Remember When You Thought You Knew Everything?
Trust the CME Folks to Remind You Otherwise

Muskegon cardiologist Gregory Bernath (M.D. 1980) has been attending the U-M Medical School's Summer Cardiology Update at the Grand Hotel on Mackinac Island every year for the past nine years. Like most physicians, Bernath receives hundreds of invitations to programs in continuing medical education every year, but most of them don't hold a lot of appeal, he says. It's the Summer Cardiology Update that has his loyalty. "I enjoy seeing what's at the forefront at a major institution like the University of Michigan Medical School," he says. Michael J. Shea (M.D. 1975, Residency 1982), professor of internal medicine, has directed the CME courses in cardiology for the past 10 years. He estimates that 30 percent of the attendees, like Gregory Bernath, return to the Summer Cardiology Update every year and another 40 percent return every other year.

Keeping physicians up-to-date with what's happening in their field is the major goal of the Medical School's programs in continuing medical education, as it has been since the Department of Postgraduate Medicine (now the Department of Medical Education) was founded in 1927 to direct such activities. The success of Michigan's CME courses is indicated by their sheer number, nearly 100 a year. Last year, 43 of the courses were presented in Ann Arbor at the Towsley Center for Continuing Medical Education (the first building in the nation constructed primarily for continuing medical education), 11 were presented in the Detroit metropolitan area, 18 were presented in conjunction with national meetings in major cities across the U.S., and 20 were presented at resorts like the Grand Hotel.

Over the decades a number of factors have expanded the need for continuing medical education at the Medical School. New clinical knowledge has been generated at an increasingly rapid rate for over a century. A trend toward specialization of physicians began during the World War II years with a subsequent enormous push to establish community-based residency programs all over the state of Michigan during the tenure of Dean Furstenberg. A major impetus occurred in 1976, when Michigan became the first state in the nation to require doctors to attend an average of 50 hours of CME instruction per year as a condition for relicensure. (While it benefited his field, Roland "Red" Hiss [M.D. 1957, Residency 1966], chair of the Department of Medical Education since 1982, considers the legislation, which was aimed at reducing malpractice, to have been misguided. "It was a silly idea," he says, "since most malpractice is not a result of lack of education.")

Besides keeping physicians current with developments in their fields, CME programs serve an additional function: they provide the U-M Health System with a means of showcasing its physicians and their work and reinforcing the ongoing relationships they have with physicians around the state. Van Harrison, Ph.D., director of the CME program in the Medical School for the past 17 years, indicates a measurable link between physicians' attendance at CME programs and subsequent referrals to the U-M Health system. "Physicians who have taken our CME courses refer perhaps 50 percent more patients to us than those who haven't," he says. "And it works the other way as well: we find that referring physicians who are happy with the care their patients receive at U-M tend to become attendees at our CME courses." Michigan's CME program recently was reaccredited by the Accreditation Council for Continuing Medical Education for a six-year period, putting it in the top seven percent of CME programs nationally.

Thomas Schwenk, M.D., chair of the Department of Family Medicine, has been overseeing CME courses in family medicine for 20 years. "As an academic physician, I feel I have a duty to be a resource to practicing family physicians," he says. "And I find the one-on-one interaction with them to be enormously rewarding, especially when I can help somebody solve a problem."

The success of any CME course rests largely on the same factors that always make for great teaching: lively, informed teachers, and material that speaks to the interests and needs of the participants. Harrison describes the most successful CME presenters as "translators," people who are good at taking the latest in scientific and medical information and putting it into a practical context that relates to the immediate concerns of those in the audience.

There will always be one constant in the continuing education of physicians — the need, first noted by the regents of the University more than a century ago, for doctors "to keep abreast of modern advances in practice."

Will CME's traditional person-to-person classroom mode survive the information revolution? Van Harrison thinks it will, at least for a long time. "Most doctors don't like sitting in front of a computer screen for extended periods of time, " he says. "And a computer can't substitute for the complex human interaction among physicians that takes place during a class." Bernath, the Muskegon cardiologist, agrees. "It's the one-on-one I especially like," he says. "Teleconferencing is not the same, and a CD or Web site is not as enjoyable either."

Hiss thinks it may be time, though, for a new model of continuing medical education, one that might be described as more succinct, more targeted, more precisely aimed at a physician's specific needs. Hiss has had a lot of time to think about the best way to educate physicians: he's been involved with education in the Medical School for more than 30 years. "The primary care physician seeing adults probably has between 15 and 20 diagnoses that he or she makes frequently," Hiss says. He envisions somehow packaging what's important and new in managing those 15-20 conditions so that the physician can access the information when it is needed. Hiss's logic is simple: nobody really learns anything, really absorbs anything, until they desperately need to know it.

