Last week, experts at the CME Summit in Chicago outlined current and future performance improvement requirements from hospital regulators, certifying boards and licensing boards. (Talks will be posted to the CMSS site later this month.) An internist in private practice, Dr. Marie Brown, was asked to react:
"Wait a minute! My typical patient has 6 comorbidities, takes 10 medications, and I can give him only 17 minutes. We are overwhelmed with non-patient care clerical work. And an article I read said that there were 8000 important clinical articles published every month!
"What's missing from CME is giving us a little knowledge that is practice changing -- and telling us how to translate that knowledge into practice."
The experts didn't ask her a single question. I wonder why. Perhaps it is because they are too focused on proving the effectiveness of CME through testing and evidence of practice improvement -- and on proving to the public that doctors are competent.
That's not what Dr. Brown wants -- for herself and other practitioners. She suggests that translating knowledge into practice requires tools that help physicians implement change, tools such as Rx adherence programs, quick ways to identify depression, fitting cancer screening into a busy practice, etc.
The result might be what the experts want: improved performance.
Speaking of which, here's an update on performance improvement (PI): In response to last month's commentary: Dan Mjolness agreed with the obstacles: "PI was initially blocked by those within the CME area of the American Academy of Family Physicians who apparently felt threatened. It took 3 years to succeed." Ellen Cosgrove MD agreed that PI is not ready for prime time, but described an effective program of success in achieving weight loss in pediatric practices in New Mexico.
Dear CME colleague,
While many in European CME are demonstrating knowledge improvements from elearning and team-based seminars, those in the US are reaching for more sophisticated measures of CME: competency and performance improvement. Yet a "consumer" of CME wonders why CME doesn't tell her HOW to implement the important new knowledge. A good challenge for us all.
2 CME pilots in Germany test print, elearning and team-based seminars
Results of 2 CME pilots in Germany were recently reported. One showed that elearning is superior to print in knowledge change. The other emphasized the value of small teams learning together. Perhaps a combination of the 2 would be even more effective. Here are summaries of the studies:
The Quaime study, comparing knowledge gains from print learning vs. online learning among groups of GPs and neurologists.
An interactive team-based CME concept evaluating knowledge, motivation and expectation of 159 GPs and internists at the medical education unit of Munich University Hospital
The Quaime study, reported by Prof. Peter Henning of the Institute for Computers in Education, Karlsruhe, showed a 25% average individual knowledge gain for print learners, and 50% for elearners. Each group completed a pretest, an identical learning module (hard copy and audio CD for print learners, online for elearners) and a posttest. The print learners reduced test failures from 70% pretest to 20% posttest; the elearners from 85% pretest to 0% post test.
78% of elearners reported a time saving vs. typical CME. No data were available regarding the size or selection of participants.
The Munich study, reported by Dr. Lisa Kuhne-Eversman et al in Journal of Continuing Education in the Health Professions, described a structure of a 5-hour seminar including a pretest, a short topic introduction by an expert, an interactive discussion group of 4-6 participants with facilitators and a posttest. During the seminar, each group was required to make joint decisions on a number of cases presented on paper and to discuss these with an expert. Subsequently the same cases were put online as a followup course. Results: pretest scores of 47% rose to 70% posttest. Participants claimed to have changed their clinical practice as a result. But online participation was very low.
Francophile countries present their approaches to CME to help the stalled French system
The 4th annual meeting of MS7, an organization of representatives of medical associations from France and francophile countries including Canada, France, Belgium, Italy and Spain, convened last week in Rome to discuss the comparison of specialty systems and CME systems. At almost the same time, a similar meeting was held in Paris to discuss best practices in CME.
Says Dr. Alfonso Negri, a WentzMiller associate and speaker at both meetings: "We were asked to show the way of CME development in Europe, in order to help French authorities follow a simple approach to accredit CME, in view of the country's new medical law." The new law will attempt to replace the French CME system that was about to be implemented at the beginning of 2008. More details to come on its expected impact.
