Continuing Medical Education and The Anesthesiologist

The majority of states require physicians to attend and verify completion of continuing medical education (CME). Subsequently, a wide variety of postgraduate CME activities are available with different formats in varied locations for every subspecialty of organized medicine. Anesthesiology is no exception. The financial responsibility is often partially or completely assumed by the physician’s employer, be it a hospital, foundation or group. Those who absorb the cost themselves, often designate this activity as a business expense, and the cost (at least in part) becomes a tax deduction. Society membership frequently entitles members to reduced tuition, but travel expenses remain.

Since there are so many ways to meet CME requirements and resources are considerable,(1) the question often asked by Anesthesiologists and their employers relates to quality and value of CME courses. This presentation attempts to address which CME activities within Anesthesiology are the most effective. The following topics are covered; 1) what is available, 2) how it is presented, 3) reasons for participation, 4) funding, 5) evaluation and 6) future directions.

CME Options for Anesthesiologists

The American Society of Anesthesiologists provides a biannual publication in January and July to all of its members, entitled: “Calendar for Meetings”, which is the most comprehensive listing of CME activities within Anesthesiology. The 1998 edition of Calendar for Meetings lists 250 different CME activities within the United States and Canada, an additional 40-50 abroad, and some with related topics of interest to anesthesiologists, such as Echocardiography, Advanced Neurological Monitoring, Internal Medicine and Cardiology. Potentially, there are as many as 400-500 courses held annually which would provide CME credits for an Anesthesiologist.

In addition to formal lectures, there are a variety of self-study programs that provide opportunity for CME credit. The best known of these programs is the American Society of Anesthesiologists (ASA) Self-Evaluation Examination (SEE), which is provided to members for a nominal fee. The program includes a biannual test to be taken by the participant, a critique of the questions and a bibliography. If the test sheet is completed and returned to the SEE office, CME credit is awarded. The direction of the SEE task force, as determined by the ASA, is to service the educational needs of the Anesthesiologist in practice as opposed to the needs of anesthesia residents preparing for the American Board of Anesthesiology (ABA), In-Training or Written Board Examination.

The structure CME activities varies widely. The highest profile are the 4-5 day national meetings of the American Society of Anesthesiologists and the International Anesthesia Research Society (IARS). These offer the greatest number of contact hours per meeting and a wide variety of options, possible because of their size. There are also a large number of annual state society meetings, such as New York’s (NYPGA) and California’s, which attract large numbers of registrants, have large amounts of resources, and offer many courses. Smaller state societies typically offer 1-3 day courses with a smaller number of CME hours. Their appeal lies in their geographical proximity to their membership, scheduling on weekends when clinical activity is low, and their low tuition cost. Large city and county societies often provide similar activities on a yet smaller scale, usually for a single weekend day or weekday evening.

Subspecialization in Anesthesiology has proliferated and societies, such as the Society for Education in Anesthesia (SEA), the American Society of Regional Anesthesia (ASRA), the Society for Ambulatory Anesthesia (SAMBA), the Society for Cardiovascular Anesthesia (SCA), the Society of Pediatric Anesthesia (SPA) have been formed. These society meetings offer a forum for the gathering of individuals with similar subspecialized interests and allow a vehicle for the presentation of very focused research. They often offer technical refresher activities for the non-specialized clinician who foresees an increasing need to provide services in those areas or wishes to attend just for interest.

Among the freestanding meetings aimed principally at postgraduate education, the Review and Refresher Courses predominate. Review courses aim to be comprehensive, lasting 4-5 days, and provide a high number of CME hours, but they also have a relatively high registration fee. These courses attract distinguished faculty and are often used by residents and those who have recently completed residency in preparation for the written portion of the Board Certification process. The new recertification examination for Anesthesiology has also stirred interest in the review courses for those planning to take the Continued Demonstration of Qualifications (CDQ) exam of the ABA. Refresher courses on the other hand attempt to cover small focused areas in Anesthesiology comprehensively. Single subject didactic courses might pertain to a subspecialty, such as pediatric anesthesia and workshops focus on areas like difficult airway management. Panels can include discussions of new drugs, products or techniques.

