Since 1992's one-two punch of renewed threats to regulate continuing medical education (CME) by the Food and Drug Administration (FDA), followed closely by the Clinton Administration's initiative to reinvent American healthcare, CME directors and coordinators seem to have spent a lot of time looking inward. The two big questions at the time were how to avoid regulation and how to survive a drought in commercial support.

Now, with a revised set of Essentials and Standards for Commercial Support--the self-imposed rules for producing and financing CME developed by the Accreditation Council for CME--and a final guidance letter on industry-supported scientific and educational activities from the FDA (see "Capsules," page 12), CME providers can finally look outward again.

This mood of the three-day 1998 Alliance for Continuing Medical Education conference was reflected in the keynote speech by Leland R. Kaiser, PhD, president, Kaiser & Associates, a Colorado-based health care consulting firm. He told the 1,000-plus crowd at the opening plenary session held January 29 at the Hotel del Coronado in Coronado, Calif., that CME providers who were wondering what kind of programs to offer their physicians had only to look to their own neighborhoods. He challenged attendees to adopt city blocks around their hospitals. While he focused on hospitals, he made it plain that any organization with the mission of educating physicians had only to open its eyes to find meaningful contributions to make in public health.

In addition to this being the largest-ever meeting (see the news story, page 12), there were more physicians present, more physicians making presentations, and more truly interactive sessions than ever before.

A theme of this year's meeting was applying CME to achieve improved health outcomes for the populations served by physicians. Each of the examples that follow shows interest in the particular field of medicine driven less by physicians and more by patients--and that the democratizing effect of the World Wide Web is in full swing.

ISSUE: What Do Doctors Know About Genetics? "Would you like to know 40 years in advance that you're going to contract Huntington's disease?" That question came from a site on the World Wide Web, and it is symptomatic of one of the most thankless, yet important tasks for CME providers in 1998, said Judith G. Ribble, PhD, director of CME for the National Center for Genome Resources (NCGR) in Santa Fe, N.M.: teaching physicians about genetics and genomics. She told the audience at an Alliance session on public health issues that there were many such controversial topics being discussed on the Internet. "If your physicians aren't reading these reports, I guarantee you their patients are," she said.

And what makes the task thankless? "Physicians do not like to learn about genetics. They're interested, but they won't come to CME courses on the subject," she said. "Yet they feel confident to counsel patients on genetic issues!" According to a recent study by researchers at Johns Hopkins University School of Medicine, non-geneticist physicians answered less than 74 percent of questions about genetics correctly. In short, a strong needs assessment is not the issue; it is to get physicians to recognize the need to learn.

ISSUE: Women's Health "We don't address issues tied to the menstrual cycle--like the changing effectiveness of drug dosages," said Elizabeth Lee Vliet, MD, head of Health Enhancement Renewal for Women, Inc. (HER Place), Tucson, Ariz. and clinical associate professor at the University of Arizona Health Sciences Center, also in Tucson. "Women are treated the same way as men, and when the treatment doesn't work they're told they're stressed and that they should see a therapist!"

Vliet told the audience that there was a need for CME that taught physicians what they never learned in medical school about the hormonal differences between men and women. Even when physicians do prescribe hormone treatment, "Over 80 percent of the estrogen prescriptions in the United States are for one brand--Wyeth-Ayerst's Premarin--in one dose."

She also pointed out that one of the biggest problems was simply one of failure to communicate. "Primary care doctors and OB/GYNs are prescribing different drugs and not talking about it," she said, giving case examples of women taking as many as 13 different medications at once, including three different antidepressants.

ISSUE: Violence Against Women "One million Canadian women are beaten each year by their husbands," said Jane Tipping, MEd, education consultant with the University of Toronto School of Medicine in Canada. "Physicians see it present as fractures, suicide attempts, eating disorders. . . . Abused women are often characterized as problem patients because they tend to develop files of vague complaints."

Tipping has begun a program encouraging physician involvement in the identification and management of violence against women. The year-old program, she said, included courses on getting physicians to understand the importance of the problem, to identify abused women, to intervene appropriately, and to make appropriate referrals to those trained in the issue. Her first foray in needs assessment with doctors was dismal. "Physicians told us they had no training in this issue, it wasn't their problem, and they had no resources to draw upon anyway."

