How to makeCME work in an Outcomes-Driven World Remember the predictions that patients would become empowered members of the healthcare team? They're coming true, and

the pressure is on for real change in physician behavior. Is CME up to the challenge?

The post-polio patients at Chambersburg (PA) Hospital had finally had enough. They weren't receiving the right kind of treatment, and they knew it.

A group of 65 of them dubbed themselves "Pushy Polios," and, armed with information about care options, marched into the hospital president's office to complain. He sent them to the education committee chair, and Robert Pyatt, MD, FACR, clearly remembers the day the "pushy and proud" patients convened in his office.

"We are tired of inappropriate MRI scans and psych consults," Pyatt recalls them saying. "We are not crazy." Instead of designing a program with the 'experts,' Pyatt asked the patients, "Would you help me?"

Patients as Education Experts And so began an unusual continuing medical education (CME) initiative. The patients determined eight educational objectives and helped Pyatt find a speaker. Pyatt sent a personal invitation to the 20 physicians on the patients' hit list. Nineteen out of the 20 showed up. Pain clinic staff and physical therapists were also invited. Some of the patients attended as well, and patients and physicians engaged in spontaneous chat sessions after the program, Pyatt says.

According to the patients, the program changed physician behavior. Six months later, they told Pyatt they had noticed immediate, dramatic improvements in their care. To date, almost two years later, patients report the gains have been sustained.

Word of the program's success is spreading among the 350 post-polio groups worldwide. At the upcoming Alliance for CME meeting (January 28 to 31 at the Hotel del Coronado in San Diego, CA), the patient leader of the Chambersburg group will address a plenary session on the role of patients in physician education.

A New Model for Education "This is a really important model that we need to see more of," Pyatt says. "We

didn't go to the doctors and say, 'What do you think you need to learn?' We said to the patients, 'What do you need?' and then we converted that to physician education. That's a switch."

A switch that he forecasts will become a trend in CME. "There's a message for CME people: Patients are getting more empowered and educated all the time," Pyatt says. "We have to work with patients more, let them assume more of a role in their own care."

The already strong patient empowerment movement will soon grow more powerful, predicts Regina Herzlinger, PhD, professor of accounting at Harvard Business School and author of Market Driven Health Care: Who Wins, WhoLoses in the Transformation of America's Largest Service Industry. When the astute baby boomers reach their fifties and increase their use of the health care system, watch out, because "you haven't seen assertiveness [yet]," quips Herzlinger, adding that "[physicians] need to support the assertiveness of their customers."

A larger role for patients means at very least a changed role for physicians--and thus a change in physician behavior. Facilitating that behavior change, experts say, means incorporating the principles of adult learning into CME. "There is all this buzz about outcomes," Pyatt says. "But the traditional ways of lecturing doctors, and expecting them to dramatically change, [don't work]."

While many people are aware of adult-learning principles, the key is translating theory into practice, says Carol Jack Scott, MD, MSEd, FACEP, clinical assistant

professor in the division of emergency medicine, department of surgery, University of Maryland Medical Center, and senior partner in The Medical Education Group in Baltimore, MD. "There's a lot of data about adult learning," she says, "but how do you get the data from the bench to the bedside to help the real patient?"

Eight Great Ear-Openers Take heed from the Pushy Polios--and become a pushy planner. Here are eight ear-opening strategies that really work. Share them with course directors and faculty to create CME programs that really work to change physician behavior.

1.Get physicians to see a problem:"Principle number one of adult learning is that physicians won't learn solutions to problems they don't already have," explains Hank Slotnick, PhD, PhD, professor, department of neuroscience, school of medicine, University of North Dakota in Grand Forks. "If you want doctors to become more sensitive to patients' needs, doctors have to see that communication is a problem for them."

The Pushy Polios exemplify a means for putting that principle into action. "By just putting the doctors on notice that their patients said they needed to improve care," says Pyatt, "we found dramatic

improvements."

