As I listened to panel after panel of continuing medical education industry leaders at the Annual Conference of the National Task Force on CME Provider/Industry Collaboration last fall, I couldn't help but notice that there was an awful lot of white hair up there on the dais. Fast-forward a few years, and many of these distinguished folks will probably be easing into well-earned retirement. What wasn't intuitively obvious was where the next generation of CME leaders is coming from. Who's teaching them what they need to know to guide CME into the new millennium?
Those thoughts had also occurred to Joseph Green, PhD, associate dean of CME, Duke Office of CME at the Duke University School of Medicine in Durham, N.C. But he decided to do more than worry about it. He got together with other current CME leaders to hold the first of what they hope will be many CME leadership conferences on September 21 to 25 at the R. David Thomas Conference Center on the Duke campus. I begged for the opportunity to come and observe what sounded like a real groundbreaker. I was thrilled when the organizers said yes.
Then I got the syllabus. Oh my. The program started with breakfast at 7 a.m. and ran well into the night, with just a few short breaks. Even meals were scheduled as working time. I'd signed up for a leadership conference — now it was looking a lot like boot camp. What had I gotten myself into?
Fear and Loathing in Durham
When I arrived at the Thomas Center that Saturday afternoon, staff from the Professional Meeting Planners Network, which was providing in-kind support, and the Duke CME office were just starting to set up. The thud that came when they dropped the course binders on the registration table sent a chill through my soul. But the lobby was beautifully comfortable, registration was smooth, and my room both gorgeous and functional. When I asked the front desk a question about my room, an employee passing by said, “Room 268? That would be Sue Pelletier's room. Does she need something?” I knew that whatever the next few days would bring, we'd be well-taken care of.
As I sat in my room trying to clear my mind before the opening session that night, anxieties ranged from profound (How could we tackle all the items on the agenda and maintain our sanity?) to the inane (What is the dress code for this sort of thing, anyway? Business casual? Combat fatigues?). Then it was time to find out.
The U-shaped GlaxoWellcome meeting room was buzzing as people settled into their seats. Meeting co-chair Green welcomed everyone, then asked theand participants to introduce themselves and explain why they wanted to be a part of the conference.
Faculty member Nancy Davis, PhD, director of CME with the American Academy of Family Physicians in Leawood, Kan., said she saw the conference as an “opportunity to sit in a room with good thinkers. I want you to leave here taking that phrase, ‘CME doesn't work,’ out of your vocabulary.” The other program co-chair, Martin Cearnal, president and CEO of Physicians World/Thomson Healthcare in Secaucus, N.J., admitted to a more selfish notion: “The teacher always learns more than the student,” he said. “I'm here to recharge my batteries — and to drive more committed people to bring CME closer to the goal of fixing the healthcare system.” Bruce Bellande, PhD, executive director of the Alliance for CME, Birmingham, Ala., added, “CME has changed more in the past three to five years than it did in decades previously. Many organizations are rethinking the place and value of CME, and we need leadership now more than ever to handle the pressures being placed on CME.”
But it was Howard Robin, MD, who set the tone for the conference when he said, after listing his long tenure as medical director, CME, with Sharp Healthcare in San Diego, Calif.: “I came here thinking I could find someone to take this job off my hands.” We all cracked up. This may be boot camp, I thought, but at least the drill sergeants have a sense of humor.
The only problem was that all of these introductions were supposed to happen in 45 minutes. Uh huh. We still had most of the participants to go when we broke for dinner an hour and a quarter later, but it was well worth the time. We not only learned about the faculty's passion for passing on leadership skills, but also some personal tidbits — like Bob Kristofco's love of classical music, and Harry Gallis' avid orchid avocation — that made the intimidatingly august faculty more approachable.
Long Day's Journey into Night
Participants were asked to bring to the conference a challenge they face in their work. The idea was to have people relate what they were learning to resolving their challenge. After dinner, participants laid out what they hoped to accomplish. For example, a participant who works with a pharmaceutical company said her challenge was to find ways to get industry to accept the incorporation of adult learning and educational research before a program is designed, and to find ways to measure how meaningful the activities her company supports are to physicians and their patients. A medical communication company representative said her challenge was to get physicians to think about and communicate what they really need to know during needs assessment. Another pharma participant focused on finding ways to work across all segments of CME; and several from societies, hospitals, and medical schools wanted to find ways to measure outcomes.
