Are you going to use cadavers?" asked Donna M. Jackman, administrator, Center for Continuing Education, Cleveland Clinic Foundation (CCF), during what so far had been a routine planning session for an upcoming program on ocular plastic surgery.

"No, we want live people," the course director replied.

A pause. "How about me?" Jackman proposed.

And so, attendees at the cosmetic ocular plastic surgery course learned about eyelid lifts by watching the meeting planner go under the knife for four hours. "Is that giving my all or what?" Jackman laughs. While fairly pleased with the results, Jackman says that was the first--and last--time she would volunteer to be a "live cadaver" for a CME course.

Giving her all is a fair statement. In her office, a huge Action Calendar hangs on one wall. She needs it that big--CCF organized 246 activities for 41,700 attendees in 1998, once you include online education, grand rounds, enduring materials, journal CME, and jointly sponsored programs. Even without promoting her department's services to the 820 physicians on staff, she can barely keep up with demand.

She works six or seven days a week, a minimum of ten hours per day. Plants intertwine with stacks of file folders across her desk--since she doesn't spend that much time at home, she brought in the greenery to give her office a cozy feel. Pictures of her dog, Gizmo, surround her computer. She is Jackman's stress-buster. Mention Gizmo and Jackman bursts into a smile.

What do you get when you put in those kinds of hours? More to do. Recently promoted from manager to administrator, Jackman oversees what is now called the Center for Continuing Education, which includes the CME department, media services, and Unitech Communications (CCF's for-profit subsidiary; see CCF'S Third Ear, page 38).

Founded in 1921, the Cleveland Clinic is an internationally renowned teaching hospital, and was one of the country's first accredited institutions. Education is written into CCF's mission. Every staff physician is required to teach, with course directors receiving a share in program revenues.

But no matter how complex Jackman's job becomes, some things stay the same. She still has to concentrate on the basics: forging relationships with course directors and ensuring that those meeting management details--from site selection to outcomes surveys--are handled with integrity and professionalism.

Baby-Sitting Early one morning, Jackman is on the phone with an anxious course director. For his upcoming program in Key West, Fla., he expects about 150 attendees, but so far, more than two months before the date, only 50 physicians have signed on. Don't worry, she assures him. Physicians register late.

That's one of the facts of life you learn after 24 years in CME. And it's that kind of hand-holding that course directors need. In addition to taking impromptu phone calls, Jackman holds regular meetings with them. "I baby-sit 'em," she says bluntly.

Positioning herself as a consultant and resource, she lets course directors know she is not just a logistical person, but someone who can help them make sure their content and program format is on target. "You're not the only one offering CME. You've got to have something more [than your competitors]," she tells them. And she doesn't allow them to rely on past successes. "I'm saying, 'No--don't accept what you've been doing. Do it better.'"

Some course directors heed her counsel. But others are more like wild horses, as Jackman puts it. "Some are very controlling. They want the driver's seat," she says. "That stumps creativity. You revisit the same areas over and over again."

To get course directors on the right track, Jackman developed the Planning Guide for Continuing Education Courses . Bound in bright red, with big section tabs you can find easily even if you're near-sighted, it is a step-by-step workbook. Every part of the process, from budgeting to faculty disclosure, is outlined in concise, readable sections. A timetable on the first page outlines when directors should take care of details such as arranging for locations, confirming faculty, and submitting commercial support agreements to grantors. And, it informs them when they should meet with Jackman and exactly what they will discuss.

Cleveland's Space Squeeze Most CCF programs are held in Cleveland; many right on campus. But, increasingly, programs are going off campus--50 courses were held off-site in 1998 and more are slated to meet off campus in '99. Meetings that are too big to book on-site she takes to downtown Cleveland. Her top choice is the Renaissance because of the solid relationships she has built with the staff over the years. She brings an insider's understanding to hotel operations: 25 years ago she was reservations manager at the Omni International Hotel, the clinic's on-site hotel.