Farewell to a distinguished colleague
Helios Pardell MD, 62, a WentzMiller associate and a leader of CME in Europe, died October 30 in Barcelona. Helios was executive director of the Spanish Accreditation Council for CME, a director of the Global Alliance for Medical Education (GAME), active in the Alliance for CME, and a respected colleague by all who knew him.
Bernard Maillet MD, secretary general of the Union of European Medical Specialties, said: "He was a very positive colleague with bright ideas. It will be very difficult to replace him." Craig Campbell MD, director of the office of professional affairs, Royal Colleges of Physicians & Surgeons of Canada, added: "Helios contributed to the value and principles of continuing professional development not only in Europe but throughout the world."
We will miss him. Our sympathy goes to his widow, Roser, and their family.
Last month's article on election of new UEMS officers incorrectly identified the country of Dr. Gerd Guido Hofmann, liaison officer, as Denmark. It is Germany. Our apologies.
Subject: E-learning approved for European accreditation
Dennis Wentz was absolutely correct when he wrote in last month's column that performance improvement (PI) is still in its infancy. Most physicians view the concept with trepidation and irritation over the time spent to track data,
The exception appears to be in those large, salaried group practices such as Kaiser Permanente that require use of electronic medical records (EMR) and build in systems to compare individual and group performance against accepted guidelines.
The US government has been encouraging physicians to install EMR in their practices, but has not provided sufficient resources to move up from some 20-25% of practices adopting such systems. France was about to embark on a system of practice audits by outside reviewers but that has been put on hold, along with all CME systems. The UK is slowly moving toward revalidation based on physicians achieving some level of PI as determined by practice mentors.
Perhaps we have to move in smaller steps to achieve PI. One method might be "commitment to change", which asks the physician who has participated in a CME program to select one or two changes to make as a result of what was learned. Followup in 3 months, on a self-reported basis, can indicate whether the physician followed through and/or still intends to do so.
E-learning is coming to Europe in a major way, but a recent survey in the US shows that its adoption in CME is still slow, and that live meetings and journals are heavily favored. Another innovation being linked to CME, performance improvement, is also slow to gain wide acceptance. Pioneering is great, as long as there are followers to keep up.
Good news: UEMS approves e-learning for Europeanwide accreditation
At its October 10-11 meeting, the Union of European Medical Specialties ratified a proposal to accredit e-learning through the European Accreditation Council for CME, starting in January 2009. Until now, there has been a patchwork of regulation by some national authorities permitting e-learning credits, making it almost impossible to offer credits across Europe through the web. The UEMS statement says:
"The UEMS recognises that considerable advances are being made in the methodologies by which CME and CPD can be provided, and by which these educational opportunities are accessed by doctors. For this reason, the UEMS has agreed in principle to the accreditation by the EACCME of new media for the delivery of CME/CPD, that go beyond traditional lectures, symposia and conferences. "... these new media are referred to as "e-Learning", and should be taken as covering the delivery of CME/CPD by methods including: recorded audio, recorded visual, recorded on Compact Disc (CD), recorded on Digital Versatile Disc (DVD), available on Personal Digital Assistant (PDA), available online via an educational website, or any mixture of the preceding."
The UEMS also re-elected as president, Zlatko Fras MD, a Slovenian cardiologist (left), and as secretary-general, Bernard Maillet MD, a Belgian pathologist (below right). Other officers elected:
Dr Gerd Guido Hofmann (Denmark), liaison officer
Dr Giorgio Berchicci (Italy) treasurer Dr Ricard Gutiérrez (Spain), Dr Romuald Krajewski (Poland), Dr Zoltàn Magyari (Hungary), and Dr Kari Pylkkänen (Finland), vice-presidents
Among other steps approved was an action plan that includes the following statement regarding CME/CPD harmonization:
"Define and disseminate the general standards for CME/CPD activities and for granting credit points - Define the feasible and consensually agreed procedure for granting the credit points for CME/CPD activities in Europe".
A new survey of US specialists still shows a preference for live meetings, little use of eCME
What Doctors Think, a division of Telemedical Solutions, recently asked 600 US physicians, mostly hospital based, about their CME habits. Some key results:
90% are required by state law, 75% by hospital regulation, to obtain CME credits
84% go to conferences and meetings (specialty society congresses rank highest), 43% to journal CME and 24% to websites.