Then Robert D. Fox, EdD, professor of adult and higher education and family medicine with the University of Oklahoma in Norman (“a university our football team can be proud of”), stood up and blew us away with a talk on the theories and principles of planned change. I couldn't possibly summarize all that he, or any of the other faculty, said in the scope of this article (we'll be covering some of these issues in MM's new professional development column, “Life Support,” beginning in this issue on page 19). But he set the stage for all that followed by outlining some of the problems facing society, the healthcare systems, clinicians, and CME. Then, he slowly led us through learning theory 101, stopping at 10 points along the way so participants could write a standard based on what we had just learned.
For example, he explained how empirical, rational strategies like the scientific method work when someone's ready to change, and the change is small, simple, and noncontroversial, such as getting docs to switch to SSRIs for depression. Power-coercive strategies, such as regulations that force people to change behavior, aren't as conducive to real learning. “If you regulate them, they'll do it minimally and begrudgingly,” said Fox, using the example of the 55 mph speed limit. “It works when the behavior is observable — I have to catch them, have a radar gun, and be willing to fire it and write the ticket.”
Educational strategies involve extinguishing an established behavior before being able to establish a new behavior. Because they are more complex, educational strategies generally are better suited to meet the more complex problems of professional behavior. One standard that I jotted down based on this segment was: “Every decision docs make is emotional to some degree. Always take the emotional reaction to change into account when developing an activity.”
I felt as if we had rocketed through a semester course in a couple of hours. Up since 4 a.m. to catch an early flight, I was reeling, and my comrades in arms didn't look much better. Green took pity on us and canceled the first mentoring session, scheduled to begin at 9:30 p.m., in favor of some well-needed rest. But even as I lay down that night, I couldn't fall asleep. My mind kept making connections — at one point I remember thinking I had mapped out the answer to problems in the Middle East by applying some of the theories Fox laid out — definitely getting delusional. The next thing I knew, the alarm went off. Morning, already?
DAY 1: Adventures with Action Plans
Green started off the first full day of the conference, as he would each morning afterward, by sharing the results of the previous evening's evaluations, and announcing some resulting changes to the day's program. He also did something I've never seen before: He took a vote on the room temperature. (The too-hots won, so some of us too-colds took advantage of an hour's break that afternoon to tramp over to the campus store to buy Duke sweatshirts — too bad it was closed on Sunday!)
That morning we were tackling the role of leadership in physician learning, which entailed another incredible Bob Fox lecture on adult learning and the continuing professional development of physicians. Again, he asked participants periodically to stop and write a standard based on what they had just learned.
We then broke into small groups to apply what we'd learned to a case study. This one was to develop an action plan to facilitate behavioral change at a research institute in geriatric medicine. The problem we were handed was that the institute's clinicians, while leaders in their fields, were reluctant to intervene in issues they describe as tangential to “real” medicine, such as communicating with patients. Despite clinic rounds led by communication experts, and the institution of a policy on how communication with geriatric patients should be conducted, the problems continued to increase.
Based on what we had learned about shaping readiness to change through the education, feedback, reminders, and policy tools we have — and overcoming the barriers to change — we had to come up with a credible plan, and report our findings back to the larger group.
My group decided we were in the CME nightmare-land of learners who don't see a problem and aren't motivated to change. To get these docs' buy-in, we decided to concentrate on strategies to enhance their self-assessment and motivation by involving them in the process. And we decided to chuck the coercive policy that obviously was just making them more resistant to change. It was interesting to see how each group found a slightly different way to apply the knowledge to the situation.
The next chunk of learning: the current state of reality CME providers face in the worlds of academia, hospitals and health systems, medical communication companies, and the pharmaceutical industry. J. Lloyd Michener, MD, professor and chairman, Department of Community and Family Medicine with Duke University, explained the shifting paradigms in healthcare, such as a move from paternalism to partnership with patients; from anecdotal care to evidence-based medicine; and from cures to preventative medicine. He also looked at how medical education is shifting from passive “spoon feeding” to active, learner-directed education; from rote learning to curiosity-driven, patient-based lectures; and from departmental courses to interdisciplinary segments.