Reasons for CME Participation

State and Licensing Boards

In 1995, the majority of states required documentation of CME to renew medical and paramedical licenses. The majority (21/23) of subspecialties (91%) accredited by the American Board of Medical Specialties have either recertification programs or a time-limited certification of credentials.(2) State programs in Michigan,(4) Connecticut,(5) Minnesota(6) and Washington(2) specify requirements for type and amount of credit hours. Some credits can be earned through self-instruction, although a percentage must be documented, are subject to audit, and have penalties associated with non-compliance. Recertification

Recertification should stimulate modern practice and encourage ethical behavior.(3) The American Board of Anesthesiology has recently adopted a policy for a 10-year duration of initial ABA certification to take effect after the year 2000. This would complement the already existing CDQ program. Some mandatory recertification programs incorporate required CME.(7) The quantification of physician CME in “units” was driven by the AMA, which also developed the American Medical Association/ Physician’s Recognition Award (AMA/PRA) and developed the American Council for Continuing Medical Education (ACCME). The ACCME defines and controls CME activities for the AMA/PRA.(8) Further development of self-directed learning and CME research are the future goals of the ACCME.(9) Similar activities exist with the Royal College of Physicians and Surgeons of Canada(10) and the American Osteopathic Association.(11) Subspecialty Recertification is described in detail for Obstetrics and Gynecology is Australia by Nambiar.(12) Risk Management and Quality Assurance

There has been some interest in linking CME with risk management.(13) One example, not related to Anesthesiology, occurred in Massachusetts and focused on the issue of proper deep venous thrombosis prophylaxis.(14) A follow-up questionnaire designed to evaluate the DVT information program confirmed increased DVT prophylaxis in the practice of those who participated and presumably improved patient outcome, since DVT is the leading cause of in-patient morbidity. Almost two-thirds of 127 medical schools surveyed regarding CME activity responded that they had been driven primarily by risk management.(15) The rapid advancement of biomedical science also has contributed to the linkage of CME with quality assurance. New technologies are evolving from experimental to “standard of care” in progressively shorter intervals.(16,17) The concept of the need to keep current with new drugs, devices and procedures is presented by Curry.(3) Retraining individuals is as essential as retooling older manufacturing plants and must be done effectively and efficiently. Remedial CME

In medicine, critical incidents, litigation and peer review have created the need for remedial CME. Several states have formal programs, summarized in table one.(18,19,20) In the state of New York, about 200 physicians are censured annually and required to take remedial CME, programs which were developed by the Deans of the Associated Medical Schools of New York.(18) Evaluation of remedial CME may be best modeled after undergraduate medical education.(20) Internationally, in New Zealand, an anesthetic mortality reporting system is the basis for the material selected by the Continuing Education Committee.(21)

Table One.

Remedial CME Programs

State	Title	Location	Comments
New York	Physician-Prescribed Education Program	Syracuse University	At site and Home Practice (38)
Oregon	Individualized Physician Renewal Program	Home Practice Site
Maryland	Physician Remedial Focused Educational Program	University of Maryland	Targeted CME
Colorado	Personalized Education Program for Physicians	Home Practice Site	Targeted CME. Accepts Self-referral
North Carolina	Clinical Enhancement Program	East Carolina School of Medicine	Consultation and Rural Support
California	Professional Competence Assurance Program	Administrative	Record Review-Driven Directed CME
Iowa (39)	State Medical Board	Administrative	Directed CME and On-Site Follow-up

There are other reasons for attending CME activities. Invited speakers attend to teach and lecture. Others attend to facilitate administrative work within the sponsoring organization. Preparation for primary and sub-specialty certification (i.e. Pain, ICU) and CDQ constitute significant reasons for CME attendance.

