective is intended to complement the growth orientation by provid- ing opportunities for health professionals to broaden the often narrow viewpoints they bring to bear on their work roles. Although mainly utilitarian in focu:;, the personal development perspective come:; closest to fulfilling the orig- inal intent of the intrinsic values orientation noted previously.

Whereas most -emedial approaches to con- tinuing education are normative in orientation, the growth persprctive emphasizes the unique attributes of botk the individual professional and his or her practice setting. Within this kame- work, learners assume an active role in co- operative partner: hip with providers, applying situational and prcblem-solving strategies appro- priate to their needs, interests, and ambitions.24

Facilitating chanJ:e The health professions, like society as a whole,

are in a constant state of dynamic change. Changing social, tconomic and political condi- tions; alterations in societal and professional values, norms and expectations; and rapid ad-

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vances in technology all have a dramatic impact categorized according to the intended targets upon the role and functions of the modern or beneficiaries of the educational effort. health professions. For the individual profes- sional, such changes often demand significant reform in the nature of one’s practice or the very way in which one views the field. For a profession as a whole, such changes can neces- sitate profound alterations in its delivery system or even a reconceptualization of its collective mission.8 Continuing education is increasingly being applied to facilitate such change.

Examples of this approach, although not yet as common as the remedial or growth orienta- tions, are numerous. Automation of the clinical laboratoly over the last two decades has ne- cessitated a massive reorientation of medical technologists formerly trained in manual test- ing approaches. During the same time period, changes in the philosophical bases of nursing practice have demanded widespread reorienta- tion of professional nurses and nursing educa- tion faculties. More recently, the shift in the Medicare reimbursement mechanism to pro- spective payment by diagnosis-related-groups (DRGs) has resulted in the need for major re- forms in the role and function of hospital ad- ministrators. Likewise, continuing education is being employed as a change agent in medicine’s ongoing reorientation toward health promotion and disease prevention.

Depending upon its focus, the change orien- tation toward continuing education may employ conceptions of the learner, provider, content and process of education similar to o r distinctly different from those underlying the remedial and growth approaches. These various assump- tions depend, in part, upon the intended target for change, i.e., the individual, the organization or the delivery system.

7he indiukiuulpractitioner With the traditional conception of “profes-

sional” representing an autonomous practitioner in an entrepreneurial setting, it is little wonder that most continuing education, until recently, was oriented to the individual. This individual orientation, however, is not to be conhsed with individualized approaches to education. Indeed, the ideology currently dominating con- tinuing education (the remedial approach) em- ploys normative assumptions in identifying group needs, selecting educational methods, and evaluating learning outcomes. Increased attention to the growth and change orientations, of course, is necessitating greater emphasis on truly individualized approaches to both learning and its evaluation.25 -27

The organization With the increasing obsolescence of the en-

trepreneurial mode of practice has come grow- ing recognition of the educational needs of health professionals employed in organizational settings.27>28 In contrast to the individual orien- tation, in which the upgrading, improvement or change in a professional’s practice represent the desired end result of intervention, the or- ganizational approach conceives these impacts as only intermediary steps toward a further end, i.e., increasing the effectiveness of the organi- zation. In this context, the distinctions drawn by Nadler29 among an organization’s training, education, and development activities closely parallel the various assumptions underlymg the deficiency, growth and change orientations pre- viously described.

The delivery system A professional delivery system represents a Intended beneficiaries

The instrumental goals of continuing edu- complex combination of interacting structures cation, i.e., remedying deficiencies, fostering and processes ultimately designed to provide growth, and facilitating change, may be further service to a targeted group. Shareholders in a

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professional delivery system include the profes- sionals themselves, their formal organizations, educational institutions and collegial associations. Stakeholders in the system, i.e., those providing the capital, having needs for or making demands upon the system, include society as a whole, its individual members, and the government.

A professional delivery system is effective to the extent that it meets the needs and expecta- tions of its stakeholders. Unlike its individual and organizational counterparts, therefore, con- tinuing education oriented toward correcting, improving, or changing a professional delivery system must recognize and address the needs and expectations of those with a stake in its operation. Despite widespread acknowledgment of the need for this broadened perspective? only dentistry formally requires that the goals of continuing education providers, in addition to meeting the needs and interests of the profes- sion, address the needs of the public at large30

Application to Practice Evolving from the literature then, are nine

major goal orientations toward health profes- sions continuing education, each based upon different values, beliefs and premises (refer to Figure 2).31 Although the updatinglcompetency assurance orientation (#1) currently dominates continuing education practice, all nine perspec- tives are operative in the field, with many pro-

Figure 2 Goal orientations of health professions' continuing education.

viders simultaneously subscribing to multiple approaches.

Besides providing the opportunity to more clearly conceptuzllize what we do and why we do it, examirlation of these various goal orientations can gjve sound direction to prac- tice. Practical implications arising from the model include bc)th programmatic and polity considerations.

Programmatic considerations Program develDpment should begin with

careful consideratton of purpose.13 Subsequent planning, implementation and evaluation activi- ties should reflect the goal orientation(s) selected and be consistent with their underlying assump- tions. A comparative analysis of three different goal orientations to continuing education in a health services agency will be employed to chi@ these important clinsiderations.

