1. Smile--It's a PeachofaMeeting "This is the very best meeting ever. Great job--no glitches!"

How's that for a meeting planner pick-me-up? It's the second full day of the Alliance for CME's 24th Annual Conference, held in January. Suzanne Ziemnik, director, division of CME, American Academy of Pediatrics has just burst into the curtained-off corner next to the registration area--the meeting planners' hideout--with her big smile and unsolicited compliment.

"This is where we do scream therapy," Allison P. Kinsley, CMP, president, Kinsley & Associates, jokes with Ziemnik, after thanking her.

Well, whatever it takes. With feisty humor, team work, and daily doses of caffe latte, Kinsley and her cohorts, Bernie T. Halbur, PhD, professional development director for the Alliance; and Harry A. Gallis, MD, annual conference program chair, and vice president, regional education, Carolinas HealthCare System, Charlotte, N.C., have pulled off another record-breaking meeting. A whopping 1,277 people have registered, topping last year's record of 1,140.

During the planning stages, they weren't at all sure 1999's meeting would draw big numbers. The site is the Atlanta Hilton and Towers; attendees view skyscrapers from their rooms. Compare that to last year's venue, the Hotel del Coronado near San Diego, where participants strolled along the Pacific shoreline during breaks.

"No reflection on the city or the hotel," Kinsley explains. But [we wondered] if it would be as good a draw as the beach?"

The answer is yes. Atlanta has definite advantages: easy air access and a hotel big enough to accommodate most of the attendees. (Alas, the Alliance has outgrown the Del.) And those shut out of the Hilton just trooped across the street to the Marriott. (A dose of good karma: During the opening plenary, Gallis reveals that the Marriott stands on the site of what once was St. Joseph's Infirmary--where he was born.)

Making Connections But the location of Alliance conferences, whether seaside or city-centered, is not the primary reason for the record numbers, say organizers. The theme of this year's conference is "Reaching Out--Making Connections in CME, Linkages for the 21st Century." It is that chance to make connections that attracts participants, says Gallis.

"Why are 1,200 people here? Because it's an exciting opportunity to hear what's going on all across the country and take home [ideas]," he says.

But as increasing numbers of providers, from a widening range of work settings, flock to the conference, it becomes more of a challenge for organizers to create those crucial opportunities for connections. The dilemma facing the Alliance now is, as Halbur puts it, "How can the conference grow and still retain its family, small-meeting feel?"

Warm and Fuzzy One way to retain the conference's close-knit atmosphere is through venue selection. "We are really trying to keep [the meeting] under one roof," Halbur says. Sites are selected through 2002, and so far, the Alliance is sticking to larger hotels, preferring not to go the convention center route.

To help keep the family ambience this year, the plenary session seating was set up in rounds for the first time. "It's psychological," says Halbur. "If you walk in and see an army of 1,200 chairs, you don't have a warm, fuzzy feeling." Organizers also arranged for the Connections Center, an area near registration set with comfy furniture, a cash bar at night, and box lunches, all to provide relaxed networking opportunities.

Intimacy is also an important factor in the exhibitor/attendee relationship, say organizers. Though they have a record number of exhibi-tors--51--they have no intention of creating a convention center-sized exhibition in the future.

No Tidy Categories Not only are more people attending the Alliance conference, but they are an increasingly diverse crowd. Tailoring the conference content to suit the expanding spectrum of needs is the most difficult challenge faced by conference planners, Gallis reflects. "We have a wide array of CME professionals, from support staff to MDs and [people] with two PhDs," he points out.

Attendees no longer fit into tidy, traditional categories. Providers who work in insurance companies, for instance, attended for the first time this year. And pro-viders' work settings are increasingly complex and heterogeneous, observes Halbur. In fact, adds Gallis, they are a mishmash--medical conglomerates comprising insurance companies, medical schools, HMOs. Add another complication to the attendee mix: About 30 percent of participants each year are first-timers.

Of course, the changing attendee demographics represent the cataclysmic changes that continue to rock America's health care system. Organizers extended presenter deadlines, allowing them as much time as possible to finalize seminar content to ensure that sessions addressed the latest seismic shifts. Even as the conference begins, speakers are sending in handouts and AV requests. "Faculty are calling from their airplanes with changes," Kinsley says, adding that it's a good thing she has a cell phone this year, so she's easy to reach.

