The Journal of Continuing Education in the Health Professions, Volume 24, pp. 197-204. Printed in the U.S.A.

Copyright 0 2004 The Alliance

for Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Association for
Hospital Medical Education. All rights reserved.

Review
Commitment to Change: Exploring Its Role in Changing
Physician Behavior through Continuing Education
Jacqueline G. Wakefield, MD
Abstract
Statements of commitment to change are advocated both to promote physician change and to
assess interventions designed to promote change. Although commitment to change is only one
part of a complex process of change, recent progress has established a solid theoretical and
research base to support this approach. Studies have demonstrated that it can be used effec-
tively with many different types of educational activities and that statements of “plans to
change” practice can predict actual changes. The importance of follow-up as part of the com-
mitment to change model is becoming clearer; although questions remain about the most
effective process to accomplish this and the optimal timing. Further research is needed to
establish the effectiveness of the commitment-to-change approach itselj as well as to better
understand thefunctions (and thus theforms) of the different components of the commitment-
to-change model.
Key Words: Commitment to change, continuing medical education (CME), continuing pro-
fessional development, intention to change, practice change, program evaluation, reflection

Introduction
Statements of commitment to change (CTC) have
been advocated to stimulate changes in practi-
tioner behavior and to assess the effectiveness of
different educational interventions. 1-7
The CTC model, as originally described by
Purkis,’ has two steps. In the first step (the CTC
statement), physicians are asked a question such
as “As a result of this educational activity, do you
plan to make any changes in your practice? If so,
please describe the specific changes.” Explicitly
indicating an intention to change then becomes an
important ingredient in the process of ~ h a n g e . ~ - ~ effectively, clarifying our understanding and
In the second step (the follow-up), participants are
surveyed some weeks or months later and asked
if the intended change was made and, if not made,
what prevented the change.
Although the first step in this model is widely
used in continuing medical education (CME)?’
much is still unclear about the influence of process
and context when CTC are solicited. Also, under-
standable concern has been raised that partici-
pants will tire of providing this information if it
is routinely asked at every CME activity.6In addi-
tion, the second step often is not enacted by plan-
ners, an omission that may jeopardize the overall
effectiveness of the CTC strategy.
Over the past decade, studies of CTC have
added to our knowledge, but to use this strategy
answering some of the following questions will
become increasingly important.
What Do We Know?

DI: Wakefield: Director of Module Development and
Research, The Foundation for Medical Practice Education,
McMaster University, Hamilton, Ontario.
Reprint requests: Jacqueline G. Wakefield, MD, The
Foundation for Medical Practice Education, McMaster
University, 1280 Main Street West, DTC Basement,
Hamilton, ON L8S 4L8.
CTC Can Be Used in Many Ways
CTC has been used across a broad range of top-
ics and with a variety of educational activities-
from organized journal r e a d i ~ ~ gto, lectures,1°
~,~ to
small-group sessions,11 to short courses and

197
 Role of Commitment to Change in Changing Physician Behavior

symposia.1 , 6 ~ 1 2CTC have been used successfully
in stimulating reflection and change, in CME,
planning, and in program evaluation (Table l).1J97J:’
CTC Change Can Predict Actual Change
learning how to make the change and deciding or
planning to change (the focus of the CTC strategy)
are necessary, other features of change and the CTC
strategy have a significant influence on subse-
quent a d o p t i ~ n . ~*’ x ~ ~ ~ ~ *

