Response to letters for Doctors further from Medical School Graduation John J Norcini, 1 John R Boulet, 2 Amy Opalek 1 & W Dale Dauphinee 2 Editor, We certainly agree with Lee and Chong’s observation in their response 1 to our paper 2 that continuing professional development (CPD) and continuing medical education (CME) are keys to improved performance. However, there is much more we need to know and do in order for those interventions to have the desired effects. What doses of CPD or CME are required, for whom, at which intervals, and focused on what content? Historically, participation in CPD and CME has been of low intensity, voluntary and self-directed. We envision some form of periodic, mandatory, formative, practice- based assessment that is designed to identify strengths and weaknesses and thus to drive participation in CPD or CME in specific and appropriate areas until a satisfactory level of performance is achieved. Traditional CPD and CME have focused on individuals, who certainly represent a large part of the equation. However, CPD and CME aimed at improving team performance and team hand overs in clinics and institutions are also required. We also picture this wider approach as needing to be driven by a system of periodic, mandatory, formative, practice- based assessment and linked with educational interventions. That said, the assessment of teams is in its infancy, as is the development of educational experiences for teams. This presents several challenges, but also opportunities for research and development. Finally, one of the major impediments to the effectiveness of CPD and CME initiatives is the willingness of health care professionals to embrace them. Programmes in CPD offered by specialty boards in the USA have met with considerable resistance, yet the results reported in our paper clearly indicate that the present system is not working. 2 Current CPD and CME programmes need to be better adapted to clinical practice, to be regarded as associated with professionalism by patients and providers, and to be both required and supported by health care systems. We also very much appreciate the comments of Chua and Patil. 3 The 2005 literature review 4 included only seven studies that focus on patient outcomes and hence we certainly agree that this area, which is critical to quality of care, should be explored more fully. Although the majority of patients with the conditions we studied were treated by general internists and family doctors, 2 we also agree that it is important to explore ambulatory and chronic conditions, as well as the care offered by different medical specialists. In addition, we fully support the call for prospective studies. However, it will be decades before the results of such studies can begin to inform practice and we do not believe we can wait that long. REFERENCES 1 Lee JC, Chong JW. Can continuing professional development mitigate adverse patient outcomes. Med Educ 2017;51 (9):978. 2 Norcini JJ, Boulet JR, Opalek A, Dauphinee WD. Patients of doctors further from medical school graduation have poorer outcomes. Med Educ 2017;51 (5):480–9. 3 Chua A, Patil V. Response to: ‘Patients of doctors further from medical school graduation have poorer outcomes’. Med Educ 2017;51 (9):976. 4 Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142 (4):260–73. 1 Foundation for Advancement of International Medical Education and Research (FAIMER), Philadelphia, Pennsylvania, USA 2 Clinical and Health Research Group, Division of Clinical Epidemiology, McGill University, Montreal, Quebec, Canada Correspondence: John J Norcini, FAIMER, 3624 Market Street, 4th Floor, Philadelphia, Pennsylvania 19104, USA. Tel: 00 1 215 823 2170; Email: jnorcini@faimer.org doi: 10.1111/medu.13399 977 ª 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education; MEDICAL EDUCATION 2017 51: 974–978 letters to the editor