43% are traveling less to CME meetings; 65% because of cost, 50% because of loss of income
70% get 10% or less of CME credits online; only 16% more than 25%, and only 38% have increased their web time in the past 2 years.
If commercial support of CME were discontinued, 59% would pay for all required CME credits!
Conclusion: Despite the increased volume of accredited CME on the web, it's not likely to replace live or journal CME for years to come, if ever. Keep in mind that the survey did not include primary care physicians; their CME patterns may differ.
CME in Ukraine: Mandatory but hard on doctors
Doctors in Ukraine -- there are about 125,000 in practice -- must take 1 month of postgraduate courses every 5 years to meet the government requirement for licensing and accreditation, according to family doctor Ludmila Himion. Unfortunately, the doctor must attend the full month's course at one of the academies or faculties of postgraduate education, and it must be in the doctor's specialty. Courses are held in big cities, so many doctors have to leave practice and family to comply.
On the positive side, the courses are free to doctors who work in the state health care system (about 90%). In addition, doctors get a chance for career advancement if they pass specific exams after the course: second qualification is the starting point after 5 years of practice; first after 7 years, and high after 10 years. In Dr. Himion's family medicine department, some interactive courses are available on the web, but these provide no official credit. Internet is not widely used in rural areas, she says.
Subject: ACCME call for limiting commercial support gets little support!
Performance improvement -- 42 years old, and still in its infancy
Dennis Wentz's commentary
When Bob Dylan wrote "The Times They Are A-Changing", he wasn't writing about CME today - but it hauntingly comes to mind. Reflecting on the swarming hurricane winds buffeting CME, a monograph came to mind published by the AMA in 1966, authored by Pat Storey and John Williamson, "Continuing Medical Education: A New Paradigm.
Reported was a 3-year experiment in Utah whereby physicians were taught to judge their own performance and then plan their personalized continuing education. Wow! There was enthusiastic response from these docs in moving CME from didactic "exposure" to a new CME linked via audit to outcomes, helping them focus their own learning.
Now, 42 years later, we are touting a similar emphasis. Good physicians want and welcome meaningful feedback on their practices. The AMA's moves toward CME credit for participation in Performance Improvement (PI) and other new methods of individualized and deeply personal learning are where the future lies.
But what does have to do with the buffeting winds? A lot. Everyone must think differently about the financing of CME -- our new generation of physicians want and expect more than lectures. Yet the process of PI, based on identification of gaps between accepted guidelines and actual results in an individual physician's practice, doesn't lend itself easily to industry's traditional methods of supporting CME in specific therapeutic categories.
Will and can industry respond to this new challenge? There certainly aren't any easy paths linked to products. Stanford medical school recently shut off all commercial funding for CME courses -- but left the door open for generic grants from pharma to be used for the greater good. Is that realistic? Can the providers of CME produce what is wanted and works? Will any medical school or medical specialty society provide what's needed if industry funds are no longer available? Or foundations? What I hear is that eleemosynary giving is at a totally different level (usually lower) than the current levels of support for CME - and it is controlled by people unfamiliar with CME.
Our whole system is in trouble -- the accreditation system still focuses mostly on courses, retrofitted at times to deal with the new initiatives. I believe that no one grasps where the new emphases in CME is going, how we are going to live up to the promise made by Storey and Williamson 42 years ago -- yet for quality patient care, we must develop the new paradigms and funding sources to match.
Dear CME colleague,
More controversy over regulating pharma's involvement in funding CME-- and the possible bias it might (or might not) cause -- in the US, UK and Australia. Perhaps Ukraine's system of funding through the government is better. Or is it? Can't government funding be biased as well?
ACCME's call for limiting commercial support gets very little support
The hot issue in the US is still the question of whether CME is biased by pharma funding and what should be done about it.
Early in the summer, the Accreditation Council for CME (ACCME) issued a Call for Comment on 3 proposals related to restricting or eliminating commercial support for CME, which now totals $1.2 billion a year, slightly more than half the total spent on accredited CME.