Another angle: Use physicians' concern about compliance to help them recognize their need to better communicate. "Ask: 'Would you like Mrs. Smith to be more compliant?'" says Slotnick. "If the answer is yes, then say, 'Let's talk about some communication techniques that might make her more compliant.' Make certain that people see participating [in programs] as satisfying their needs."

2.Involve physicians in solving their problems: Even if physicians have identified a learning need, the program won't motivate them to change if they don't actively participate in their own learning. Programs need to nurture physicians' reservoir of expertise and their readiness to learn, Scott says.

In small group sessions, facilitators have lots of options for involving learners. When conducting their experiential "Role Playing Difficult Patients and Solutions: A Workshop for Physicians," Jeannie Lindheim and Steven K. Shama, MD, MPH, ask participants to describe their most troublesome situations. "I get 50 [scenarios] up there on the board," Lindheim says. "They might say, the angry patient, the drug-addicted patient, breaking bad news. Then we take a vote. It's very democratic." Then, participants work on solving the problems they selected.

At the Bayer Institute for Healthcare Communication in West Haven, CT, facilitators use videotaped case studies to teach physicians how to better communicate with patients. The cases are drawn from actual practice, because, says Vaughn Keller, MFT, associate director for education, "physicians see through any kind of 'hoked-up' examples very quickly."

The facilitator stops the video at different points and asks participants, "What would you say now to this patient?" Every time participants solve a problem, they are given immediate feedback, "so they have some sense of the impact of what they have done," Keller explains. The participants comment on each other's strategies. "It's not simply the facilitator taking on the role of judge and jury," Keller says.

Physicians also present their own cases to the group. "Colleagues offer suggestions. They actually try to work through cases, so they go home with something specific," Keller says.

3.Let physicians learn from each other: Data suggests that physicians are most likely to change their behavior when they learn from each other. Participatory programs such as the ones described take the problem-solving that occurs spontaneously among physicians during hallway conversations and structures it into programs.

One reason bringing peer education into programs is so important, says Lindheim, is that physicians "work behind closed doors. They never see how anybody else [handles situations]." When role-playing how to break bad news to a patient, for example, physicians get to see "ten to twelve different, wonderful approaches," Lindheim says.

4."Leading edge" physicians are not necessarily leaders: Another way to integrate peer learning into CME programs is to identify opinion leaders--physicians who are influential in their communities--and train them as facilitators. "There is an assumption in CME that if you bring in the best expert, people come, learn, and change their practice behavior" says Don Nelinson, PhD, director of CME Services with Impact Communications, Inc., a New York City-based CME provider. "There is no data to support that. But conventional wisdom is hard to change."

What has been found, Nelinson says, is that most physicians rely on peers in their practice settings for advice and consultation. Why not tap into those relationships to maximize learning during CME?

Impact Communications identifies opinion leaders and puts them in a classroom with experts on a particular topic. The opinion leaders in turn educate their peers, either presenting on their own or team-teaching with an expert. The advantage of teams, Nelinson says, is the expert brings the creditability of a large, prestigious institution to the program, while the opinion leader offers reality testing.

5.Throw out the lectern: Obviously it is easier to structure peer education and learner involvement in a small group session, but there are strategies presenters can use to engage participants in large groups, too. Both the Bayer Institute and Impact Communications run faculty development programs that teach presenters these skills.

At Impact, that ubiquitous presenter prop--the lectern--is tossed out. Instead, faculty are given lavaliere mikes, to encourage mobility and audience contact.

Question-and-answer periods in large groups work well, as long as participants can hear each other's questions. Arrange for hand-held microphones for attendees. At an Impact symposium there are a minimum of three microphones in the audience. That's not all: Staff people are trained to read attendees' nonverbal cues. "We see when a doc is itching to say something," explains Nelinson. The physician is invited to comment, and, he says, "That inevitably gets people going."