CME attendance can also be favorably influenced by needs-assessment surveys(23) and tailoring subsequent activities to those needs. A general interest in medicine as a whole and socioeconomic impact of disease will always be a part of the motivation for CME.(24) Since the practice of medicine involves interactions of human beings, CME can involve the teaching of communication and interpersonal skills.(25) A favorable image of the location on a CME brochure was found to be more effective in attracting registrants than a text cover.(22)

Funding for CME

Since there is a cost associated with CME activity it is reasonable to ask “Who pays for these costs?” Some CME is funded directly by the individual physician, although the time away from practice must be allowed by the hospital or employer.(26,27,28) In the past, however, much of continuing education was funded commercially often, by choosing selected speakers, paid for directly by the sponsor. There is an increasing trend away from this kind of funding for CME because of the perceived potential for commercial support to influence scientific judgment about drugs or procedures.

Commercial Funding of CME

Both the AMA and FDA require clear identification of any speaker or faculty that has commercial interest in a subject, product or procedure presented in a CME activity.(29) According to ACCME standards, this financial interest as well as other conflicts of interest must be defined in syllabus material and verbally stated for oral presentation. Should a speaker fail to sign a conflict of interest release statement, the course director is obliged to disclose this fact in writing. A written conflict of interest policy must exist for an institution to accredit CME activities for AMA/PRA contact hours.(30) Furthermore, commercial activity must not be concurrent with CME activity.(31)

In Italy, commercial funding is permitted, but funds are managed by a board completely independent of the CME activity.(32) A survey in Germany(33) noted the potential for commercially sponsored CME to support a given company’s product and approach to use of that product. There is a requirement that promotion of the product be distinctly separate from information about approaches to treatment which utilize that product. Physicians self-police this commercial support to avoid governmental control.

The alliance between CME and industry is not without benefit. The financial resources associated with product development allow for rapid dissemination of information. The vast majority of investigators who are called on by industry to give CME presentations about new drugs or devices present data and not sales information in a CME setting.(33,34) Peer review by course directors as well as educated participants further increases the likelihood that the information presented is not biased. Voluntary industry standards encourage complete disclosure of the results of clinical trials at CME activities.

Employer Payment

Employers fund much of the costs associated with CME for physicians. Anesthesiologists, being hospital-based, usually work for a hospital or a group. Employers are induced to reimburse CME costs in this setting due to the CME requirements for licensure. Employers will demand the best value for their money, but an objective way to assess this will be difficult. Partial funding of CME from grants will become less common as the number of funded grants with this amount of latitude decreases. In countries, such as Great Britain or Scandinavia, where health care is funded by the government, CME also tends to be governmentally funded. It is provided at regional centers and is structured to fit the practice setting.(35) Courses are scheduled throughout the year and on appropriately predetermined days of the week.(36) In Norway, governmentally funded committees create specialty specific CME.(35) In under-developed countries, universities are presumed to be the providers of CME.(37) The burden on universities to be the providers of CME is not as great in the United States due to the strong commercial interests involved in the provision of CME.(38) Influence of Health Care Reform

Health care reform in the United States will probably modify the structure of CME.(39) Emphasis on recertification and outcome studies may become important forces.(40,41) Improved physician performance with newer technologies and better resource utilization may decrease the cost of health care.(42,43)

Styles of Presentation

Numerous theories exist about the ideal method for adult learning and focus on the way information is conveyed. The success, both educationally and commercially of CME is dependent on the extent to which adult learning is achieved in an aesthetically appealing manner.

Problem Solving

The primary goal for a CME activity should be to meet the needs of the consumer. The ideal learning method for a professional medical practitioner is known to be problem solving.(44,45) This is especially true for “long-distance” learning in rural areas where stress is high and the incentives to learn relatively low.(46) Structured information, such as curriculum modules is valuable in this setting, so that responses can be used to modify the information presented in subsequent presentation. Practice Medical Education

Caplan(47) makes clear the notion that any form of mandatory education for physicians must be individualized to fit their needs or it will meet with opposition. If evaluation is planned, the most effective approach is structured self-assessment. Properly structured self-assessment has been validated enough to be acceptable to both governmental regulators and third party payers. Watts(48) echoes this concept and describes the ideal mandatory CME as PME (practice medical education), which requires the incorporation of learning into the context of clinical activity. The superior quality of learning from practice is recognized in other professions. Judges and airline pilots recognize the unique structure of their tasks and the learning which evolves from each application.(49) In medical practice, case study, peer review and quality assurance data collections are examples of potential practice-based CME tools. Auditing