Should commercial support of CME end? Or should it follow a new paradigm in which learners' needs, practice gaps and content would be identified by "bona fide" independent means, certified free of commercial bias? The consensus is that there is no evidence that commercial support increases or decreases bias. The editor of the Journal of the American Colleege of Cardiology believes it is a bad idea to end commercial support. Most organizations opposed the new paradigm as burdensome and unclear. 77% of SACME members believed it would have a significant negative impact, though 60% favored a new paradigm -- but not as ACCME proposed it.
Accredited providers should receive no communication from commercial supporters prescribing any specific content that would be a preferred, or sought-after, topic, nor providing any internal criteria. Most organizations felt that the current Standards for Commercial Support cover this, though, once again, some 60% of SACME respondents agreed with the statement. Others found it confusing.
Professional writers or faculty that have been employed by a pharma company for a promotional project should not be allowed to present on the same topic in accredited CME. The opposition to this is based on the fact that such dual roles are common among clinical researchers -- and again on a lack of evidence that bias would exist.
The Washington Legal Foundation said the ACCME's proposed policies "raise serious First Amendment concerns" and that "basic notions of due process require the ACCME to give a better account of its intent and why its proposed changes are justified ," according to Matthew Arnold in Medical Marketing & Media online. While we await ACCME's response, we recognize that some critics believe that ACCME is really a quasi-governmental body and should behave with much more transparency. We'll see!
The commercial support debate continues in the UK and Australia
"Increasingly anxious about the industry's influence over their education, a small group of psychiatrists in Australia tried to wind back drug company sponsorship" of their 2009 annual congress, reports Ray Moynihan in a recent article in the British Medical Journal. While they won support from the South Australia chapter, the federal council of the national college rejected the idea as discriminatory toward one category of sponsors, Moynihan writes. Several of those on the organizing committee then resigned.
In the same issue of BMJ, Mark Gould quotes Richard Tiner, medical director of the Association of the British Pharmaceutical Industry (ABPI): "It's more likely nowadays for groups of companies with a specific interest in a particular branch of medicine ... to sponsor events so the chances of bias are even less." In the future, suggests Dr. Tiner, industry will contribute to an educational pool of funds for postgraduate centers; teachers and clinicians would dictate subjects and speakers. He noted that industry sponsorship of CME became more important when the government cut such funding a couple of years ago.
CME in Italy at a standstill, as in France
Changes in government in Italy, as in France, have disrupted the steady progress of the CME system, according to WM&A associate Alfonso Negri MD. "The Health Ministry doesn't exist any longer, but is now under the Welfare Ministry, which includes Labor, Health and Social Services," he says. "There is practically no mention of what is going to happen to CME, which is moving more and more toward a regional system. Actually only the Lombardia region is working properly." The end of the Health Ministry appears to be a money-saving move, consistent with other changes in the ministerial structure.
What is the practical impact of these changes? According to Dr. Negri, "Pharmaceutical companies are not sure about the future, and are investing less in CME. Events are not receiving credits at a national level. We are living on borrowed time, since you can apply for credits on the government website, but the application remains on hold."
WentzMiller welcomes a new Associate
Barbara Pritchard brings a wealth of experience as WM&A's newest associate. She is president and CEO of Intermedica, Inc. which is part of the InterAlliance Group of companies in Mexico, bringing the best of US CME to Latin American physicians through live meetings, journals, print self assessment programs and online learning. She is also director of US operations for Aramuc India, Ltd, a medical publisher/communications company in India. She is past Global President of Healthwomen's Business Association; was executive vice president at the Medical Economics Company in charge of clinical journals and medical education programs, and was general manager of Advanstar's Healthcare Division.
Pfizer's US medical education group has shocked the CME world by refusing to accept grant applications from medical education companies (MECCs)-- whether or not they have received exemplary status from the Accreditation Council for CME.
"Pfizer's new approach reflects its goal of meeting the highest standards for medical education, and academic medical centers, hospitals, associations and medical societies best meet these standards," says the Pfizer news release.