Identifving putpclse Continuing education in a health services

agency common14 falls into one or more of three major categories: professional develop- ment, organizational development, and staff training. Although there is considerable overlap among these activities, each approach clearly represents a different goal orientation. Profes- sional development activities best exemplify the individual growth orientation (#2). Organiza-

Remedying Deficiencies

UpdatingKompe tency Assurance

Employee 'Raining

Systems Deficit

Individual Orientation # I

Organization Orientation #4

System Orientation # 7

Fostering Growth

Orientation #2 Individual Growth Orientation #5 Employee Education Orientation #8 Systems Improvement

Facilitating Change

Orientation #3 Professional Reorientation Orientation # 6 Organizational Development Orientation #9 Systems Reform

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tional development efforts clearly represent the organizational development orientation (#6). Staff training activities, especially those designed to correct shortcomings in the delivery of health services, best characterize the systems deficit orientation (#7).

Planning Once a clear distinction is drawn among goal

orientations, clear differences emerge in one’s approach to planning. Under the assumptions of the individual growth orientation, the “content” of professional development activities would be generated by individualized assessment of felt needs, interests and ambitions. Needs assess- ment for organizational development would fo- cus on more objective determination of changes necessary to increase the effectiveness of the institution in achieving its overall goals, with major emphasis on its key shareholders, i.e., the professional staff and administration. Content underlying staff training processes would evolve from the assessment of deficiencies in the deliv- ery system, provided, in part, by its key stake- holders, i.e., the patients or clients.

Implementation Implementation of professional development

activities would be heavily founded upon prin- ciples of social-developmental psychology and include individual and collaborative group efforts to enhance the professional and/or personal growth of those involved. Implementation of organizational development activities would be based upon principles of organizational theory and include methods such as team building and action research. Implementation of staff train- ing activities would employ the assumptions underlying educational systems theory and in- structional technology, and include remedial- behavioral approaches to learning and improved performance.

Evaluation Under the individual growth orientation, eval-

uation of professional development efforts would focus on assessing individual‘s enhanced profes- sional and/or personal capacities, using both objective indicators and self-assessments, Eval- uation of organizational development activities would strive to document the effectiveness of instructional change in terms of progress toward goal achievement. Evaluation of training efforts would employ assessment of patient records, incident reports, morbidity/mortality statistics and patient surveys as multiple indicators of improvements in the delivery of services.

Policy considerations Many of the ambiguities involved in contin-

uing education policy formulation arise fiom lack of clarity or consensus regarding goal orien- tations. Current debates over mandatory contin- uing education and its effectiveness are good examples.

Manahtory continuing education The debate over mandatory continuing edu-

cation (MCE) represents a classic example of values in conflict. Those supporting MCE for health professionals base their arguments upon the assumptions and premises underlying the remedial approaches to continuing education, i.e., goal orientations 1, 4 or 7 Those opposed to MCE base their arguments on the values and principles inherent in the growth orientations to continuing education, i.e., goal orientations 2, 5 or 8. The power or validity of opposing evidence notwithstanding, resolution of the issue will not be achieved unless or until the parties reach agreement on what constitutes the “appropriate” goal for continuing education. In the absence of such consensus, policy decisions regarding MCE will continue to be based upon political or economic exigencies, as opposed to more fundamental values premises.

Effectiveness of continuing education Clear differentiation of the various goal orien-

tations also helps explain why both the research

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literature and rhetoric on the effectiveness of continuing education present so many conflict- ing viewpoints. All too often, the measures employed to assess the effectiveness or impact of continuing education are inconsistent with the premises underlying the goal orientation of the intervention. A classic example of such in- congruency is the oft-cited study on the effec- tiveness of continuing medical education con- ducted by Lewis and Hassanein.32 The primary intervention scrutinized by the researchers was “traditional” continuing education offered by a medical school- traditional in the sense that it focused on the principles underlying the up- dating/competency assurance goal orientation (#l). The measures of effectiveness chosen, however, (incidences of specific procedures and mortality in the population), represented criteria most appropriately used to assess outcomes of the systems-deficit orientation. Similar flaws in problem definition are likely to persist as long as we lack clarity regarding the premises under- lying the various goal orientations to continuing education. It is time that we stop asking un- answerable questions such as, “Is continuing education effective?” and start addressing the validity of the model’s components, i.e., “Does continuing education based upon the assump- tions inherent in a given orientation achieve the goal intended?”

Conclusion As stated by Kohlberg and Mayer, “the most

important issue confronting educators and ed- ucational theorists is the choice of ends for the instructional process.”20 Within this context, the various goal orientations currently charac- terizing continuing health professions educa- tion have been elaborated and their practical implications identified. I hope that the model described here will assist continuing education practitioners to articulate their own “working philosophies” more clearly and, ultimately, strengthen the important link between purpose and practice. 00

REFERENCES/FOO”NOS 1. Moore DE. Evolvin 4 approaches to continuing medical

education: Efforts to eihance the impact on patient care. In: Green JS, GrosswaLl SJ, Suter E, Walthall DB, eds. Con- tinuing education for tlie health professions. San Francisco: Jossey Bass, 1984.