But how will the physician access the information? Will it be on the Web? And how will it be paid for? Hiss doesn't have the answers yet, but he and Harrison are both acutely aware of the competition they face from drug companies with their own reasons for wanting to provide physicians with clinical information related to the specific drugs they are producing. As new drugs have been developed at an increased rate, Hiss and Harrison have seen a worrisome increase in the flow of money from drug companies to CME programs.

Harrison was involved in the early 1990s in helping to develop national guidelines for commercial involvement in CME activities, but both he and Hiss remain highly concerned about commercial influences on physician learning. But they also see the advantage: reduced costs for those attending. Harrison estimates that an average day of CME, because of various subsidies, costs the physician attendee about $130, compared to an average $980 per day for attendance in the U-M Business School's executive education programs. CME at Michigan has its high-priced programs, too, however: the vascular intervention course, with attendance limited to six physicians, costs $2,000 for four days of training.

The larger questions that have challenged people like Red Hiss and Van Harrison for years remain: How does a physician keep on learning? What separates those who do from those who don't? What works best? What works at all? And how do you know when learning has taken place? After all these years, Hiss remains modestly insecure about the effects of his work. "Measuring physician behavior is difficult if you don't have access to their records to see what they did," he says. "There's no way to know if something they learned here subsequently changed their behavior." Harrison, though, is optimistic that research on the effects of various kinds of physician education may became easier as clinical and administrative databases are linked with one another and with third-party payers.

Whatever answers may present themselves, there will always be one constant in the continuing education of physicians — the need, first noted by the regents of the University more than a century ago, for doctors "to keep abreast of modern advances in practice."

For more information, visit the Web site of the Department of Medical Education at http://www.med.umich.edu/meded/.

Eighteen Years Running and Still Hot:

Pathologists Can't Seem to Get Enough of Bruce Friedman's Automated Information Management in the Clinical Laboratory

One of the most popular and longest-running CME courses at Michigan has never attracted interest based on its catchy name, but it doesn't have to: the Automated Information Management in the Clinical Laboratory course in pathology has been running for 18 years and attracts about 250 registrants every year from all over the world. Run since its inception by Bruce Friedman, M.D., professor of pathology and director of pathology data systems, the course brings together professionals in pathology — physicians, laboratory managers, pathology administrators, technical people — and vendors who pay a fee as exhibitors. Such is the stature of the course, and Friedman's interest in making it a great resource for professionals in his field, that a number of outside organizations are also invited to take part. This year they included the Clinical Laboratory Management Association, the College of American Pathology, and the American Association of Clinical Chemistry.

Reaching Out:

The Medical School Has Been Doing It Since the Very Beginning

In his dedication address on March 27, 1969, when the Towsley Center for Continuing Medical Education opened, the late Harry Towsley (M.D. 1931, Residency 1934) noted that the history of continuing medical education at Michigan was a long one, going all the way back to the School's beginnings. Towsley, chair of what was then called the Department of Postgraduate Medicine, referred to what he called "a monumental historical document" by Victor Vaughan, A Doctor's Memories. In A Doctor's Memories, Vaughan had written that Moses Gunn, professor of anatomy and surgery, announced to the physicians of the state in the 1850s that "…the forenoons of Wednesday and Saturday would be devoted to consultations with them over their difficult cases. Emergency cases would be seen at any time," and that "there would be no charge to either the doctors or their patients so far as these consultations were conducted in the presence of the students."

A resolution by the regents in 1878 stated in a more formal way the School's responsibility to reach out to physicians in the state, stating that "any graduate of any respectable and recognized medical college who may desire to attend the medical courses in this University be permitted such attendance on the payment of the usual matriculation fee only."

James D. Bruce, a Saginaw physician who became a member of the Medical School faculty in the 1920s and was chair of the Department of Postgraduate Medicine from its founding in 1927 until his retirement in 1942, contributed a chapter on postgraduate medical education to Wilfred B. Shaw's The University of Michigan, an Encyclopedic Survey (U-M Press, 1951). He noted that the regents in 1892 again authorized the faculty of the Department of Medicine and Surgery to admit physicians and "in a forward-looking policy, provided an opportunity in this country for the medical graduate to keep abreast of modern advances in practice," offering to them not only "already established courses, the subject matter of which has been greatly increased since their graduation," but also special courses in "hygiene, bacteriology, electrotherapeutics, microscopic and gross pathology, physiology, histology, chemistry, and therapeutics." The courses, Bruce noted, were given "once a year, in the summer, and were usually six weeks in length."

Van Harrison, the head of continuing medical education in the Medical School for the past 17 years, attributes Michigan's leadership in this area to three factors, including the School's longstanding mandate to reach out to the state's physicians. He also credits the program's success to the presence of a large number of physicians in a single institution unified by their teaching mission, and a series of directors who, by virtue of their mostly lengthy tenures, have been able to build extensive relationships with physicians throughout the state of Michigan.