All that last-minute decision-making means organizers must be extremely flexible when it comes to logistics. Every inch of meeting space at the Hilton was reserved for the Alliance, but deciding what session to put where was an ongoing task. Kinsley made an initial game plan in December, forecasting which sessions were likely to be most popular, then rearranged rooms as registrations poured in. The pocket-sized schedule-at-a-glance, which lists session meeting rooms, didn't go to press until the week before the conference.

The Big Easy Celebration Next year, in New Orleans, attendees will not only celebrate the new century, but also the Alliance's 25th anniversary. And, even in the midst of the Atlanta meeting, organizers were already abuzz with enthusiasm. For starters, the board created a new, more structured planning process for the new millennium. The three plenary speakers are confirmed: Holly Atkinson, MD, will cover the major milestones in medicine during the past quarter century; Susan Pauker, MD, will tackle the current controversies surrounding the potential impact of human genome research; and John Stone, MD, will examine physician/patient relationships.

As for the silver celebration gala, plans are yet to be finalized. But don those Mardi Gras beads and come prepared to laissez les bon temps rouler, as they say on Bourbon Street. "We want to create a good learning environment, but we also want to have fun," says Halbur. "It's a celebration--what better place to do it than New Orleans?"

2. The NewEssentials: OverturetoOutcomes? System98--the ACCME's new set of accreditation guidelines--is designed to allow providers more flexibility. But some providers argue that it presents insurmountable obstacles by requiring them to demonstrate program outcomes.

The new, streamlined ACCME guidelines are designed to encourage provider creativity and promote a more objective accreditation pro-cess. The seven Essentials have been synthesized into three Essentials areas, followed by "policies." (There are no changes to the Standards for Commercial Support.) Despite the positive aspects, a few sentences in System98 acted as tripwires, sparking acrimonious debate at the accreditation Q & A sessions.

System98 stipulates that pro-viders must

* Include in the mission statement the expected results of the CME program [emphasis added].

* Use a planning process that links identified educational needs with a desired result in its provision of CME activities.

* Evaluate the effectiveness of CME activities in meeting identified educational needs, as measured by practice application and/or health statusimprovement [emphasis added], according to the criteria for exemplary compliance.

Is the push for results an overture to outcomes, as one delegate put it? While the intent is to raise the bar in CME, "the outcomes word is not used [in System98]," stressed Murray Kopelow, MD, executive director, ACCME. But he seemed to be talking to the wind, as providers chided the ACCME for demanding outcomes data.

"Nobody knows what [outcomes] means," Kopelow quipped, "except that people like you say it is expensive, bad, and hard."

"Expensive--good--and hard," corrected the provider at the microphone.

It is the hard and expensive aspects that rile providers. Physicians come from all over the country to attend national meetings, making it impossible to track physicians' behavior change, contended delegates.

One provider said she sends out questionnaires three months after each course, asking physicians if they have used their new skills, and if, not, why not. "We think that is outcomes," she said. "And it [only] costs us stamps." Kopelow assured her that her method was on the continuum required by System98.

But more comprehensive outcomes research is required for exemplary compliance, which some delegates said they will never achieve, as their boards forbid outcomes research. And research costs money, delegates said. "You remind me a lot of Congress," fumed one provider. "They legislate activities but don't allocate the appropriate funds to carry them out."

3.AMA PRA Credit Under Fire Will the AMA guarantee that its Physicians Recognition Award (PRA) credit stands for quality education? If not, licensing boards say they'll take the issue to the legislatures.

"We've got a problem to fix, and, frankly, we need your help."With that appeal to CME providers, Dennis Wentz, MD, director, CME, American Medical Association, and his fellow AMA panelists opened the AMA CME Town Meeting during the Alliance conference.

The AMA, the agency responsible for awarding credit to physicians who participate in accredited CME activities, is receiving an increasing number of complaints about the quality and integrity of CME programs, reported Wentz. The complaints cover two areas: programs that have inappropriate content, and programs that are more promotional than educational. The complaints roll in from a variety of sources, said Wentz, from irate physicians, to academic centers and specialty societies, all the way up to the powerful state licensing boards.