The Renaissance team "goes overboard for us," she says. "They know our standards." The staff are also flexible, she says, when her budget is tight. "I can say, 'I have only X-amount of dollars,' and they work it out for my benefit. I'm honest. I don't cry wolf. For some courses, I can spend, others, I can't."

Jackman would like to keep more programs in Cleveland, but there aren't enough guest rooms or meeting facilities. And as Cleveland has become a more popular convention destination, she has had an increasingly difficult time booking rooms, despite her clout. "I used to book one year out with no problem," she says. "Now, I can't do that. Cleveland has really come into its own."

Complicating matters further, the Omni is closing in November. That's good news in the long run--CCF is replacing it with an Inter-Continental hotel, which will complement the two other on-site hotels, increasing the number of rooms on campus from 500 to 650. The new hotel will feature a 700-seat, state-of-the-art conference center. The downside? Construction will take two years, during which time Jackman will hold all courses off campus.

The city is also taking steps to accommodate its growing convention business: Eight new downtown hotels are in the works, which will bring the room total to 5,000. And downtown hotels do have a greater appeal for attendees than on-campus facilities, Jackman says. Cleveland's new attractions also entice attendees. While confessing that she is a country music fan, Jackman says that the Rock and Roll Hall of Fame and Museum is a great place for receptions.

Content Counts Most While a few of Jackman's brochures picture the Cleveland skyline and include information on the local sights, most focus on content. Even the brochure for a summit on cholesterol and coronary disease held at a Disney resort in Florida, depicts such healthy treats as carrots and grapes rather than palm trees on the cover. It is superior content that brings physicians to CCF programs, Jackman insists, and the results of the CCF's CME 1998 survey of primary care physicians bears her out. Only 15 percent of the 307 respondents said that location was their prime motivator in attending courses, while 72 percent named program content as the number-one reason.

Challenging course directors to make sure they address physicians' real--rather than perceived--needs, she suggests sending questionnaires about upcoming courses to those who attended similar programs in the past. That serves a double function; it advertises the new course, and "lets attendees know we care," she says.

Jackman also gives course directors a sample needs-assessment form. "They just have to plug in [questions related to] their area," she says, "It's not like they have to develop their own tool." Nevertheless, she says, getting them to use the tool is difficult at times, and she has to keep reminding them: "You must always address the needs of the end-user."

That means not only picking the right content, but designing programs in formats conducive to learning. Case-based lectures, with audience interaction, are the most well-received programs, according to Jackman. A case in point: the Intensive Review of Internal Medicine course, a board review program now in its 11th year, is delivered in a case-driven format. The course draws capacity attendance because of its excellent content and format, says Jackman. And it works: Ever since the course became mandatory for senior residents, 95 percent of them have passed their internal medicine board exam.

The case-driven format worked in Mexico, too, when the CCF offered a similar course in Monterrey recently, in collaboration with the Asociacion de Medicina Interna de Mexico. The course was such a hit that the association has invited CCF back next year.

Physician Response To facilitate audience participation, the Internal Medicine course uses the CCF's electronic Audience Response System (ARS). Like similar systems, presenters ask questions, attendees enter their responses on a wireless keypad, and the results are projected on a screen in the form of a colorful graph.

An increasingly popular device, the CCF was one of the first to employ an ARS 10 years ago, says Jackman with pride. It is so integrated into CCF programming that ARS connectors are tucked under each of the 272 seats in the Clinic's Bunts Auditorium. Course directors pay a fee for the system and operator, but Jackman says it is more than worth it.

Of course, it is what happens after an educational program that is the true measure of its success. During a series of dinner meetings designed to inform family practitioners about hepatitis C screening, Jackman decided to go after those elusive outcomes--to find out if physicians actually changed what they did as a result of taking a course. She gave questionnaires to the attendees before the program, right afterwards, and two months later to assess whether they had altered their practice behaviors. She offered an incentive--a free monograph on the subject--to physicians who completed the survey. The resulting data could very well be publishable, Jackman says.