Consistently, studies have shown that physicians
who make a CTC are more likely to make prac-
tice changes than physicians who do not, sug-
gesting that a CTC may be a marker for an actual
change in practice. Most studies have reported
rates of “compliance” with expressed CTC rang-
ing from 47% to 87%.1J,7,10 However, because
these studies used only self-reports to document
outcomes, concern was expressed that the results
were invalid because self-reported change may sig-
nificantly overestimate actual performance.l4Stud-
ies of CTC in prescribing,1’.12 using more objec-
tive outcome data, have partially dispelled this
concern. The magnitude of actual practice changes,
however, may be considerably lower than sug-
gested by self-report-only studies. For example, in
the Better Prescribing Project,” the relative changes Few studies have examined the impact of the CTC
in prescribing ranged from 25% to 57% (depend-
ing on the condition), whereas the absolute change
in prescribing was a more modest 14.7% overall.
CTC Are Only One Part
of a Complex Process of Change
Changing clinical practice is complicated, with
many interwoven components. Models of physi-
cian change, derived largely from interviews with
physicians in practice, have identified “stages”
in the change process.lS-l8Although the models
vary somewhat in the description and number of
stages, all involve awareness of the value of poten- CTC groups. They concluded that “requesting
tial change, development of an image of an alter-
native practice, learning what is needed for the
change, deciding to make the change, and then
implementing and adapting the new way of prac-
tice. It is extremely unlikely that any single edu-
cational intervention can address all of these stages participants in a geriatrics short course to either a
and effect a specific change in the clinical prac-
tices of the majority of parti~ipants.~J~~~~~~Althoughreported changes in the CTC group at 1 month was
What Do We Need to Know Better?
Why and How Do CTC Work?
When considering CTC as an intervention to pro-
mote change, theoretical foundations and con-
ceptual models exist to inform the ~ t r a t e g y . ~ . ~
These include goal setting, promise keeping,
reflective learning, the transtheoretical model of
change, and the PRECEDE-PROCEED
mode1.4,s,9,1”.11,13,22
However, the role and influ-
ence of each of these on components of the CTC
process remain unclear.
How Effective Is the CTC Process?
approach itself by randomly assigning partici-
pants to either be asked or not asked about any
plans to change as a result of the course. Curry and
PurkisI2 randomized 61 participants at a 2-day
therapeutics course into four groups: two groups
(CTC) were asked about plans to change and two
groups were not asked (non-CTC). Using auto-
matic duplicate prescription pads and self-reported
changes, they found that although physicians in the
CTC groups did change prescribing “in the direc-
tions indicated by their commitments” (p = .04 and
p < .001), there were no significant differences in
actual prescribing between the CTC and the non-
participants to give commitments to make specific
changes adds little to the effectiveness of the CME
course in producing behavior change.”
The study by Pereles and her colleagues3
yielded different results. They also randomized 17
CTC or a non-CTC group. The number of self-

198
 Table 1 Overview of Commitment to Change Studies*
Study CTC Request
Purkis’ (1982) “As a result of what you
2-d “pain” symposium learned in this course,
what do you propose to
change in your practice?”
Curry and Purkis’* Asked to think through
(1986) course and to make CTC
2-d general review in prescribing
course in therapeutics practice as result
Jones2 (1990) Asked to list specific clinical
w 2-d national practice behaviors they
u)
u) nephrology planned to initiate as result
conference of information gained
during conference
Pereles et aL3 (1997) Asked to make written CTC
1-d short course in care using 1-page contract,
of elderly; combination listing future changes that
of didactic and they were prepared to
small-group workshops commit to make as a result
of the course
Mazmanian et a1.I0 “Upon deciding to attend
(1998) this CME activity, did you
I-h lecture on have any intention of
cardiovascular risk changing your clinical
practice related to multiple
risk factor management for
Participants CTC Follow-up: Methods and Results
Invited N = 39 MDs-CTC n = 28 (72%) At 2 mo
All 39 attendees asked to Number of CTC = 67 Mail survey (personal CTC card):
complete CTC card (average = 2.4) self-report; return rate 100%
Physicians from various 93% (26/28) MDs-CTC reported at
disciplines least one change; 63% of CTCs
CTC strategy used with implemented; 27% “failed” because
all participants lack of suitable cases
Invited N = 103 MDs-CTC At 2 mo for CTC groups, 4 mo for all
Participants n = 61 (59%) n = not reported groups
Primary care physicians Number of CTC not Mail survey (self-report) and
Random allocation to CTC reported duplicate prescriptions
or non-CTC groups (average = 2) Actual change in behavior
“Not all of these” related “significantly correlated” with CTC,
to key points or “to but no evidence that CTC process
course content at all” itself increased behavior change
N = not reported MDs-CTC n = 53 (63%) At 3 mo
Participants n = 84 Number of CTC = 132 Mail survey (personal CTC):
3
??
cc
(completed CTC form) (average = 3.2) self-report; response rate = 73% h
Nephrologists/internists 2
Number of CTC among (61/84) a
CTC strategy used with respondents = 91 51% (46/91) CTC implemented
all participants
N = 26 MDs-CTC n = 7 At 1 and 3 mo
Participants n = 17 MDs-non-CTC n = 9 2 interviews: self-report; response
Family physicians Number of CTC = 15 rate = 94% (16/17)
Randomized factorial (average = 2.14) Type of changes described; changes
design with random in both groups but CTC group
allocation to either CTC 3 X more at first follow-up;
group or non-CTC group strong trend toward more changes in
CTC group but did not reach
statistical significance (small sample)
Follow-up increased number of
changes in both groups
N = 738 MDs-CTC n = 173 At 3 0 4 5 d
Participants n = 299 (58% of participants; Mail survey: self-report; response
(40.5%) who completed 23.4% of all attendees) rate 41.8% (125/299 participants)
CTC Total number of CTC 72% (90/125) respondents reported
Primary care physicians and average per making changes; this represented
(family physicians, respondent not reported 30% of all 299 participants
 Table 1 continued Overview of Commitment to Change Studies”