"We understand that even the appearance of conflicts in CME is damaging," says Dr. Joseph Feczko, Pfizer's chief medical officer, "and we are determined to take actions that are in the best interests of patients and physicians."
MECCs are up in arms, since they have been a major supplier of certified CME to Pfizer and other commercial supporters. And they are worried that other pharma companies may follow suit. In a letter to Pfizer, the North American Assn. of MECCs (NAAMECC) protested the decision, stating that the ACCME data for 2006 "demonstrates that MedEd companies perform at least as well as, and in many cases better than, other provider types."
The good news, if it is such: MECCs can continue to be joint sponsors with the medical organizations, though they cannot be funded directly by Pfizer.
There are many contradictions in who can provide CME around the world. Many countries in Europe will accept only CME from medical organizations; others accredit MECCs. In fact, Pfizer's subsidiary in France has been accredited as a CME provider!
We applaud Pfizer's earlier decision to raise the bar on the quality of CME by requiring measurable changes in physician behavior and patient care. My colleague, Dennis Wentz MD and I differ over this new policy. He believes that the medical profession should be in charge of all medical education, including CME. I am not so sure until there is clear evidence that MECCs cannot provide the same quality of CME as medical organizations.
Dear CME colleague,
No one can says CME is dull these days. France's system appears to be falling apart before it has gotten underway. Pfizer US has caused a firestorm with its decision to fund only academic medical centers and medical societies as CME providers. More shockwaves to come?
What next in France? The new CME system is halted, awaits "simplification"!
French doctors are disappointed and discouraged. Their new CME system was nearly implemented at the end of 2007, reports Dr. Hervé Maisonneuve, president of the Global Alliance for Medical Education (GAME. ), with 215 accredited providers and a credit system mixing knowledge improvement and performance improvement.
Then the ax fell, says Dr. Maisonneuve, who is also director of medical education at Pfizer France. "The members of the regional CME committees were on the point of being named, when the new Health Minister appointed by the new president (Sarkosy) stopped everything," he says. The new minister wants to "simplify" the system, and hopes to do so as part of the new law reforming the health care sector, due for approval in early 2009.
According to rumors, the credit system could be abandoned, the missions of the national CME committees (there are 3) could be transferred to other bodies, and a performance improvement system could replace CME. Then, Dr. Maisonneuve adds, decrees have to be published to implement the law, taking months or years.
How are physicians responding? With disappointment.and to some extent turning their backs on existing CME offerings. Considering that CME became mandatory in France in 1996, and is not yet working, "we cannot imagine when it will," Dr. Maisonneuve concludes. "Truly France is the laggard in European CME."
At least a CME blog is popular in France
FMC is French for CME. BlogFMC.fr, a unique multi-author physician's blog, was launched with the institutional support of Pfizer France in the fall of 2007. BlogFMC provides an online space for dialogue regarding the organization of CME in France. Permanent features include: vodcasts (videos), podcasts, polls, physician bios, links. Recently the blog incorporated a section for accredited CME organizations to promote their programs (despite the delay noted above). Visitors can consult nearly 200 items to-date.
To ensure independence, Pfizer delegates editorial and technical management to an eHealth consultancy whose founder is herself a recognized eHealth blogger.
BlogFMC.fr has been very well-received by the CME physician community. Its traffic ranking surpasses that of official CME organization sites.
Are CME credits in Europe an obstacle to mobility?
That's the concern of Michl Ebner, an Italian member of the European Parliament. In a written question to the European Commission, he asks what specific possibilities there are for a binding system of 1:1 recognition of CME credits without national or regional boards. Qualifications earned through education should be recognized without problems arising.
Mr. McGreevy, a European Commissioner, responded that the Commission is aware that CME can differ greatly between the member states of the European Union. "The introduction of a binding system of recognition of CME could only be based on minimum harmonized standards," he said. "This would require unanimity among all member states." He noted that the Commission welcomes the initiatives taken by the European Accreditation Council for CME (EACCME), which "helps bring about more transparency and comparability of CME at national levels."
Harmonization was the theme of the June annual meeting of the Global Alliance for Medical Education (GAME).
