For medical conference organizers who struggle from year to year with parsimonious budgets, recalcitrant boards, and self-absorbed course directors, it really does seem impossible to believe that for three consecutive years, CME Information Services, Inc. (CMEIS) in Mount Laurel, NJ-a company that is at least nominally in exactly the same business they are-has made Inc. magazine's list of the country's 500 fastest growing private companies. Founded in 1989 by Louis J. Bucelli and Timothy I. Crouse, the company grew from revenues of $100,000 its first year to $10 million in 1995, with a substantial increase projected for 1996, far outpacing the 20 percent annual growth expected of small businesses. "We've been packing five years growth into one year," Bucelli says. "It makes life pretty entertaining."

Exponential growth? Millions in revenue? In CME? How does he do it?

Easy: He treats physicians as customers-and customers come first. And not so easy: He became the first provider to package CME programs on video and audiotape, and now produces and markets programs sponsored by such premiere medical institutions as the Mayo Clinic, Johns Hopkins Medical Institutions, and many others.

Local Meetings With National Reach His vision continues to redefine CME. Last year, CMEIS acquired the Chicago-based National Center for Advanced Medical Education, and appointed Sue Ann Capizzi, formerly the associate executive director of the Accreditation Council for Continuing Medical Education (ACCME), as its president. His next goal is, once again, to offer a first-of-its-kind product. Bucelli imagines a whole new concept in the distribution of CME: multimedia training centers.

The centers, to be launched through the National Center, will offer live CME programs in regional settings, and then link them interactively, via phone lines or satellite, to live audiences elsewhere.

With increasing time and budget constraints, physicians are finding it harder to justify traveling hundreds of miles to attend meetings. This way, says Bucelli, "a physician in Los Angeles can benefit from things happening in New York or Atlanta or Denver, without having to travel."

A High-Tech Conduit for Information But the centers have yet another purpose-to provide more individualized CME, something Capizzi and Bucelli foresee as a future trend. Bucelli wants to help physicians assess their own strengths and weaknesses, and develop their own CME plans. The learning centers would act as conduits for information, offering not only National Center content, but content from Mayo and Hopkins and UCLA and national specialty societies, says Capizzi. If a physician needed assistance with a particular problem, he or she would have access to all that information, and thus be more likely to find a solution.

The multimedia centers are very much an idea-in-progress, Bucelli and Capizzi emphasize, and won't be launched until at least 1998. "It looks like an opportunity to revolutionize CME delivery," says Capizzi.

Part of that revolution will include fostering teamwork among sponsors, Capizzi believes. Her goal is for the National Center to lead the way in developing networks of sponsors.

"When I think about the National Center's relationship to the 570 other national sponsors and 2,200 state accredited sponsors, I'm not overwhelmed by the fact there is competition," she asserts. "I'm excited about the potential for partnerships. Together we can do greater things."

Two Million Hours of CME Bucelli's vision was to widen the audience for CME by delivering it to physicians who were unable to attend meetings. Bucelli has been able to realize that goal. "The reality is," he says with pride, "that in seven years, together with our medical sponsors, we've delivered over two million hours of CME to 60 million physicians worldwide."

It all began, appropriately enough, on Independence Day in 1989, when CMEIS videotaped a Gimbel Eye Foundation program on cataract and refractive surgery in Canada. One-half of the 375 delegates bought the tape. "We thought, whoa, this is kind of cool," Bucelli recalls. "We're on to something."

The new company was a collaborative effort, Bucelli says. In fact, the idea of videotaping programs came from a resident. "The premise was that information being communicated at these meetings is visual in nature," says Bucelli, "and the natural thing to do is videotape because that is a visual medium."

Customer surveys revealed that physicians also wanted to listen to materials in their cars. While the next step was clearly audiotape production, Bucelli resisted. "I was probably the hardest headed," Bucelli says. "I kept saying, 'no, no, we are a video company'." The audiotapes, which include entire meetings and all collateral materials, are now selling faster than the videos. "It goes to show-you need to listen to customers," Bucelli says.

Video Increases Attendance Bucelli, whose background is in health finance, says that when he first introduced CME on video, he encountered some resistance from the CME establishment. When approaching large medical institutions, he had to show he was "not out to jeopardize all the good stuff they had developed over the years."

One concern was that by capturing information on media, attendance would decrease. "It turns out, the exact opposite happens," Bucelli says. Because of the company's marketing efforts, physicians can preview meetings on video or audio, and that has resulted in increased, not decreased attendance. "That made us feel good," Bucelli says, "and really convinced our medical sponsors."

Fears that technology will supplant meetings are groundless, say Bucelli and Capizzi. No technology can ever replace the eyeball-to-eyeball contact and spontaneous exchange among presenters and attendees that happen at live meetings, they declare.

The Mantra: Customer Satisfaction Whatever the distribution method, the single most important element in creating successful CME, say Bucelli and Capizzi, is developing physician-centered programs. "It sounds simplistic," says Capizzi. "But never forget that the physician is the focus-from educational content to faculty selection to delivery mode. If we fail to recognize this, we fail completely." And that means being "absolutely dogged" about finding out what physicians need, she adds.

Physician-centered CME doesn't stop with program content. Capizzi and Bucelli have adapted the business world mantra: customer satisfaction. "We call them our guests," says Capizzi of attendees at National Center meetings. From the employees who handle the phones at the National Center to the onsite audiovisual consultants, she makes sure her staff people know it is their job to ascertain and fulfill participants' needs. The National Center has even hired its own meetings concierge, who will provide attendees with information on everything from babysitters to restaurants. "We really want to take care of the care givers," Capizzi says.

That commitment to customer care, and businesslike assessment of the marketplace, will continue to drive Bucelli's growth. "I don't believe in that 'If you build it, they will come,' " he says.