Study CTC Request Participants CTCs Follow-up: Methods and Results

cardiovascular disease?’
“Do you intend to make any
changes in your practice as
a result of this activity?’
Dolcourt7 (2000) Given form at start of
Annual 3-d conference with request
lecture-based course to self-identify and (at any
with “breakout sessions” time during the course) write Physicians (pediatricians
on the form the changes
they intended to make or
c3
0 to influence others to make
0 during elapsed time in follow-up
Mazmanian Immediately after session,
et a1 (2001)26 all participants asked to
CME conference with specify a change they
lectures and Q-A intended to make in practice Physicians randomly
sessions on three and to designate a level of
different clinical topics commitment to that change
general internists,
gynecologists)
26 schools ( I 3 matched pairs):
random allocation of pairs
to program in which
participants received or
did not receive information
about barriers to practice
change
CTC strategy used with all
participants
N=61
Participants n = 43 (70.5%)
who completed CTC form
and family physicians),
nurses, advanced practice
nurses, physician assistants
CTC strategy used with all
participants
Total N = 110
Participants n = 88 (80%)
(Completed initial CTC)
assigned to signature or
non-signature groups
Physicians who made CTC were
significantly more likely to report
change than those physicians who
did not make CTC: 47% (81/173)
vs. 7% (9/126); p < ,001
Information about barriers did not
increase successful changes in
practice
MDs-CTC n = 43 At 1 mo
(70.5% of all Mailed questionnaire with personal
study MDs) CTC: self-report; response rate
Mean number of CTC; 76.7% (33/43)
range 3.6-3.9 54% of intended changes
accompiished; “Iailed” mosl o k n
attributed to lack of suitable cases
MDs-CTC n = 75 At 2 and 3 months
(85% of participants) Mail survey: self-report; response rate
There was no significant = 73% (64/88)
difference between the 55% (41/75) reported success in change
signature and Physicians expressing intention to
non-signature groups change were significantly more
#CTCs = not reported likely to report change on follow-up
(p = ,035).
There was no significant difference
between signature and non-signature
groups

Lockyer et aL6 (2001) “As a result of this workshop, N = 352 MDs-CTC n = 344 At 6 mo
Day-long short course identify five concrete, Participants n = 344 (97.7% of all study MDs) Mail survey: self-report; response
on sexual dysfunction measurable changes you will (97.7%) Number of CTC = 1,635 rate 57.3% (197/344)
employ in your practice.” 2 1 centers (average = 4.8) 66.5% (602/935) CTC completely
CTC strategy used with “Significant correlation” implemented
all participants with course content
 Table 1 continued Overview of Commitment to Change Studies”