Realizing that physicians were in fact the weak link in the chain of providers who care for abused women, Tipping began to work on raising physician awareness. Her programs are small--limited to eight people. "Partly this is because we sometimes find physicians themselves have abuse problems," she said. "And it is interactive, because we are working on sensitivity and communication skills."

ISSUE: Alternative Medicine "The Program in Integrative Medicine started two and a half years ago, and the field is being invented as we speak," said Susan Fleishman, assistant director of continuing medical education for the Program in Integrative Medicine at the University of Arizona Health Sciences Center in Tucson. "Interest in the field is consumer-driven, and there is enormous demand from physicians who want to be leaders in the subject in their own community."

It's called integrative because "alternative sounds as though it is opposed to conventional medicine," she added. The program, from which the CME offerings have developed, mixes physicians trained in Western medicine with practitioners of Chinese medicine, acupuncture, osteopathy, botanical medicine, and other alternative medicines. "Our practice list is somewhat arbitrary, but it's expanding," said Karen Koffler, MD, a fellow in the program.

The program was built around Andrew Weil, MD, who founded the Center for Integrative Medicine at the university. Weil is something of a celebrity in alternative medicine, and Fleishman said the initial conferences drew attendees on the strength of his name. "By the third session, this was no longer so," she said. "We began to find a wider audience." Fleishman's mailing list for the conferences has grown from a handful to 5,000--of which 80 percent are physicians. "Not all of them are coming to Tucson, but they want to know what we're doing," she said.

The issue of offering CME on this subject is a sensitive one. At the Professional Convention Management Association meeting (held January 7 in Kansas City), when asked about giving Category 1 CME credit for alternative medicine, Dennis Wentz, MD, director of CME for the American Medical Association said, "It is out there, and we want doctors to know about it. What we won't do is give credits for teaching doctors how to perform alternative medicine--unless it has been scientifically established."

Some CME providers are resistant to programs in alternative medicine for this very reason. "We had 1,100 people at an alternative medicine meeting at the University of Texas Southwestern in Dallas," said Claudia Stravato, MA, director of professional education at the school. "But the school refused to allow credit for medical school courses."

Koffler, who is receiving her first exposure to alternative therapies in the Arizona program, is well aware of the difficulties of talking about scientific legitimacy. "To use unresearched techniques is very difficult for all of us," she said.

Fleishman's advice for would-be organizers of conferences on alternative or integrative medicine was to be ready to screen speakers. "You'll be inundated by people who want to present. It's really difficult to sort out who has something worthwhile to say."

On a hopeful note, Fleishman pointed out that the Journal of the American Medical Association was running a series on "alternative complementary integrative therapies," which she saw as a sign of acceptance by the medical establishment.

She added that one of the largest groups of physicians attending alternative medicine sessions was surgeons, who came because "they were concerned about econo- mics--they wanted to know who was doing what."

Issue: Patient involvement The story of the "Pushy Polios" was told in our September/October issue ("Opening Doctors' Ears," pages 32-39). At the Alliance meeting, in an extraordinary session that included emotional outbursts from the audience, Robert S. Pyatt, MD, medical director of the Cumberland Valley Health Network in Chambersburg, PA, (and program director for the 1998 Alliance conference), gave the lectern over to Phyllis Bailey, MSW, a polio sufferer and a post-polio coordinator in Chambersburg, and Joan Headley, MS, executive director of the International Polio Network, St. Louis.

As Headley presented a chart stating that traditional medicine promoted "fear, anger, and hopelessness," physicians in the audience loudly objected that she was presenting a worst-case scenario and defended their own approaches to treatment. Still other physicians in the audience gave Headley support for her claims.

Pyatt's main point was that conference organizers seeking strong needs assessments--since physician need for information is key to attendance--had to go beyond just polling physicians. "Go to the people on whom the physicians have an impact," he said. "I believe this is a model for the future. What the patients say never ends up in a needs assessment."