Multi-media computers and simulators are tools that may move practice-based learning from theoretical to practical in the future. Al-Shehri(50) and Cervero(49) further expand this approach of adult learning for the physician. They emphasize not only learning in a clinical situation but to learn from clinical situations. Audits, retrospective series review and continuous quality assurance activities are potential tools. The review of information that is now easily accessible from computer databases make these learning tools all the more powerful. Auditing as a learning tool can be done randomly, however, more interest is generated when the audit has a focus. For instance, when the characteristics of a pathological process or health care delivery system are identified, clinical problem solving occurs.(50) Audit methods which identify the needs of patients are particularly powerful learning tools.(8,9,51) Self-Directed Learning

Doyle(52) identifies the needs of physicians in smaller states and rural areas of large states with the concept of self-directed learning (SDL). The physician is presumed to be an educated individual with greater than 20 years of formal education. The natural curiosity of the educated mind is a potent stimulus for continued learning if supported by some structure. Such a learning program exists at the University of Arkansas Medical Center.

Some adult learning skills are accentuated by the format of presentation.(53,54) Self-learning requires either structure or support. Input into the program from outside a physician’s specialty or even outside of the physician community is an enhancement to adult learning.(55) The first source of information about need is from the target physician pool and is followed by multi-disciplinary team evaluation about how to deliver these needs. These ideas reflect the evolving concept that there are needs of physicians which are reflected in their practice and could be improved with ongoing education programs.

Role of Computers, Video and Multimedia

The concept of multi-disciplinary input for CME easily incorporates the use of computers with multi-media capability. Jackson(55) describes a number of programs sponsored by the organizations within the field of Emergency Medicine, which are made available “on-line” to members. Utilization and consumer satisfaction are high. Despite the lack of a structured format (physicians are allowed to review what they think they need from large amounts of available data), the passing level on a post-CME activity test was greater than 80%. Piemme(56) reviewed and enumerated the immense amount of on-line information which is available to physicians, including the bibliographic databases, journals and full-text activities, but notes that presently, none are certified for formal CME credit. Piga(57) describes the powerful impact of on-line video capabilities via personal computers (PCs). Barber(58) further expands the potential of video. He proposed a complex interactive learning style utilizing the review of videotape of teaching of clinical activity by peers with didactic feedback. The review of videotapes did not change the content of teaching, but it did change the style of delivery in subsequent presentations of the same material. Post-course evaluations revealed an improvement of the overall teaching. This may have potential application in Anesthesiology with the expanding use of simulators, as is the case with airline pilots. Interactive videotape as a CME tool was prospectively studied for Family Practice by Premi.(59) A defined clinical situation was chosen and a pre-test given. The physicians were then divided into two groups, with one asked to study independently, and the other given a specific group of journal articles to accompany a teaching video. Significantly better improvement occurred in the video-reference group. Bearon(60) also expands on the advantages of defined video and hard copy references for learning , in a program for CME in the field of Gerontology, created at Duke. Review of the video for content, accuracy and effective delivery was performed by a multi-disciplinary group. The combination of the video content with the multi-disciplinary input was felt to enhance the learning in a synergistic manner. Briley(61) reports on the use of computer image transfer for learning at sites peripheral to a tertiary center for neuroradiology. Image transfer libraries for anesthesiology within WorldWide Web sites are just beginning to develop on the Internet with similar educational potential. Style of Presentation

The format of CME courses varies. The speakers range from honorary invitees ("Rovenstine Lecture"), to the peer-selected individuals (Refresher Course) to those selected by course directors. Panel discussions often combine experts. Some CME presentations involve first time presentation of scientific research (abstracts) and part of the CME is the interaction about the validity, merit and future directions for the research. Scientific Exhibits are put together for large meetings to show new technology. Peer-review for scientific merit is done during the selection process. This is not the case with the commercial exhibits of drug and technology products at major meetings, whose express purpose is scientific advertising. Use of a coached moderator has a favorable impact on audience satisfaction and outcome assessment by exit interview.(62)

