New Orleans was a little on the cool side at the end of January, but the Hyatt Regency-vacated just the day before by the National Football League-was hot with the friction that comes when new ideas are tossed back and forth. Much, though not all, of the anxiety that permeated last year's meeting in Orlando had been dispensed with. The more than 1,100 registered attendees-a record-at the 22nd Annual Conference of the Alliance for Continuing Medical Education were in a working mood, which was a good thing, because there was a lot to thrash out over the course of four days.
The meeting's theme was outcomes-driven continuing medical education. The theme received an extra fillip because the Accreditation Council for CME used the Alliance meeting as a forum for discussion of its new plans for restructuring the accreditation process. Wherever the Accreditation Council eventually comes out on restructuring, it was made clear at this meeting that outcomes would play a far more prominent role in judging the success of a CME sponsor than ever before.
At the opening session, new Alliance executive director Bruce J. Bellande reported-unable to hide his amazement-that there would be 145 events at the meeting, including 105 tracked sessions and the largest number of commercial exhibitors-33-to ever have participated.
The exhibit floor, in fact, turned out to be a smash hit with attendees and exhibitors alike. "This is my chance to meet with people I don't have time to see in my office," said John Gillespie, Jr., assistant director of education with the Southern Medical Association (SMA), the organization that sponsored this year's meeting. Remarking on the size of the exhibit hall, he added that SMA had only really kicked in its exhibit sales effort in November, making the final tally of exhibitors all the more remarkable.
At the podium with Bellande was James C. Leist, EdD, associate dean for continuing education at Bowman Gray School of Medicine in North Carolina and outgoing Alliance president. Leist enumerated what he saw as the major issues facing CME providers in the late 1990s, including the continued consolidation through hospital mergers, the increased importance of geriatrics as a medical discipline, the consolidation of the pharmaceutical industry, the continued growth of managed care organizations, and the explosion of new medical technology.
Leist also commented on another new Alliance initiative, which is to gain international recognition for the organization. He said he expected the Alliance to pay more attention to developing international linkages in the coming years, especially at a time when other nations are looking seriously at a more structured approach to lifelong learning for physicians. During the conference, a special focus session, chaired by David A. Davis, MD, associate dean of continuing education at the University of Toronto, was held to discuss the implications of this change for Alliance members.
Mulling Over Outcomes and Standards Joseph Gonnella, dean of the medical school of Thomas Jefferson Medical College in Philadelphia, gave the opening remarks at the first plenary session of the conference. He seemed an appropriate but also curious choice: He was a pioneer in outcomes research back in the 1960s. He was also an early leader in the Alliance for CME, yet no longer participates in the organization. His message regarding the linking of physician outcomes to the measurement of CME was cautionary: "I urge that we avoid making promises on which we cannot deliver," he said. "Knowledge, skills, and performance are interrelated and complex." He suggested that while CME providers are in a good position to increase a physician's knowledge, they are in a less certain position when it comes to solving the mystery of why physicians sometimes fail to act correctly based on their knowledge. "It may be that wine turns to vinegar," he said, "but vinegar does not become wine. It is difficult for a competent physician to act correctly on what he knows. It is impossible for an incompetent physician to do so. We can help doctors who do not know, but it is harder to help physicians who know but are not capable."
Gonnella also pointed out that the role of the physician has changed dramatically in recent years. "Doctors must be clinicians, patient educators, and resource managers. Years ago, the only thing doctors managed was time-mostly their own time." He suggested that it was in the areas of increasing physician knowledge about being good at these three roles where medical school education, bolstered by continuing medical education, could have an effect on physicians. But, he added, the expectations brought by others to the physician/patient interaction-those of patients, those who managed the setting in which physicians provide care, and those of the communities in which physicians practice-are outside the province of CME.
Credentialing: Whose Standards? "The American College of Physicians was the first organization, nine years ago, to suggest that kidney specialists ought to have performed a certain number of renal biopsies," in order to earn the title of specialist, said David Nash, MD, director of health policy and clinical outcomes at Jefferson Medical College, following his boss to the podium at the opening session. Nash's point was that measuring CME in terms of physician outcomes suggested some standard of physician performance-and the current standard, board certification, is really an inadequate measure.
Discussions of the importance of CME often revolve around the issue of credentialing and awarding admitting privileges to physicians. It is among the main motivators for physicians to seek out Category 1 CME. But board certification is not much more than a paper trail, according to Nash, and therefore not a very good tool for measuring physician performance.
"Board certification is tops because we have nothing else," he said. He went on to say that he knew of only one study that tried to correlate board certification to physician competency. Board certification, inadequate though it may be for measuring physician competence, is not even available as a measure for the 40 percent of the physician population who are not certified.
Nash explained that HMOs use board certification as a screen, mainly because it is much easier than formulating a physician performance assessment. He added that where board certification did prove a good measure of physician performance, it only confused the issue for HMOs that want to rely on primary-care gatekeepers.
"Board-certified specialists do a better job by measures of diagnosis and survival rates in cases of heart failure and myocardial infarction, and do it cheaper, according to our study," said Nash. "Should they be the front-line doctors?"
