Place matters in physician practice and learning.

Since the early 1960s, most discussions about the improvement of continuing medical education (CME) have begun by seeking a better understanding of how physicians learn. The goal of this movement has been to put physician learners and their learning needs, not new research findings, at the center of the educational process. This has led CME away from the update model of education and into many innovative and exciting educational developments. However, as the conditions of medical practice have been changing in the past 20 years, the possibilities and conceptions of CME have also changed. Many in medicine and CME now recognize that the real world of physician decision making takes place in a highly charged political-economic context, where the interaction between the patient and physician is perhaps the least complex element. From this fundamental starting point, an emerging discourse has begun in CME that addresses physicians' changing work environments, the accountability schemes and financial incentives built into medical practice, and the importance of physicians' community of peers in making practice changes. We need to build on these observations to change the focus from "how physicians learn" to "where physicians learn." From this new perspective, physician practice and learning are seen as fundamentally social acts, and our attention is drawn to all of the ways in which "place matters." Attention to where physicians practice and learn can be used to improve CME.