Style of delivery is also influenced by choices of audio-visual support.(63) The education literature clearly establishes that adults learn more when the information is presented through the use of multiple modalities. The combination of verbal communication with visual information (35-mm slides, written syllabus material) is clearly superior to either component individually. This remains the most popular style of presentation of physician CME. Resistance to alternatives is probably based on lack of prior experience with other styles.(63) Computer-generated slides allow instantaneous generation of audio-visual support during a presentation . Multi-media audio-visual support will become more common as it becomes possible to instantaneously call up pre-prepared slides, video clips and sound clips. The audience’s role will become more interactive. The development of the computer-based Audience Response System will allow the audience to interact directly with the speaker’s audio-visual materials. Creation of CME syllabus material will not disappear, but may evolve toward CD-ROM, or home pages on the World Wide Web of the Internet.

Evaluation of CME

The mandatory nature and cost of CME activities necessitates evaluation of the CME product. A number of approaches have been described and criteria for quality defined.

Needs Assessment

The ACCME mandates that for accreditation for AMA/PRA credit hours, CME activities must have a pre-presentation statement of objectives. Evaluation, through a systematic analysis of retrospective needs assessment given to each attendee, is based on their response regarding the success of the presentation and the potential for improvement.(64) In this way, the evaluation of the CME entails methodically determining the extent to which the stated objectives were met.

Vanek(66) carried this need assessment a step further by identifying the target group for several physician meetings prospectively, mailing a questionnaire to the potential participants and using the information to modify presentations. Combined with the post-course evaluation of outcome, the information was used to modify subsequent versions of the meeting. The cost was $1200.00 per meeting which was 5-10% of the meeting’s administrative budget. If this process were implemented as a standard routine and combined with brochure mailings, the cost would be reduced considerably.

Swanson(67) describes a needs assessment process whereby refresher course goals, objectives and physician perceived learning needs were evaluated and subsequent presentation of this course was modified to include didactic material and case presentations. Those attending the first version were asked specific questions about their most common treatments of a variety of clinical situations. Common errors were added as case material for the subsequent session. Sherman(64) describes needs assessment sources beyond the individual participant, such as licensure, credentials, board certification, quality assurance, peer review and evolving new technology. Sources for this information include the American Heart Association, medical schools, the AMA (through ACCME), the federal government (through Medicare), and the states (through licensure). This idea is a logical continuation of Continuing Education Systems Project (CESP) formed by the Association of American Medical Colleges, which suggested that regional medical centers provide and monitor CME.(68) Although not fully accepted, this process involved more than 100 different criteria of a CME activity from notification, through content to post-activity evaluation. The use of quality indicators and external review to improve ongoing CME activities is integral.(14) The state of Connecticut accredits hospitals to provide CME with its own set of criteria which also meets ACCME standards.(27)

CRISIS Criteria

A modification of the needs assessment was developed in 1982 by Harden(69) with the acronym CRISIS. The categories are indicated by the letters: Convenience, Relevance, Individualization, Self-Assessment, Interest, Speculation and Systematic coverage. This allows a systematic approach to needs assessment and the evaluation of outcome comments by participants. Convenience was defined by location, timing and the speed of delivery. Relevance is determined after the fact by the participant.

Pre-course surveys and use of post-course evaluation for subsequent programs should improve this variable. Assessment of relevance by physicians is often most focused on priorities in clinical care of patients. The extend to which didactic teaching provides this need will determine relevance. Individualization is determined by the extent to which the course meets the needs of the practice style of the participant. Self- Assessment is a tool for evaluation which requires participation of course registrants. It typically involves a question from the speaker, a response by the audience and some discussion of the outcome. This has become electronic with the Audience Response System. A speaker asks a question, each participant in the audience has a keypad which feeds answers into a database on a small personal computer, and the answer is displayed electronically. The purpose of self-assessment is to get immediate feedback about the actual learning occurring during a given presentation and to use this information to further increase learning. Interest as an evaluation tool is obvious. The kind of response described earlier to subject material and brochure covers fits in this category. Interest will directly determine registration. Speculation is that part of learning where the teacher stimulates further ideas in related topics and interest in further learning in the same area. Physicians are scientists and the extent to which a given presentation can increase their intellectual curiosity is the extent to which success in this area is measured. Systematic refers to the instinctive need of participants to have the course presented in an organized fashion. Subjects should flow in a logical sequence; there should be minimal repetition and as few omissions in key areas as possible.

