Rediscovering Medicine's Mission

At the 25th Anniversary Alliance for CME Conference, speakers looked to medicine's past to find guideposts for CME of the future.

When Rorie Fore was in the operating room, waiting for a mastectomy, her doctor invited her husband, Robert, to stay with her until she was put under anesthesia. "Since you go to sleep together every night," the doctor told her, "I know he needs to be there when you go to sleep today."

That act of kindness had nothing to do with treating Rorie's breast cancer, but had everything to do with helping her and Robert make it through an ordeal that had the potential to devastate their lives. It meant so much to them that Rorie shared it when she addressed the third plenary session at the Alliance for CME's 25th Annual Conference held January 18 to 25 in New Orleans.

The Fores' session was one of three moving and thought-provoking plenaries. To commemorate the Alliance's Silver Anniversary, speakers revisited the medical milestones of the past 25 years and forecast medicine's future, thus identifying CME's priorities. Despite the different time periods speakers addressed, each stressed a similar theme, uncovering the paradox facing physicians today.

As we move into a millennium that promises amazing scientific advances, such as decoding the entire human genome, physicians

will be able to treat disease far better than in the past. Yet, to improve patient care, physicians need to relearn the importance of tending to the patient's spirit as well as the physical disease.

Laying-on of Hands "Some physicians forget that for most of the history of medicine, there was little they could do but sit by the bedside and offer hope," said Robert Fore. "That is just as important today."

When preparing for their presentation, the Fores sent an e-mail to the members of their Internet-based breast cancer support group, which has hundreds of members worldwide. "In CME, we think about needs assessment," explained Robert Fore, who is associate dean, graduate and continuing medical education, School of Medicine, Mercer University, Macon, Ga; and a former Alliance for CME board member. "I told them I would be talking to a roomful of doctors and CME professionals, and asked, What do you want me to say to them? I got 85 responses in two days."

Most important, said the support group members, is that physicians offer respect, empathy, and loyalty to their patents. "Physicians need to listen," members wrote. "Physicians need to remember to offer hope."

One patient wrote to Fore, "The first time I met my oncologist she asked me how I felt about my breast cancer, about my children, and how they felt about my cancer. She asked about me, not just my medical history."

Patients also said how crucial touch was. "My lady breast cancer surgeon held my hand on the way to surgery," one patient wrote, "and said, 'Don't worry. I will be with you and I will keep you safe.'"

As medicine becomes more advanced and physicians lose sight of those cost-free, interpersonal techniques, there is a growing tension between patients and physicians, said opening plenary speaker Holly Atkinson, MD, president and CEO, Reuters Health Information, Inc., New York City. "As we get more sophisticated technology, there is a backlash, a wish for more laying-on of hands."

Patients are increasingly turning to alternative therapies for the kind of healing they aren't getting from their physicians, she said. Two years ago, she noted, the New England Journal of Medicine reported that consumers were spending more money on complementary medicine than on traditional medical intervention.

"Massage therapy, reflexology, spinal manipulation, involve the laying-on of hands," Atkinson pointed out. Acknowledging that critics say alternative medicine is predicated on the placebo effect, she added that placebos can work. "There is no doubt that the human imagination has a very powerful effect," she said. "Clinicians and researchers make a clear distinction between illness and disease. Illness is what patients experience, the emotional and social ramifications, how their lives are altered. Disease is what the physician treats. There is a growing tension between illness and disease."

While physicians need education on complex developments such as genetics, Atkinson said, CME also should address what is humanistic and spiritual in medicine. "Somehow," she said, "those divergent paths need to be brought together."

Family-focused CME There's no better indicator of the future of medicine and its impact on society than the field of genetics. In his final State of the Union address, President Bill Clinton said advances in genetics "are leading to a revolution in our ability to detect, treat, and prevent disease." Genetics education must be interwoven in all CME, said Susan Pauker, MD, Harvard Vanguard Medical Associates, Boston, during the Alliance's second plenary session.

Yet, even in this highly technological area, physicians' communication skills are of paramount importance. When applying genetics in their practices, physicians will need the same approach that the aforementioned oncologist used--they'll need to treat their patients not only as individuals but as members of families. "What's unique about genetics is that it involves more than one generation," said Pauker. The focus of CME needs to change, she said. "Think family. Think of the patient as a person in a family." Clinicians need training, for example, in how to take accurate family histories, she said.

But despite the fact that even the President is highlighting the importance of genetics advances, physicians "are not beating down the doors for more CME activities about genetics," observed panelist Glenn Bingle, MD, PhD, senior vice president, medical and academic affairs, Community Hospitals Indianapolis.