Consider scheduling roundtables to ensure interaction. They are very popular among attendees, says Susan West, vice president, operations, National Managed Healthcare Congress (NMHCC), Wal-tham, MA. All NMHCC meetings include at least two roundtables, rather than breakouts with speakers. Each table has a moderator to keep the discussion going.

6. Seat physicians so they can talk to each other: The Bayer Institute uses the

"U" format. It's not novel, says Keller, but it works. "The facilitator interacts with the group in a way that is easy for everybody."

For larger sessions, one arrangement that works well to facilitate discussion is half-rounds--regular banquet tables set halfway for four or five people, all facing the front of the room, says West. The half rounds arrangement, while the most popular setup among her attendees, is not always practical, because it depends on the availability of enough large meeting rooms. A room that accommodates 150 people theater-style, for instance, will hold only 75 people in half-rounds. As a fallback, West may use full rounds of ten, which means some people will have to turn their chairs to face the speakers.

That solution is still more effective for generating peer discussion than a theater- or classroom-style setup. It is even more effective than placing chairs in semicircles without tables. "At a table, they feel the need to introduce themselves," she says.

When arranging for an unusual room setup, it's a good idea to inspect the meeting room early enough to make changes. Occasionally, West says, a convention services manager asks, "What do you want to do?" Also, try out the lighting. Bright light glaring in a speaker's eyes makes audience interaction more difficult.

7.Create opportunities for interaction: "Arranging chairs--that's the physical aspect," points out Scott. "Planners also need to create an interpersonal climate of learning." That means making sure the program hand-outs are easily accessible. And it means creating opportunities for people to meet with each other. "Make it easy," Scott stresses. "Some courses make it tough. How do you talk to the professors on the panel if they bolt out right after the session?"

To encourage faculty/participant interaction, schedule time for them to meet each other. Before a weight-management seminar, for example, Impact Communications holds a breakfast where the faculty talk to attendees. "It's not an informal roam and schmooze," clarifies Nelinson. "They are trying to identify specific issues of the audience. I was at a weight-management seminar in San Francisco and one in New York. The audiences at each had different needs and demands. We use faculty to do on-site needs-assessments."

8.Create opportunities for reflection: After sessions, "it is important for doctors to have opportunities to reflect on what they learned," observes Slotnick. Meeting planners should make sure there are coffee breaks where doctors will discuss what they have learned with their colleagues. Even if the speakers bolt out the door, "what is most important is that participants have the opportunity to talk among themselves," says Slotnick. "Our research suggests that doctors are more likely to process what they heard with other participants than with speakers, and are more likely to do so in informal than formal settings."

Do the Real Thing Finding out what patients want, and determining what physicians need to know, and then creating interactive CME is a lot of work. It's certainly easier to stick with the familiar lecture formats and expert presenters--or to fake a new approach.

"People know it's chic to say they apply adult-learning theories," says Scott. "There are many gimmicks people are using now to claim their programs are based on adult-learning theory, like just changing the sequence of teaching. Don't just use gimmicks," Scott challenges. "There is an opportunity to be innovative."

When It Works,They'll Come Back for More So far, research indicates that physicians really do listen--and change their behavior--when adult-learning techniques are put to work. Six month follow-ups of the Bayer Institute's intensive communication skills workshops, for example, show significant gains in patient satisfaction. And other studies show that when patient satisfaction and compliance increase, healthcare providers are also more satisfied with their work. If you can document learner and/or patient outcomes, you can use that documentation as an option in maintaining accreditation under the new guidelines set by the Accreditation Council for Continuing Medical Education.

Best of all, from the conference organizer's point of view, if your CME programs succeed in helping physicians solve practical problems, achieve better patient satisfaction scores, and feel happier at work, they are much more likely to return to your CME activities for more education.

And it is also rewarding for planners and educators to create programs that motivate physicians to change behavior--and, ultimately, improve patient care. Reflecting on his ongoing relationship with the "Pushy Polios," Pyatt notes that what started out as a confrontation has turned into a great experience. "I'm learning a lot," he says. "It's awesome."