The challenges he outlined for physicians — stemming the escalation of healthcare costs, and re-establishing trust in the doctor-patient relationship, among others — tied directly into our next small-group case study, which asked us to develop what we thought the role of CME should be in reducing medical errors.
“CME providers can't wait to be invited to come to the table” when it comes to working out healthcare issues, said Michener.
DAY 2: Curing Our Cataracts
You know that moment in a great meeting when everything suddenly falls into place? That happened on the second full day, sometime during a talk on the visioning process. As Bellande and Harry Gallis, MD, vice president of regional education and director of Charlotte, North Carolina Area Health Education Centers, explained how to think beyond today's issues and problems to create a vision of the future, the participants, who up until then had mainly been willing to sit at the feet of the masters, began speaking up, even interrupting when questions just couldn't wait until the Q&A. The faculty also seemed to relax into the meeting's rhythm, encouraging questions and challenging each other to find new perspectives on the issues. As Gallis said after one exchange, “Don't let your vision develop cataracts.”
Being a total sucker for the power of visioning, I gave up all pretense at holding to my “fly on the wall” journalist status and began to join in. Who could resist wanting to know more when Leist said, “When I began to do strategic visioning, it changed my life”? Robert Kristofco, director, Division of CME, University of Alabama School of Medicine, Birmingham, got us rolling when he told us his turning point came when he was asked to run the 16mm projector during a meeting. So he learned how, and thought he was doing a great job of it until the meeting director pointed out that the film was piling up on the floor beneath the take-up reel.
“That disaster taught me that my future lay in strategic planning, not logistics,” he said. “We began to tell people that we weren't meeting planners anymore, we were strategists who used education to look at larger issues and accomplish our vision.”
The rest of the day flew by in a blur of information on the regulatory environment of the future, evidence-based CME and accreditation, patient safety and medical errors, and challenges and opportunities for CME in physician maintenance of certification.
My writing arm was starting to cramp from all the note-taking, and it was a relief when we broke into small groups to apply what we were learning to a case study. It concerned a healthcare organization with a new president who's under pressure to cut costs and improve quality. Our theoretical CME department's budget was being reduced by 15 percent, and would be further reduced if we couldn't contribute to the organization's bottom line. Our mission was to develop a vision of how we would make that happen. My group didn't quite get all the way to the vision, having gotten hung up on identifying the key issues and developing strategies for dealing with them, but we got the idea, anyway.
We also had a grand time heckling the faculty member, who shall remain nameless, who wrote the case study. He referred to the new president as a “lady physician,” which got the “lady learners” in the room up in arms. “In what way is a lady physician different than a physician?” we asked. We accepted his apology — once he got down on his knees and begged forgiveness.
That night we heard how some CME departments used entrepreneurial strategies to develop partnerships and raise their programs to the next levels. “I challenge you to move beyond just maintaining your organization,” said James Leist, EdD, co-director of faculty development, Department of Community and Family Medicine, Durham, N.C. “Maintenance is boring. Take responsibility to revitalize your organization.”
We later heard the personal stories of how several faculty members worked their ways into leadership positions through involvement with the Alliance for CME, Society for Academic CME, and other industry organizations. “If you start by volunteering to be on a committee,” said Green, “you can move on up the ladder. The hardest part is balancingactivities with what you need to do at home.”
DAY 3: Problem-Solving
OK, now we were armed with a vision of where we wanted to go and the knowledge we needed to get there, but how, exactly, were we to put it into practice? We dove into how practice-based learning works in CME in a fascinating discussion led by Donald Moore Jr., Phd, director, Division of CME, Vanderbilt University School of Medicine in Nashville. He explained the concepts, then broke us into small groups based on organization type. We had seven minutes to identify a problem in our segments and come up with a plan for a CME activity to address it.
The problem my group came up with was an unacceptable number of falls in nursing homes. Our barriers were resistance from staff, funding, staffing issues, and disagreements over how to solve the problem. We set up an academic detailing system to present the data outlining the problem, an office system that would have inter-related activities carried out by multiple staff toward the common goal of reducing falls; and looked to other industries, such as rehab centers, that have innovative ways of reducing falls without adding staff.