Study CTC Request Participants CTCs Follow-up: Methods and Results

Green et al.25(2003) Asked to identify up to 3 N = 26 MDs-CTC n = 24 At 3 mo
1 evening; integrated “changes that you will Participants n = 24 (92%) (92.3% of all study MDs) Mail survey: self-report; response rate
CME and teaching employ” in practice as a who completed CTC Average CTC 2.4 92% (22/24)
skills in genetics result of this workshop Physicians (general internal (teaching), CTCs implemented
medicine) 2.0 (clinical) Fully 38%
CTC strategy used with Partial 41%
all participants Failed 21%
(32% lack skills; 60% lack
suitable patient)
Wakefield et al.” (2003) For each session, N = 413 MDs-CTC n = 5 1 At 6 mo, actual prescribing records
1- to 2-h small-group asked to describe if Participants n = 207 per condition from provincial registry
sessions, each session Planning to change (50.1%) (52.6% of all study No reminders to participants
involving discussion Considering changing Family physicians MDs) If CTC expressed, physicians
of one “module” on Confirmed current practice Randomized factorial design, Number of CTC = 64 significantly more likely to change
a selected clinical Not convinced with control groups using per condition actual prescribing (absolute change
condition modules on different (average = 1.24; of 14.7%, 95% CI 9.8%-19.5%)
h, clinical conditions range 0-3)
3
?T
0 (h
Y
CTC strategy used with k?
all participants !2
Q
White et al.I3 (2004) Asked to list up to 3 things N = 602 MDs-CTC n = 291 At 3 wk, “Memo-To-Myself’ mail
20 consecutive but they intended to change Participants n = 291 (48% of all study MDs) reminder
diverse CME programs (48%) who completed Number of CTC = 803 At 6 mo, mailed summary of CTC
CTC forms (average = 2.8) reported by peers
Family physicians No data collected as part of follow-up
CTC strategy used with
all participants
Cole and Glass8 (2004) “What change(s) (if any) Invited N = 170 MDs-CTC n = 37/138 At 2 wk
Journal reading for do you plan to make in your Participants n = 138 (26.8% of all study Survey regarding learning
CME credit practice as a result of reading (81%) participants) progressions; if CTC made,
any of these 3 articles?’ Random sample of physicians Number of CTC = 45 physician significantly more likely
in various specialties (average = 1.2) to report learning progression
invited to participate Learning progression: (RR 1.14, 95% CI 1.06-1.22)
CTC strategy used with “ready to apply” = 134
all participants (average = 3.6)