Genome-ophobia Why not? Because genetics hits physicians on a personal level, he said. "We avoid and deny our own genetic heritage. Get in touch with your own genome," he told the audience. "Then you can motivate physicians. Many of you have mutations that human genome [research] will uncover. We are all genetically programmed to die." Physicians need to face their fears of their own morbidity. And that knowledge, said Bingle, "cannot be taught over the Internet." CME providers need to offer face-to-face discussions.

To learn genetics counseling, physicians must be able to try it out in a safe environment," added panelist Robert Fox, professor, Center for Continuing Professional Education, University of Oklahoma, Norman. "They need an environment where it is OK to fail."

Genetics raises enormous ethical dilemmas for health care providers and for all of society. Physicians are hesitant to do genetics testing, said an attendee, because they are concerned about the employment and insurance discrimination that patients may face--a concern raised by Clinton in his address. Although 23 states have laws protecting people from discrimination based on genetics-related diseases, the fear is real, said Pauker. "What kind of system is this, that when you have an illness you lose the care to take care of the illness? We have a long, long way to go."

Grandmother Medicine To continue on the long road toward improving patient care, physicians should return to their roots, and practice "grandmother medicine," said Fore, meaning that physicians should treat patients as their own grandmothers would, with love and caring. Another speaker in the final plenary, John Stone, MD, professor of medicine (cardiology), Emory University, Atlanta, said that once when making his hospital rounds, he found a patient listening to Beethoven's symphonies. Asked why, he told Stone, "Because it's healing." His answer gave Stone a flash of insight. A poet as well as a physician, it is perhaps fitting that Stone best summarized the conference theme, saying, "We must learn to say 'heal' in the language of the patient."

"It still gives me goose bumps." Marcia Jackson, PhD, program chair, Alliance for CME 2000 conference, is referring to the plenary session, The Patient as Teacher, where Robert Fore, a former Alliance board member, and his wife, Rorie, told the audience about her experiences as a breast cancer patient; and John Stone, MD, wove poetry and prose together to illustrate how patients touch doctors' lives. The session was the final one in a series of three plenaries, all of which compelled attendees to focus on the core of CME--improving patient care.

When brainstorming about the anniversary conference plenary sessions, Jackson and her two team members knew they wanted a theme that connected CME's past and future.

"Over the past several years, [the conference] looked at changes in health care systems and delivery and how those changes are affecting us in CME. This year we decided it was important to come back to medicine itself and the main reason we are in CME, which is translating research into practice," says Linda Casebeer, PhD, conference program co-chair, and associate director, CME, University of Alabama at Birmingham.

Whatever changes occur in medical practice, adds Jackson, the goal of bettering patient care is "what endures." That's important for CME providers to remember, she says, so they can remain energized about their work.

"I work with doctors day in and day out," says Jackson, who is senior associate executive vice president, education, American College of Cardiology, Bethesda, Md. "The thing that makes it valuable for me is their commitment to patient care. Talk to anybody on my staff and that' s what motivates them, why they feel good about spending time in the field. That is an important message to convey to people involved in CME."

For CME providers who are also physicians, that message is even more critical, given the current health care delivery environment. "We feel threatened by the way in which we are forced to deliver care of patients in HMOs and other organizations," says Robert Raszkowski, MD, PhD, program vice-chair, and dean, academic affairs and CME, University of South Dakota School of Medicine, Sioux Falls. "The most important aspect of what we do is the one-on-one patient relationship. When that is threatened, it threatens the core of our values."

Provider, Heal Thyself While program chairs underscored the importance of patient care, Bernie T. Halbur, PhD, the Alliance' s professional development director, paid attention to CME providers' care. At her behest, yoga sessions were offered each morning during the conference. Despite their hectic schedules, about 60 attendees woke before dawn to join the 6:30 a.m. classes.

In looking over past years' evaluations, Halbur noticed that one of the pressing problems for attendees was that their workloads were increasing, while their resources were decreasing. Halbur wanted to offer something that would help people cope on a personal as well as professional level. She had recently spent a month at an ashram, studying yoga and meditation, an experience that "fundamentally changed how I live my life," she says, and has helped her manage her own job stress. She invited one of the instructors she met at the retreat, W. R. Van Nostrand, III, MD, medical director, The Health Conservancy in Tucson, to teach yoga at the conference.

"It is a relatively inexpensive way of addressing who [attendees] are, not just what they do," says Halbur.

CME Odyssey--2001 The 2001 conference may include the ancient art of yoga, but the name is futuristic--2001: A CME Odyssey.

"Envision major light shows," quips Raszkowski. "A big space ship will swoop down and take someone away."

Seriously, the conference theme, he adds, is Best Practices in CME: Changing Educational Design, Physician Behavior, and Patient Outcomes. For more information, visit www.acme-assn.org.