As anthrax was discovered in U.S. Capitol office buildings in mid-October, the American College of Emergency Physicians was in the middle of its annual scientific assembly in Chicago. The sessions on bioterror and disaster preparedness — usually a weak draw — pulled in standing-room-only crowds.
“We try to be all-inclusive, and we'd planned these sessions back in December ,” says Debbie Smithey, meetings and education manager for ACEP. “When we wrote anthrax into the “Derm and Doom,” course description back then, I don't think anyone really felt that it was a big threat. Emergency physicians check out sessions about problems they're likely to see more often, so our bioterror sessions in the past haven't been crowded. People in America never thought they'd have to worry about this.”
Preparing the Nation's Sentinels
With 16 confirmed cases of intentionally caused anthrax in the U.S. as of this writing in late October, four of them fatal, biological terrorism has ceased to be an abstract threat. While infectious disease experts have warned of the possibility for years, the reality came as a shock to the nation's health system, and CME providers are scrambling to give health care professionals the information they need to recognize and treat anthrax and other potential bioterror agents.
Medical societies are rising to the challenge. The American Academy of Family Physicians, which held its annual scientific assembly the first weekend in October, added a lecture on bioterrorism as the first step in a campaign to “ make sure the nation's family physicians are prepared to serve in the role of sentinel physicians,” according to Norman J. Kahn Jr., MD, vice president of science and education. A video of that session, an audio home-study program AAFP produced in July on the role of the family physicians in defending against biochemical attacks, and links to other materials for helping doctors respond to terrorism, have gone up on the AAFP's Web site, at www.aafp.com/resources/.
To cite just a few more examples: The Interscience Conference on Anti-microbial Agents and Chemotherapy, postponed from September to December, has put out a call for additional papers related to the anthrax and other terrorist threats. The National Medical Association's task force on bioterrorism met in late October to begin designing a national education program for physicians and the public. The Massachusetts Medical Society planned several bioterrorism programs for the coming months. And the list goes on.
Most of the experts we talked to agreed that today's anthrax scare is only the wake-up call. “Anthrax is the big issue right now,” notes Gordon West, education specialist with the Annenberg Center for Health Sciences in Rancho Mirage, Calif. But CME providers need to focus beyond today's news to the future possibilities, too. “Medical educators can't get caught up in focusing on just one thing,” West says. “CME people need to be aware that there are other potential problem bugs out there.”
“We need to be more proactive in determining potential threats and providing more educational interventions that will help physicians deal with the unexpected,” says Bruce J. Bellande, PhD, executive director of the Alliance for Continuing Medical Education. “We're now seeing the scope of our lack of preparedness to appropriately diagnose and treat even just anthrax, which is the only one that has manifested itself so far. There are countless other agents, and we're going to have to begin to prepare for them as well.”
Toward that end, the AAFP is organizing a series of work groups aimed at giving their members the tools needed to respond to the spectrum of possible terrorist tactics.
“We have a several-pronged strategy to make sure physicians on the front lines are prepared to recognize possible bioterrorist agents without over-reacting, and to treat and report what may be clusters of new symptoms appropriately,” says Kahn. “They're going to need to know the possible biological agents and how they present, and they're going to need to know about chemical agents and even what to do with nuclear exposure. Biological agents are on the forefront now, so that's what we have to start with. But we need to work over the long term, in partnership with the CDC, to educate our members to take that sentinel role in all these areas.”
Terrorism will definitely be on the agenda for future meetings. “I think for the next couple of years this will influence what we'll provide. I think it will have to,” says ACEP's Debbie Smithey. “We plan a hot topics conference every year, and of course this year it's going to be on terrorism. Not just bioterrorism, but the whole range: nuclear, biological, chemical. Certainly this is a bigger focus — we would not have done a day-and-a-half stand-alone conference on this type of thing.”
While emergency department clinicians and laboratories have seen the bulk of the anthrax action so far, the primary care specialties — pediatrics, gynecology, family practice, and general internists — as well as trauma surgeons, pathologists, and dermatologists will need to be educated to respond to future terror attacks.
Your Rolodex of Resources
Right now the CDC is taking a central role in providing the nuts-and-bolts on anthrax. And government and military resources are probably among the best for terrorism medicine. But addressing the larger, long-term need for bioterrorism education will call on many resources in the CME community.
To assist members in meeting those needs, ACME (www.acme-assn.org) has put out a call for materials to include in a proposed “Bioterrorism Compendium of Resources.” In conjunction with the Agency for Healthcare Research and Quality, the Alliance for CME is hoping to make available on its Web site comprehensive, peer-reviewed, information on prevention, diagnosis, and treatment of the most likely bioterror agents, including anthrax, smallpox, botulism, tularemia, viral hemorrhagic fever, and plague.
“We're in phase one of this project, the collection of the resources,” says ACME's Bellande. “Those that have already been peer-reviewed — articles or textbooks — and things from the CDC or other reputable federal or public health organizations, we hope to put up on our Web site very quickly. Others, we'll put into a peer-review cycle. We're going to be using the University of Alabama's Center for Preparedness for that. We see it as something that will go up sequentially and will be continuously built and updated.”