Levine(70) fractionated needs assessment, focusing on participant satisfaction data, administrative data and attitudinal data as they influence outcome. Evaluation of CME programs can also be accomplished by groups of CME providers. To improve outcome they disseminate information, measure the rate of adoption of the material and evaluate the change in an outcome variable.(71) With increasing emphasis on outcome and economic performance, this method may become the standard for evaluation of CME.

In our era of consumerism, it should not be surprising to see complex advertising techniques involved in publicity and evaluation of CME. One approach uses the classical focus groups of new-product development for the needs assessment and evaluation of CME activity.(72) The key role of local CME supervisors in directing the curriculum of CME toward the needs of the community is recognized.(73) Since not all CME is external, there needs to be evaluation of self-directed CME. The Royal College of Physicians and Surgeons of Canada(74) have developed such a program called The Maintenance of Competence Program. The primary purpose is to provide education, and the assessment is a self-completed diary. The feedback to the program is provided by the participant about what was learned from the presentation and also whether content will modify his practice.

The Future of CME

Multimedia and the Internet

Some future directions of CME have already been discussed and elements, such as the use of computers in CME, already exist. Access to medical databases has become routine.(75) Chao(76) has reviewed available CME software and makes a case for steady expansion. As medical practice steadily becomes more technological and the use of computers in clinical work more common, computer-generated CME logically follows. Ideally, software should address clinical problems, have a reasonable cost and be easily updated. Comprehensive materials may utilize CD-ROM, and have the advantage of huge capacity, but the disadvantage of not being able to update the information without producing a new CD-ROM disc. Vanek(77) establishes the value of computer networks for pre-course needs assessments, which decreases cost and provides improved response rates. Staab(78) presents the role of multi-media presentation to improve adult learning. Interactive video with computer enhancement via the Internet is an example.(79) Pre and post-testing can validate the education benefits of material available on-line. Interactive CME via computer videodisc is also possible although interactivity is much less.(80) The use of multi-media for learning is even more beneficial though networks because the learning is interactive among the students.(81) Folberg(82) presents the evolving technology of compact disc, videodisc and interactive versions of these as the teaching tools of the future for highly technical learning, such as eye surgery. In this setting, choices elicit responses and can be modified to improve technique outside the operating room. Virtual hospitals exist on the Internet and via modem at numerous sites.(2,21,83,84) Virtual schools are also possible(83) as is the presentation and evaluation of new products and technology on-line.(4) Because of the multi-media capability of the World Wide Web (WWW), different data formats such as video, audio, physical diagnosis, algorithms, teaching files, x-rays and even whole textbooks can be available immediately, either alone or in combinations. Anesthesia Simulators

The present and future of CME in Anesthesiology will be heavily influenced by the development and increasing availability of full-scale anesthesia simulators. Simulation of clinical care in anesthesiology parallels simulation training in the airline industry, where a combination of mechanical, audio-visual and intellectual resources must be used simultaneously for problem solving.(85,86) This type of training not only facilitates adult learning from multi-media presentation, but also may actually improve crisis-management skills.(86) Prior simulation of critical incidents improved the technical response to subsequent simulated crisis scenarios, compared to individuals without prior exposure in groups of fully-trained anesthesiologists.(87,88) Other fully trained anesthesiologists were asked to compare simulator scenarios to critical events in the OR and found them highly realistic in a majority of subjects.(89,90) In addition to technical experience, simulator training is ideally suited to the evaluation of learning and performance.(91) Ideal characteristics of CME via simulator take advantage of learning in the context of clinical care, which is easily and safely repeated, driven by commonly known data and technologically feasible.(92) Virtual reality, artificial intelligence and clinical simulators are those areas in the future where technology will have a heavy impact on adult education and CME.