As to where CME will be in five years, Bucelli gives a response that underscores what will not change about his approach: "The future depends," he says, "on where customers want it to go."

It was 1972 and a new lab technique, competitive protein binding, was sweeping the nation. Sue Ann Capizzi (right), who had just graduated from DePaul University with a degree in medical technology, was recruited by the American Society of Clinical Pathologists (ASCP) as director of education program support services. "I was setting up gamma counters and refrigerating centrifuges in hotels across the country. The technology was hot, and the pathologists and technologists were excited about learning. They were going back in droves to set these up in labs," Capizzi recalls, her voice vibrant. "It was real exciting to be part of that. I was hooked."

Twenty-five years later she remains passionate about CME. "It still kind of amazes me when I hear people say, 'Does CME really do anything?'" Capizzi says. "I have a voracious appetite for results. I saw it as active in changing behavior in patient care."

From ASCP, Capizzi joined the Illinois State Medical Society, where she was vice president of education and licensure, gaining experience in regulation issues.

She achieved national prominence as associate executive director of ACCME during the turbulent years of threats of direct regulation by the Food and Drug Administration and the Clinton administration's healthcare reform efforts.

This past August her career came full circle when she was appointed head of the National Center for Advanced Medical Education, which had just been acquired by the for-profit CME Information Services, Inc. (CMEIS). When CMEIS president, Lou Bucelli, approached her, her first response was, "no, no, no." But the lure of creative freedom is what finally convinced her to make the big leap. "Less bureaucracy provides us with greater opportunity for creativity," she says. "It is that, quite honestly, that drew me to the position."

Asked how she feels about moving from a regulatory agency to a for-profit provider she says, "I always had a certain sense of denial that I was ever a regulator." Her dedication to CME allows her to transcend differences. She defines her role as an advocate for physicians. "I believe that wherever I am, in any setting, what I am doing is making education more valuable to physicians," she says.

Lou Bucelli, president of CME Information Services, Inc., is hardly alone when it comes to innovation in CME. We also went to four CME professionals with reputations for inventiveness, and asked them what they thought were key factors for designing successful CME in today's market.

The most crucial element, they all agree, is recognizing that physicians are the experts about their own learning, and that providers need to listen to them. To help him find out what participants want, John L. Schwartz, MD, FAPA, chair and CEO of for-profit Continuing Medical Education, Inc. in Irvine, CA, conducts numerous forms of needs assessments. He telephones not only physicians who have attended meetings, but those who have never come, asking, "Why not? What do you really need to learn?" He puts written surveys in his publications, and posts an ongoing survey on his Web site. He scans more than 200 publications every month, tracking new developments.

But doesn't asking physicians what they want and giving it to them amount to a kind of pandering? Not if you ask about problems, rather than ask what might be appealing. For example, Suzanne Ziemnik, MEd, director of CME, American Academy of Pediatrics (AAP), Elk Grove Village, IL, says, "Programs must be centered around participants' problems." She adds that this is a characteristic of adult learners: They want solutions to problems they actually have.

Hunt for Excellent Speakers Exciting and practical content will fall flat if the speaker can't grab the audience. Select speakers for their ability to communicate, rather than their research credentials, suggest our innovators. Using a variety of sources can help you discover new talent, says Ziemnik. Like most specialty societies, the AAP relies heavily on expert opinion to select speakers. But Ziemnik doesn't stop there. "We try to reach out from the inner circle," she says, "to all the subspecialty groups in pediatrics." The Academy has a sophisticated Faculty Information Management system-an online database that includes information and evaluations on every one of the few thousand faculty members AAP uses in a year. And, as always-listen to participants. Ziemnik goes directly to her attendees, who are asked to make recommendations in their evaluations. And she values those recommendations. "We're not an organization that does evaluations for paper's sake," Ziemnik asserts.

What, No Experts? Listening to an expert lecture won't lead physicians to change their behavior. But recent research indicates that they do change when they consult with peers-and behavioral change is the Golden Fleece of the outcomes-based CME movement. Richard F. Tischler, PhD, former director of CME at the Baltimore-based company COMSORT, and now president of RF Tischler Jr & Associates in Mt. Airy, MD, explains that in everyday hallway conversation, physicians share problem-solving strategies, and as a result, evidence suggests, they do change their behavior. Tischler is now helping develop a peer learning process based on the hallway conversation model.

Physicians Will Pay to Learn When providers create programs that really meet physicians' needs, physicians will pay to attend, asserts Michael Kessler, MD, president of Medical Communications Center (formerly Physicians Medical Seminars) in Atlanta. His programs have never even been accredited, but he has achieved success-for precisely the same reasons he seems to get the skunk-at-a-garden-party treatment from the CME establishment. Because he is an independent, for-profit company, free of the constraints of slow-moving CME committees and nonprofit bureaucracies, he can react to the marketplace and offer programs years before they are deemed acceptable by the big medical centers and societies. He became the first provider to offer programs in specialties geared for non-specialists, and in the early 1990s, several years before the advent of managed care, he switched from the clinical to the communications arena, running programs on patient/doctor communication. Kessler had tried to sell communications programs in the 1980s, but says, "I couldn't give it away. [The attitude was] doctors need to do what they need to do and to heck with the patient." Then managed care hit, and people started listening.

The Fast Eat the Slow But Kessler is used to being regarded with skepticism. What he and other innovators have in common is the courage to implement new approaches in the face of sometimes virulent opposition. And like others we spoke with, he has a special understanding of how CME has changed. Specialty society and medical center boards that were designed to maintain stability but instead are obstacles to change make it easy for entrepreneurial innovators to thrive. Once upon a time, the big ate the small. Today, the fast eat the slow.