The site will eventually include not only materials but also a list of expert speakers. “We haven't had that much difficulty finding experts,” according to the AAFP's Kahn. “There are a few family physicians who are experts because of their research interests or their background. There are some folks from family medicine and from other specialties who are in the military, both MDs and DOs, who have this as their assignment and are experts.”
ACEP's Smithey also relied on the resources within her organization. “We have just a huge resource cadre ofwho have expertise in all these different areas. Between committee members and the people they know, we can find the experts by networking.”
For instance, Kristi L. Koenig, MD, national director, Emergency Management Strategic Healthcare Group, Veterans Health Administration, Department of Veterans Affairs, Washington, D.C., conducted the session “Derm and Doom: The Rashes of Common Chemical and Biological Terrorism” at ACEP's annual meeting.
“She almost had to cancel because she's doing training sessions for the federal government,” says Smithey. “So certainly they think she's an expert.”
Most of the people we talked to agreed that, at least at the outset, what funding there is for bioterror CME will probably come from government sources. In the longer term, the manufacturers of testing equipment, vaccines, antibiotics, and related palliative treatments may be interested in underwriting educational sessions.
“The bioterrorism programs I've seen have been primarily government funded,” says Annenberg's Gordon West. “I think in the future, out of a sense of common goodwill, some pharmaceutical companies and medical device companies will be interested in funding this kind of education. My guess is that they would be more willing to contribute that money to a larger national effort than smaller local programs, but that's speculation on my part.”
ACME's Bellande thinks the potential for support is varied, but agrees that the government will remain a major player. “I think, similar to many of the other interventions of CME, where you have products involved, that naturally would be a source of potential funding,” says Bellande. “The whole regimen of things for prevention, such as vaccinations, the tools for appropriate diagnosis, and then the interventions themselves after the onset of the condition — typically drugs — are all possibilities. In light of the public health threat, I think the government is going to put more emphasis on providing education in these areas — there's already some gearing up on Capitol Hill and through a lot of the agencies. It is public health, but the majority of first-line health care in this country is provided by private practitioners and not by the public health network, and that's where the dire need for training is. The government will certainly realize this and shift the appropriate resources.”
The Need for Speed
In the first weeks of the anthrax outbreak, the need for information has been so acute that the main consideration in providing medical education has been speed.
“We need to try to find ways that educational programs can be done quickly and reach people,” says West. “CME can be a laborious process, and what we have to focus on is how we can have quick turnaround and still maintain educational integrity.” Thus, the CDC's use of satellite broadcasts and the Web. “We're pursuing a multimedia strategy, in order to reach a diverse audience,” says Dennis L. McDowell, director of the division of professional development and evaluation for the CDC's Public Health Practice Program Office. “That includes print, through our use of the MMWR; video, both satellite broadcast and tape; audio broadcasts; audio bridge, where we allow people to call in and interact; and also the Internet.”
For crisis response, new and electronic media have print and meetings beat hands down. “In light of what we're experiencing now, there's nothing any quicker than the Internet, e-mail, and Web sites,” says ACME's Bellande. “The degree of its effectiveness is yet to be measured,” he adds.
But medical personnel are so hungry for information right now that traditional measures of effectiveness may not apply. “I think this is a bit of an outlier,” says AAFP's Kahn. “It almost doesn't matter what the delivery vehicle is. In theory we know from some research and study that certain delivery vehicles work better for some people — some people are auditory learners and some people are visual learners. But the recipients are so motivated right now that it's overcoming the vehicle; they'll take it any way they can get it.”
- The Centers for Disease Control has already done two satellite broadcasts of its program, “Anthrax: What Every Clinician Should Know,” also available for download from the CDC's Public Health Training Network Web site (www.cdc.gov/phtn). It gives the basics for identification and treatment during the current crisis. CDC's Morbidity and Mortality Weekly Report is providing weekly updates on the current anthrax outbreak, including guidelines for exposure management and antimicrobial therapy.
- The American Academy of Family Physicians has produced a video of the bioterrorism session given at its annual meeting in October. An audio home-study program AAFP produced in July on the role of the family physician in defending against biochemical attacks, and links to other materials for helping doctors respond to terrorism, have gone up on the AAFP's Web site, at www.aafp.org/resources/.
- The American Medical Association is posting resources on its site at www.ama-assn.org. Also, beginning in 1999, the Journal of the American Medical Association published a series of articles that outlined recommendations for health professionals dealing with biological warfare. The articles are available, free of charge, at jama-ama-assn.org. (JAMA subscribers take note: The October 17 issue featured an article on how the health care community is mobilizing to cope with the psychological aftermath of the terrorist attacks.)
- The American Psychiatric Association has posted resources and fact sheets for health care professionals and patients on trauma-related disorders, including information on how to help children, and on disaster mental health services. Visit www.psych.org and click on Coping With a National Tragedy.