Continuing education is a challenge for primary care physicians.1–3 The changing emphasis on long-term conditions, the escalating cost of health care delivery, and the impact of new knowledge, new technologies and new treatments, all clash with daily pressures to deliver the highest possible quality of care to our patients. In this issue of the PCRJ, two papers explore models of delivery of education to primary care physicians in general practice in Australia and Denmark.4,5

The Australian study4 reports on a study to translate the methodology of Physician Asthma Care Education (PACE), developed by Professor Noreen Clark in Michigan, USA, with adaptations to Australia. PACE teaches clinicians about current best clinical practice in asthma, communicating more effectively with patients, and how to support patients' management efforts. An interactive seminar lasting for five hours over two sessions with trusted knowledge experts, video resources, case studies and advice on access to remuneration formed the educational intervention. The study was funded by the Australian Government, at a cost of AU$2,000 per practitioner trained.

The Danish study5 focused on COPD education delivered in the general practitioner's own practice. The principal intervention was a 3-hour teaching session with a respiratory specialist, supported by up to five additional visits from a representative of the sponsoring pharmaceutical company focusing on coding of patients, spirometry and device technique. There are some questions about the identification of patients with COPD based solely on prescribing records, but as the purpose of the study was to demonstrate a change in practice as a result of the educational intervention, the authors argue that the matched control group methodology minimised possible confounders. The cost of training was not recorded.

Both studies4,5 demonstrated positive outcomes. The Danish study showed a trend that the educational intervention had a positive impact on adherence to guidelines, but the findings were only significant for increased spirometry testing in a subgroup of practices identified as having a high potential for improvement. The PACE study showed that the US programme could be translated to Australia and successfully implemented, but longer term health outcomes shown for patients in the US programme could not be evaluated in the time available. However, we should critically examine the continuing education of primary care physicians in a broader, global context.

The translation of a physician's knowledge to the attainment of better health outcomes by his or her patients is, on the one hand our raison d'être, and on the other, a small element in a complex series of interactions that are necessary to achieve those results. Informed patients increasingly expect to be at the centre of care, and expect to be involved in decision-making in relation to their health.6 Advances in mobile communications technology will result in most people in the world having access to high quality information, and this will open up exciting and challenging opportunities7 for the delivery of health care advice remotely. Traditional cultural influences that underpin current health and illness behavior will diminish, with the sharing of common global aspirations. Simultaneously, the emergence of teams to deliver care to people with long-term conditions8 will enhance the role of the primary care clinician, from ‘care provider’ to ‘care coordinator’.

Similarly, the applicability to primary care of clinical practice guidelines developed in settings remote from primary care is being questioned — as highlighted by D'Urzo in his editorial in this issue, and by Gruffydd-Jones recently.9 Even in specialist groups, clinical practice recommendations by bodies such as the UK National Institute for Health and Clinical Excellence (NICE) are not universally adopted.10

Education per se leading to changes in clinical practice has been shown to be most effective when delivered as a parcel of multifaceted interventions,1–3 but there is little understanding of how readily models that are successful in a single region or culture can be adapted to other regions, cultures, health funding systems or provider groups.11 Inevitably, the cost of delivery will limit the way in which education can be delivered. While many countries will eschew pharmaceutical company assistance, other countries may not be able to afford programmes that are not subsidised12 — another manifestation of Tudor Hart's Inverse Care Law?13 The efficiency of targeted education noted in the Danish study is worthy of further consideration — aiming to provide preferential access to those practitioners who most need the education.

The nature of the daily work of the primary care practitioner is shifting from the acute management of diseases in a single episode of care, to prevention and the extended management of people (and communities) with a diverse range of long-term conditions.14 Accordingly, models of education may need to address the common generic elements of chronic disease management15 — assessment, treatment, monitoring and communication — with modules relating to best clinical practice for a specific disease.

Are our methods of educating health professionals sufficiently robust to cope with these pressures? And are our institutions — academic and professional — sufficiently flexible to support quality education leading to affordable quality outcomes in the face of the pressures of global social marketing?

There is, therefore, a role for communities of practice like the International Primary Care Respiratory Group (IPCRG) and its member bodies to explore innovative ways to achieve our goal of improving the respiratory health of people worldwide. The IPCRG E-Quality programme,3 launched in 2012, seeks to support small scale educational initiatives, and to demonstrate changes in clinician behaviour and improvement of health outcomes. Strategic alliances with other groups such as Wonca, foundations seeking to effect improvement of care or to implement proven strategies to improve health of populations, consumer organisations, and specialist groups, will add to the momentum for change. In this way, we hope to be able to meet the challenges involved in the continuing education of primary care physicians.