Despite having to move its meeting from New Orleans to San Francisco after Hurricane Katrina struck last fall, the Alliance for CME drew more than 1,350 attendees to its 31st annual conference, held January 25 to 28. Several attendees said that they thought the educational offerings this year—which covered everything from systems theory to needs assessment to commercial support—surpassed any previous Alliance annual meeting.

R. Van Harrison, PhD, professor of medical education and director of CME with the University of Michigan Medical School, Ann Arbor, kicked off the conference with a plenary presentation that introduced the concept of systems theory. This theory proposes that every living system, from a cell to a global society, is affected by factors in its environment, has its own way of doing things, and creates something of its own. What is output at one level can serve as input at another level. For example, in the healthcare environment, there are systems of scientific discovery, social resources, healthcare as a whole, and medical education. Each of these systems can affect how physicians learn and what they do with what they learn.

“In medicine, the focus tends to be on the biological level. [People in medicine] tend to have blind spots in other areas of the system where they don’t have training,” Harrison said. He pointed out that physicians live in larger systems, and those issues are not usually addressed in CME. It’s not enough just to point physicians toward new clinical information in journals. CME should help physicians translate that information into something they can actually use in their practice environment.

“I see my role as protecting the public from academic physicians,” Harrison said with a smile. “They generally don’t know the realities of daily practices in a smaller setting,” including the cost of implementing a new treatment. “If they recommend more costly treatments, they have to provide justification for the added cost,” he said.

One example of systems-based CME for his organization, he said, could be activities about mammography for women who are over 50 years of age. “Our physicians don’t need more of the usual CME on mammography. They need to be able to translate it into practice.” One way to do that, he said, could be to provide a system that allows physicians to check against the electronic medical record to see which patients are due for a routine mammogram, and send those patients a letter that lets them go straight to the mammography center. “This would allow doctors to use their time to focus on high-risk cases.”

The bottom line, said Harrison, is to recognize that your CME unit is a system of its own and a subsystem of a larger framework of systems. To make sure your CME works within this framework, he said, CME providers must prioritize the topics they tackle in activities, and address all the information physicians will need to translate what they learn into practice, from the biological and psychosocial levels to operational and financial realities. (A PDF of Harrison’s slides is available at the Alliance for CME’s Web site,

Real-World CME

Putting this type of systems thinking into action in the real world of CME can be difficult, however. Bernard Marlow, MD, director, CME/CPD with the College of Family Physicians of Canada in Etobicoke, Ontario, spoke on a panel following Harrison’s presentation about a survey his organization did of family physicians, most of whom work in different settings, each of which has its own barriers and challenges. Based on the results, the College decided to abandon “one-size-fits-all” CME, since it didn’t address the specific needs of different individual settings. It also decided to inject more interactivity into sessions, so physicians can get a more real-life feel for what they’re learning. It resolved to think of clinical practice as being “one big classroom,” and to find ways to give credit for point-of-care learning.

Outcomes measures can also point to system barriers. After a one-day, intensive course about using spirometry for people with lung disease, the College asked the participants to sign a commitment to change. But six months later, only 40 percent were using the test. The problems they had in implementation had nothing to do with what they learned: There were system problems, such as the procedure not being covered under provincial insurance. It was a big wake-up call, he said.

Marcella Hollinger, MEd, director of education and accreditation, Illinois State Medical Society, Chicago, said her organization is starting to see some of its community hospitals melding their CME and Quality Improvement committees, so they are essentially functioning as one committee. So the CME committee can look at QI data, determine that a particular procedure is being overused, design an intervention, and follow up with further review of QI data to see if things have improved.

In addition, her organization has used its relationship with a medical malpractice group in Illinois to spur some changes. The insurance group has a risk-management process by which it conducts individual practice audits. It then gives the practice recommendations for improvement, and gives a 10 percent discount to those who pass the audit.

Starting in 2006, Hollinger’s organization will hook into that system by partnering with the insurance group in three phases: Phase 1 will ask the practicing physician what he/she will do to implement change; Phase 2 will ask what they learned by undergoing the audit process; and Phase 3 will explain the changes that were implemented and how they were implemented. Physicians can get up to 20 AMA PRA Category 1TM credits for participating in all three phases.

Barbara Huffman, MEd, CME manager, Carle Foundation Hospital, Urbana, Ill., said, “If your administration changes, your processes and culture change along with it. “Your system will always have an effect on you,” she said.

AMA Update

Near and dear to CME providers’ hearts is another system: that of the AMA PRA Category 1 CreditTM. At a packed session, American Medical Association representatives outlined four areas that are new for 2006. The first is that providers need to call it AMA PRA Category 1 CreditTM (including italics and trademark symbol, preferably superscripted), the first time they use the phrase in any publication, and they should scatter the full phrase in a few more times as well. This is to protect the AMA’s intellectual property through trademarks (the italics make it clear exactly what is trademarked). Providers also have to use a revised designation statement in their materials, which is available in the AMA Physician’s Recognition Award Booklet 2006 revision, which can be downloaded from the AMA Web site,

The AMA will not begin monitoring for compliance until July 1, 2006, to give providers time to make these changes to CME materials.

Another change is that providers no longer have to undergo a provider application process to make international physicians eligible for AMA PRA Category 1 Credit. The AMA has taken out the “U.S. licensed” requirement. So that CME providers don’t have to keep track of all the non-U.S. degrees, the credit claim form now just asks, “Are you a physician?” The AMA is, however, updating its database to allow non-U.S. designations.

Another change is that accredited providers now can award AMA PRA Category 1 Credit to their live-activity faculty. Faculty can earn two AMA PRA Category 1 Credits for each 60-minute teaching period, but they can’t claim credit for both teaching and learning at the same activity. But they can claim credit for other activities held in conjunction with the one they’re teaching. This policy also goes into effect July 1, 2006. The AMA also has been adopting performance improvement activities into the list of formats approved for AMA PRA Category 1 Credit, and this year, it has added Internet point-of-care learning to that list.

For more on the conference, click here.