That afternoon we took on evaluation, outcomes, research, and publications as leadership imperatives. Don Moore, in a presentation on outcomes, explained how all too many CME providers focus just on how many attend and their satisfaction level with an activity. Some go to the next step of trying to determine if attendees actually learned something, but very few go to the next level: tracking behavior change, and that change's impact on individual patient health and the health of the disease state population as a whole.
Kathy Andosek, MD, a clinical professor with the Duke Department of Community and Family Medicine and medical director of Duke's Office of CME, explained how she asked people to write down what they intended to do as a result of what they'd learned at her session, then mailed their intentions to them six months later with a self-addressed envelope to use for their response. “I was pleasantly surprised at the response rate I got,” she said.
On the last morning, we began by watching the movie, “Concerto.” It showed a symphony playing three movements — creation, destruction, and rebuilding — illustrated by nature and urban scenes. Again, the implications of what we were attempting to do stretched far beyond our professional horizons. Maybe it was the nearness to the 9/11 date, but I was incredibly moved and inspired.
We launched into a discussion of the meeting itself — what went well, what could be improved, what type of funding is appropriate, and if it should be held again (a unanimous yes). Participant Charles Clark, Jr., MD, associate dean of the Indiana School of Medicine in Indianapolis, suggested that the organizers put together a CD-ROM or some other type of enduring material that we could use to convince others in our workplace to implement the ideas. That sparked lots of ideas on how to keep the momentum going into the future, such as creating a Web site where faculty could post new ideas, answer questions, and have alumni chat about the progress they're making.
Bob Fox wrapped up the event with a roundup of some of the high- and lowlights, re-emphasizing what we had learned — not the least of which was just how powerful the education process can be. Exhausted as I was, I actually didn't want the conference to end.
The day after I got home, I got an e-mail from fellow participant Mila Kostic, director of CME with the University of Pennsylvania School of Medicine in Philadelphia, who summed up what I think we all were feeling.
“As I eagerly anticipate the upcoming weekend of no scheduled activities, my thoughts are still turned to all the possible applications of the newly acquired knowledge and realizations that hit home during this time we spent together.
“Dream big, my friends. Keep that vision in mind, inspire, and partner with others who want to make a difference. The barriers are real, but they can be overcome, one at a time. And regardless of whether you are a ‘lady’ or a ‘gentleman’ leader, remember that others will turn to you for ideas (sometimes ‘concepts,’ sometimes even ‘theories’). Share your knowledge — it will only make you more powerful.”
Spoken like a true leader.
Playing Doctor with the Patient Simulator
Even boot camp participants get a breather. During the second day of the CME leadership conference, we took a much-needed three-hour break for lunch, with some of us heading over to Duke Hospital to meet the patient simulator, a very creepy-looking dude, and his keeper, Jeffrey Taekman, MD, an assistant professor with the Duke Department of Anesthesiology and the assistant dean of information technology. Taekman walked us through some of the simulator's functions, including pulse, heart rate, lung sounds. Even the pupils of its eyes dilated. Earlier on, Gonzalo López, MD, the director of Educacion Medica Continua Ltda, Bogota, Columbia, had wondered about the meaning of an Americanism in the syllabus: “Where the rubber meets the road.”
“This, Gonzalo, is what it means,” Green intoned to the reluctant physician, as we coerced him and the other reluctant MD in our midst, George Bousaba, CME coordinator with Novant Health/Presbyterian Hospital in Charlotte, N.C., to take part in an actual simulation of a medical emergency.
The docs did OK, but the simulator didn't look so hot after they “saved” him — he looked like the last one to leave the bar after a rowdy Saturday night. We laughed until tears rolled, but gave our docs a sound round of applause for taking on the dare. The simulator, which Duke already uses to educate its physicians, residents, nurses, and other staff, also serves as an up-and-coming distance learning tool that can be connected via video to remote facilities.
To keep the excitement and ideas from the CME leadership conference alive, we've started a professional development column, called “Life Support.” It will encapsulate conference content and offer a forum for you to share your strategies for developing leadership in the CME community. See page 19 for the first installment.