Nash reported that the American Medical Association was in the process of launching its own massive credentialing system "to credential everyone within the next five years." Referring to Gonnella's earlier comment about the expanded role of physicians, Nash wondered what would happen in the credentialing process to those physicians who "don't go on grand rounds anymore, but work exclusively as administrators." Would they still be assessed on the basis of their clinical competency?
He closed with the announcement that Jefferson had received a grant from the Pew Memorial Foundation to find ways "to force managed care organizations and medical schools to work together." He added that anyone in the audience wondering whether credentialing would really be that important should take a look at Massachusetts, "where anyone who can surf the Internet can look at physician records. This brings the assessment issue to a whole new plane."
The New Accreditation Standards "I don't even like to use the word 'outcomes' in front of this group," said Murray Kopelow, MD, executive director and executive director of the Accreditation Council for Continuing Medical Education (), as he prepared to address a workshop on the new accreditation standards. "We have a role in standardizing the education of physicians, and our outcome is a better educational system, not improved rates of morbidity or mortality."
Kopelow made clear to the audience that the ACCME had no intention of throwing the baby out with the bathwater. Those who were comfortable with the current standards for accreditation would be welcome to continue to use them. For those who wanted to take a new approach to accreditation, Kopelow said the main avenues of opportunity for change would be as follows:
No more prescriptive approaches to program planning. "You'll have options for self-determination," he said.
A focus on self-study, rather than generation of data. "We want the accreditation process to be an opportunity for you to reflect on what your organization is doing."
Instead of annual or two year or four year intervals between reports, Kopelow envisions a "continuous exchange of information."
A focus on evaluation of the total CME operation. "We hope to realign standards for joint sponsorship, management, and the Standards for Commercial Support into an examination of how a provider handles funds, funders, partnerships, and disclosure issues."
More Data The implications of these changes, according to Kopelow, were an increased need for frequent, regular exchange of both internal and external data about the quality of the ACCME's accreditation process and the performance in practice of accredited providers. He added that a major specialty society had agreed to work on the development of software that would simplify a sponsor's ability to participate in the kind of continuous information exchange the ACCME envisioned.
Kopelow also strongly denied that the Food and Drug Administration (FDA) was somehow behind the proposed changes. As he has said in other presentations, he believes the ACCME's relationship with the FDA has reached a high level of mutual confidence and cordiality.
"The FDA is not driving this," he said. "I don't see them as a bogeyman. The FDA is the organization that regulates the companies that make things we give to our children. It is the FDA that prevents companies from using ethylene glycol (anti-freeze) as a solvent for acetaminophen."
Call for Action "It's time for the ACCME to act," said Kopelow. "We haven't really laid down on paper how we will implement change. We'll negotiate the transition to the new framework with you." Asked why the change was going forward, if accredited providers had the option of sticking with the present system, Kopelow explained that there are some CME providers who actually can demonstrate changes in physician knowledge, competence, and outcomes, and that these organizations deserve the opportunity to have themselves measured by that yardstick.
One very new option is for accredited providers to band together and seek accreditation as a group. A pilot program is under way in Pennsylvania for that very purpose, according to Kopelow. Asked whether state-accredited providers would have the option to participate in similar pilot programs, Kopelow admitted that the state medical societies had the power to interpret accreditation rules more strictly. For example, there are some states where jointly sponsored programs are still not permitted.
"It is our responsibility to convey our intentions to the state societies," said Kopelow. "I would be surprised if state societies find our new system problematical."
A Great Opportunity Speaking from the audience, Barbara Mierzwa, director of CME for the University of Buffalo School of Medicine and Biomedical Science, voiced her hope that a new approach to accreditation would help improve the image of CME providers. "I think this is a great moment to redefine ourselves to our public," she said. "We're often seen as regulators, rule-givers, and obstructionists. We should present our goals and ideals to the larger community-to our parent organizations and to physicians."
On the subject of outreach, Richard F. Tischler, PhD, a former ACCME staffer, now head of his own CME consulting company, asked whether the organization had any plans to reach out to accreditors of nonphysician health professionals.
"No," said Kopelow. "It seemed best to get our house in order, so that at least the ACCME would move forward." He agreed, however, that "it would make life easier if nurses, pharmacists, and other healthcare professionals all asked one thing of you."
During a session on the basics of CME management, Diana J. Durham, PhD, director of medical education at Good Samaritan Hospital in Los Angeles and head of the Alliance's Hospital Special Interest Group, gave the assembled group of 50 or so CME neophytes the real low-down on what it takes to make it as a medical conference organizer: Diana's Conference Kit.
"These are items I carry with me at all times," she said. "They have saved the day on more than one occasion." Following is a partial list of the must-have items for the medical conference organizer who has seen it all-and expects to see more:
* AA batteries
* Advil ("...or other pain reliever-I have no commercial interest in this product.")
* Breath mints
* Business cards with Internet address
* Cardboard transparency frames and blank transparencies
* Computer diskettes
* Currency converter (slide-rule type) for use overseas
* Indigestion remedy ("The bottle is pink but I've obscured the label.")
* Instant coffee
* Sewing kit
* Pens and pencils
* Pointer (extendable/retractable)
* Replacement bulbs for overhead projectors