* The studies included in this table are those that described study design, methods, and some measure of CTCs and that also included information about follow-UP.
CI = confidence interval; CME = continuing medical education; CTC = commitment to change; MD = medical doctor; MDs-CTC = physicians who made commitments to
change; RR = relative risk.
 Role of Commitment to Change in Changing Physician Behavior
three times that of the non-CTC group, but the dif-
ference did not reach statistical significance, pos-
sibly because of the small sample size. At the
3-month follow-up, the changes in the CTC group
were sustained, whereas the number of changes
reported by non-CTC physicians had doubled-
perhaps as a result of being asked about practice
changes at the 1-month follow-up. They con-
cluded that behavioral change “is facilitated when
physicians have committed to make a change.”
Given the lack of clear evidence, the effec-
tiveness of the CTC approach is not known. Addi-
tional studies like these are very much needed.
How Does the Process and the Question
Used to Solicit CTC Influence Results?
The nature and intensity of the educational activ-
ity may have an influence on CTC. In some stud-
ies linked with structured journal reading or brief
CME lectures, less than half of the participants
completed the CTC section of the forms,8,’0
whereas in small-group sessions or short courses
lasting I to 2 days, consistently more than 70% of
participants described CTC when asked.
Likewise, the context and process used to
solicit CTC may be a factor. Cole and Glass8
reported large differences in response rates between
a CTC query contained within a standard form for
CME credit (“What change[s] do you plan to
make in your practice as a result of reading these
articles‘?”) and a follow-up questionnaire about
learning progressions (“Ready to apply my new
knowledge of this topic to the care of my own
patients”). Of 41 4 readings by their participants,
only 45 (1 1%) resulted in a CTC on the CME
credit form, but when prompted by the question-
naire, participants reported that 134 (32%) read-
ings had actually moved them to the point of being
“ready to apply” in practice. This threefold dif-
ference in responses may be a result of the ques-
tion asked (i.e., “readiness to apply” may not be
exactly synonymous with “plan to change”). How-
ever, it may also reflect a difference in perceived
importance and process because the follow-up
202
participants were engaged in active reflection’.22
as volunteers in a research study.
Physicians may decide not to change, and
there are many potential reasons: the change itself
may not be seen as imp~rtant,’~~” preparing for the
change will be too d i f f i ~ u l t ,or’ ~barriers to mak-
ing the change are too great. ‘o,20,23 Unfortunately,
providing information about barriers as part of
the CME activity does not increase the likelihood
of subsequent practice change.1°
In other situations, physicians may not think
that a change is necessary.I8 Interestingly, some
respondents describe “confirmation of current
practice” as a “change,” whereas others cite it as
a common reason (9% to 38%, depending on the
condition)” not to make a CTC. In practice,
confirmation can be a catalyst for even greater
“changes.” In the Better Prescribing Project,24the
largest change in prescription of diuretics occurred
in those physicians who were already above the
mean for prescribing these agents as first-line
therapy for uncomplicated hypertension. This
raises a question about the CTC query. Would
asking “plan to do” rather than “plan to change”
yield results more predictive of actual practice
changes?
After Physicians Make a CTC,
What Is the Role of Follow-up?
Physician factors in “failed change” include not
feeling sufficient control over making the change,
finding the change too difficult or time-consuming,
and not having the opportunity (about 30% in
most ~ t u d i e s ) . ’ , ~ ~If
~ ,no
~ ,appropriate
~ ’ ~ ~ ~ , ~ ~oppor-
tunity arises within a short time after the com-
mitment, it may diminish or be forgotten.
Follow-up then assumes increased importance.
However, without knowledge about the stability
of CTCs as a guide, the timing of follow-up empir-
ically has been 1 to 2 months. What is the optimal
time, and what detemGnes it? To what extent is the
follow-up3 an intervention itself? Would a second
follow-up further sustain or even augment
changes?
 Wakefie Id
References
Lessons for Practice
Commitments to change can be used
in many ways: stimulating reflection to
promote change, planning education-
al programs, and evaluating impact.
To be effective, the selection and use
of an intervention strategy such as
commitment to change must be guid-
ed by an understanding of the com-
plexity of physician behavior change.
The process used to solicit commit-
ments to change can influence results.
Although commitment-to-change strat-
egy may be “overused” and decrease
effectiveness, it may also encourage a
way of reflecting and thinking about
applying learning to practice.
More research is needed to better
understand the specific factors neces-
sary for an effective commitment-to-
change approach.
To incorporate follow-up in a feasible way,
White and colleague^'^ described a “Memo-To-
Myself” (mailed at 3 weeks after the CME session
as a reminder), followed at 6 months by a summary
of changes proposed by peers. Will this novel
strategy be as effective as the traditional follow-
up by mailed questionnaire?
Closing Comments
There are limitations to published studies of CTC.
Sample sizes of participating physicians are
small-usually less than 100 and sometimes less
than 20. Follow-up periods rarely extend to
3 months post-intervention, which limits the abil-
ity to demonstrate changes because there may be
no opportunity for physicians to act on their com-
mitment. Despite these limitations, recent CTC
studies provide some guidance for effective use and
clear directions for future research.
203
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