Questionnaires are just a first step in measuring outcomes, Jackman acknowledges. "It's a big problem [to assess outcomes]," she says, "without going into the physicians' offices." She continues to pursue the challenge. Part of a proposed CCF project, Internal Medicine in the New Millennium, involves outcomes studies. Without finding a way to measure outcomes, she stresses, you can't ascertain a program's effectiveness.

Out of the Cocoon It's past 6 p.m., after a long day, but Jackman isn't quite through yet. Over a working dinner with the director of the Center for CE, William D. Carey, MD, FACG, she discusses CCF's plans to move into the global medical education arena. While she enjoyed her first international meeting (the Intensive Board Review course in Mexico), Jackman learned that organizing international meetings is about 10 times as hard as planning domestic ones.

She wants to make sure that the CCF's program standards are upheld, no matter where the meetings are located, and even if most of the attendees are non-U.S. physicians. "My biggest thing is consistency," she says. "National, international, I don't care--when the Cleveland Clinic is involved, this is how it has to be."

She also intends to approach international CME with the right attitude. "I want to partner with the country's associations," she says, "to come in with respect, not like a steamroller."

Despite her ever-expanding workload, Jackman looks forward to CCF's growth, both domestically and internationally. "I believe you need to extend your horizons, to build bridges with outside entities. You cannot grow in your own cocoon," she says. "You must continue to reach for your dreams."

"I don't know what we were thinking," says William D. Carey, MD, FACG, director of CCF's Center for Continuing Education. With that dry comment, he proceeds to describe CCF's creation, in 1996, of its own for-profit subsidiary, Unitech Communications. The Cleveland Clinic may be the only hospital in the country to take such a leap.

Initially, CCF had worked with what is now called CME Services, Inc. to produce audio- and videotapes of educational programs. When CCF terminated that contract, the staff got together and decided to take it on themselves, recalls Donna M. Jackman, the CE center's administrator.

And so Unitech Communications was born. The original idea was that the company would produce educational materials and market them via direct mail. But they soon realized that products alone, sold through the mail, would not keep Unitech afloat. So, Unitech, in conjunction with the CME department, switched gears and solicited pharmaceutical companies to underwrite projects. Unitech now offers a variety of educational programs and products. That approach has worked. Jackman has learned that the products are not price-sensitive. If a physician prefers an audiotape rather than a video or CD-ROM, he or she will buy it, even if another version is less expensive, Jackman says.

Though there are drawbacks to being a for-profit--postal rates are double what they are for nonprofits, for one thing, hence Carey's initial comment--there is also a powerful advantage. Unrestricted by the bureaucracy that often hampers nonprofit groups, Unitech can seize on new ideas. "A small, for-profit organization can quickly respond to changing market forces," says Carey.

That responsiveness has garnered Unitech national recognition, including a Telly Award for outstanding non-network cable television programming, medical education category; and a Silver Apple Award from the national Educational Media Network.

Unitech has also increased CCF's exposure both internationally and nationally through product promotion and its partnering with other CME providers and commercial supporters. "It's like a third ear out there," Jackman says. "Unitech finds continual opportunities for growth."

The combination of CCF and Unitech is attractive to commercial supporters, says Jackman, because it offers a "one-stop shop." Some pharmaceutical companies complain that every provider and communications company has its own interpretation of Accreditation Council for CME Standards for Commercial Support, she says. "They want consistent messages." Supporters get that consistency at Unitech, where the staff is well-versed in the ACCME guidelines and works under the auspices of CCF's CE department--whose ethics police are on top of things if any company tries to bend the rules.

Members of the Interstate Postgraduate Medical Association view a demonstration of surgical procedures via a new technology closed-circuit television-at this 1962 conference convened by the Cleveland Clinic Educational Foundation. Fast forward to 1999: The whole clinic is connected via a Local Area Network (LAN), meaning conference attendees not only view surgery on large color screens, but can discuss the case-in-progress with the surgeons. Teleconferences are held regularly with Cleveland Clinic Florida in Fort Lauderdale. The CCF held 15 live-audience satellite conferences in 1998, as well as its first live online symposium, drawing 337 attendees from 34 nations.