"There is serious concern among some credentialing agencies such as state licensing boards. They've made the comment, 'If you can't fix this, we will fix it by legislating in our state what is approvable for credit and what is not,'" Wentz warned. "That is a call to arms."

Complaints are escalating now due to several factors, Wentz said in an interview following the conference. The tremendous growth in the alternative medicine arena has spawned more programs on such topics, some of which are inappropriate for AMA PRA credit, and there are more accredited providers than ever before, and so, more potential for problems. Also, due to turnover in the field, there aren't many people left who remember the Kennedy hearings ten years ago concerning overly promotional CME.

But CME providers better start remembering. The situation is at least as serious, if not more serious, Wentz said, than the threat of government regulation spurred by those hearings and the attendant publicoutcry.

Just imagine how confusing it would be if every state issued its own guidelines for CME content requirements. That would be a risky path, said Wentz, and would demonstrate a "failure of the voluntary system to do the right thing."

The CME world averted the earlier threat by instituting a voluntary system. But while the Accreditation Council for CME's Essentials and Standards regulates the scientific objectivity and independence of CME programs, those guidelines do not specify what content is appropriate. The standards do not go far enough, Michael Scotti, MD, vice president, medical education, AMA, told delegates, "to protect physicians and the patients they serve."

AMA--CME Content Judge? Is the solution for the AMA to follow the example of the American Academy of Family Physicians, the American Academy of Dermatology, and other organizations, suggested AMA speakers, and review for approval every CME activity designated for credit? Should the AMA introduce further designations, such as AMA PRA category 1a or 1b, classifications that would be determined by the appropriateness of content?

(These proposed designations are not to be confused with the system of levels introduced by the AMA last year, designed to help hospital credentialing and privileging committees determine the degree of competency physicians attained during a CME activity. The designations range from Level 1, where providers simply verify that the physician completed the course, to Level 4, which requires providers to certify that the physician is competent to perform the procedures taught in the program without further supervision.)

As to the question about whether the AMA should now also introduce content classifications, the answer from the audience was a deafening "No."

"While I might philosophically agree with your point on an ethereal level," said one provider, "I am working out in the trenches with doctors who insist that their activity is worthy of credit. When I tell physicians their subject matter is inappropriate or doesn't fit the definition [of CME], they say, 'You're not a physician. I tell you what's appropriate for credit.' If you set up types 1a, 1b, you significantly complicate my life," she asserted, to loud applause.

Providers also bristled at the idea that they needed content direction. "We know what physicians need based on our needs assessments," said one attendee, while another said the freedom to choose educational topics was critical to physicians' professional growth.

Adding another level of bureaucracy is not going to solve the problem, delegates told the AMA, in no uncertain terms. Certainly, adding more costs is going to provoke resentment. Plus, the ACCME did a good enough job handling complaints about CME programs, delegates stressed.

If the audience's response is reflective at all of the broader provider community, the AMA can forget about garnering support for implementing content rules. Whatever the AMA does, it desires input from providers, and promises to coordinate with the ACCME and state medical societies, Wentz said. If the AMA does issue content guidelines, all providers will have to do is sign an agreement to follow them.

Meanwhile, the AMA is taking preemptive action by asking state medical societies to assure licensing boards that the AMA is working on resolving the issues. The AMA has also launched a newsletter, which it will send to sponsors, to boost awareness of potential trouble spots in the awarding of credits.

System98--the new, improved version of the Essentials and Standards for Commercial Support--has been ratified by the Accreditation Council for CME's member/ parent organizations and will probably take effect by July 2000. If you're puzzled as to why the new guidelines are called System98, you're not alone.

"We called it System98 and not System2000 because we hope the criteria will evolve," explained Kate Regnier, assistant executive director, ACCME. But while the Essentials may need fine-tuning, that doesn't mean that the ACCME will come back next year and hit providers with four new Essentials, she clarified. Visit www.meetingsnet.com to view the text of System98 and express your views. Or, you can obtain System98 from the ACCME. Call (312) 464-2500, or visit www.accme.org.