2. Kempfer H. What is continuing education? Lifelong Learning 1979 11:23-21. 3. Ruhe CH. What is tlie status ofcontinuing education for

health professions? MBDius 1982; 2(2):8-14. 4. Manning PR. Contmuing education in the health sci.

ences: Can we change he paradigm? Mobius 1982; 2(2):5-7. 5. Lloyd JS. Response to historical review by Stephen

Abrahamson. Mbbius 1984; 4(4):18-19. 6. Corbett TC. The iinpact of continuing medical educa-

tion on quality o f care. Implications of the CME evaluation literature. In: LeBreton PP, Bryant VE, Zweizig DL, et al., eds. The evaluation of continuing education for professionals: A systems view. Seattle University of Washington, 1979.

7. White TJ. PhiIosoy(hica1 considerations. In: Smith EM, Aker GF, Kidd JR, eds. Handbook of adult education. New York: Macmillan, 1970. 8. Houle CO. Continliing learning in the professions. %in

Francisco: Jossey-Bass, 1980. 9. Apps Jw. Toward a working philosophy o f adult educa-

tion. Syracuse: Syracu: e University Publications in Contin- uing Education, 1973. 10. Geiselman LA. Sorie lessons from the past and future. Mobius 1984; 4(4):124-26. 11. Darkenwald GG, hlerriam SB. Adult education: Fountla- tions of practice. New York: Harper and Row, 1982. 12. Stern MR. A disorc erly market. In: Stern MR, ed. Power and conflict in continL ing professional education. Behont , CA: Wadswonh, 1983. 13. Hutchinson DJ. Tlie process of planning programs of continuing education I& health manpower. In: Charters AN, Blakeiy RJ, eds. Fosterng the growing need to learn. Wash- ington: US Governmeiit Printing Office, 1974. 14. Knowles MS. Phi1,)sophical issues that confront adult educators. Adult Educ.ition 1957; 7:234-44. 15. Lindeman EC. Th,? meaning of adult education. Mon- treal: Harvest House, ! 961. 16. Kallen HM. Philosophical issues in adult education. Springfield: Charles C. Thomas, 1962. 17. Bergevin P. A philc ,sophy for adult education. New York: Seabuty, 196% 18. Lawson KH. Phi1o:;ophical concepts and values in adult education. Nottinghani, England: Barnes and Humby, 1975. 19. EUias J, Merriam SM. Philosophical foundations o f adult education. New York: Kreiger, 1980. 20. Kohlberg J, Mayei R. Development as the aim o f etlu- cation. Harvard Educ lev 1972; 42:449-96. 21. Felch WC. CME c r EME? Alliance CME Almanac 1981; 3(4):3.

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22. EUis JR. The Pickering survey. Lancet 1978; September

23. Sheyard CR. History of continuing medical education in the United States since 1930. J Med Ed 1960; 35:740-58. 24. Nichols WH, Stewan CJ. Assessment ofthe client-centered planning approach in continuing education for public health professionals. Mobius 1983; 3(3):12-21. 25. Hotvedt M, Gunzburger L. Individualized CME. Mobius 1984; 4(4):83. 26. Richards RIG Physician learning and individualized CME. Mobius 1984; 4(4):165.70. 27 Green JS, Gunzburger LK, Surer E. Interaction o f contin- uing education clients and providers: Increasing the impact of education. In: Green JS, et al., eds. Continuing education for the health professions. San Francisco: Jossey Bass, 1984. 28. Lanzilotti SS, Finestone AJ. Application of the continuing education systems project: CME as organizational develop- ment. Mobius 1985; 5(2):18-27 29. Nadler L. Developing human resources. Houston: Gulf Publishing, 1970. 30. American Dental Association. Guidelines for continuing dental education. Chicago: American Dental Association, 1974. 31. For simplicity, the intrinsic values perspective is sub sumed under the individual growth orientation (#2). 32. Lewis CE, Hassanein Rs. Continuing medical education: An epidemiological evaluation. New Engl J Med 1970; 282:

2:512-13.

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NOTE This article is based upon a chapter in ptoblems and Pros- pects in Continuing prosesCioonal Education (New Directions for Continuing Education Series, No. 27), edited by Ronald M. Cervero and Craig L. Scanlan and published by Jossey- Bass (1985).

Craig L. Scanlan, ELD., RRT. Dr. Scanlan is associate dean for Academic and Clinical Affairs in the School of Health Related Professions at the University of Medicine and Dentistry of N e w Jersey ( U M D NJ), Newark. He is also adjunct assistant professor in the Graduate School of Education at Rutgers University. His current research interests include participation in continuing professional education, professionalizatiun and professional ethics, accreditation and goal-based evaluation. His health professional experience is as a respiratory therapist.

Requests for reprhts: Craig L. Scanlan, Ed.D., R.R.T., As- sociate Dean, Academic and Clinical Affairs, School of Health Related Professions, University of Medicine and Dentistry of N e w Jersey, 100 Bergen Street, Newark, N e w Jersey 07103.