Comments re BMJ/MSD and mandatory CME
Last month we failed to give credit to Dr. Ottfried Zierenberg, MSD's regional director Europe, Middle East, Africa and Canada, for his role in implementing the joint venture with BMJ to provide elearning on MSD's univadis site. Our apologies!
On the issue of mandatory CME, Dr. Ellen Cosgrove, senior associate dean for education at University of New Mexico medical school, responded: "Once a topic (such as HIV or ethics) is mandated by state law, it never goes away ... and even the hematopathologist spending all day chasing tumor markers has to take valuable time to earn 'a tick in the box'. This is a critically important issue of professional autonomy!"
International attendance at US medical meetings is on the rise
About 27% of attendees at US-based medical meetings come from outside North America, according to a recent report by the Healthcare Convention and Exhibitors Assn. (HCEA).
That's up from 20% 5 years ago. On average, 14% come from Europe, 6% from Asia and the balance scattered. International meetings in general are up 23%, the report said.
Top 10 meeting sites in Europe? Paris, Birmingham, England, Vienna, Barcelona, Brussels, Munich, Prague, Stockholm, Berlin and Glasgow. London? #11!
A crucial effort to wipe out industry funding of CME has failed. The proposal -- that doctors and medical organizations no longer accept such funding -- received almost no support at this month's AMA meeting.
The report came from the AMA's Council on Ethical and Judicial Affairs (CEJA), but even the AMA's board chairman, Dr. Ed Langston, urged its rejection by the reference committee considering it. Finally, the House of Delegates sent it back to CEJA for more study.
In an appendix to the report, CEJA said that the Standards for Commercial Support of the Accreditation Council for CME (ACCME) were inadequate "to guarantee professional autonomy", and that physicians "usually are not in a position to distinguish 'objective' from 'biased' information".
As for who will pay if industry can no longer do so, CEJA put the burden on medical institutions to make CME available to doctors free or at low cost, primarily on the internet. No mention of how organizations will find the resources to create their content!
At least the editor of the Canadian Medical Association Journal, Dr. Paul Hébert, proposed a more specific approach: Replace industry direct funding of CME by requiring a portion of patent profits be directed to support a new Institute of Continuing Health Education that would run all CME. Governments and the medical profession could add funding.
We have more respect for doctors' ability to judge bias than does CEJA. We don't see that industry use of patent profits instead of grants is any different -- and we seriously doubt that a monolithic educational institute would produce the quality of CME that now exists.
What would reduce the saber-rattling against industry support? 3 ideas:
... if p
harma funds professional education divisions directly instead of through marketing departments.
... if CME providers and funders make a strong effort to relate CME to performance improvement.
ACCME polices CME activities more robustly, and disciplines offenders.
Dear CME colleague,
We report highlights of the annual meeting of GAME -- plenty of excitement and discussion around the issues of harmonization -- but so far not much action!
Mandatory CME? Not a voice in its favor at GAME, so why have it?
Global harmonization of CME was the theme at the annual meeting of the Global Alliance for Medical Education (GAME) in Jersey City NJ this month, but there was little agreement on harmonizing mandatory and voluntary CME. In fact, though mandatory CME exists in most of the U.S., in Germany, France and Italy in Europe, and in a few other countries around the world, no one spoke in its favor.
Bernard Maillet MD, secretary general of the Union of European Medical Specialties (UEMS), said his organization opposes mandatory CME in Europe. "It should be a professional responsibility, and therefore voluntary," he said. Mandatory CME doesn't improve medical practice any better than voluntary, and "simply instills a fear of punishment," he added. "Incentives should be offered instead."
Helios Pardell MD, director of the Spanish Accreditation Council for CME (SACCME), agreed. Spain's system is voluntary, and physicians who participate can benefit from career advancement. Seema Baliga, CME provider in India, believes that doctors will participate on a voluntary basis if the CME is really interesting.
Several speakers viewed CME as a part of a bigger process: lifelong learning linked to performance improvement. "We can't revalidate UK doctors without CME," said Ian Starke MD, director of CPD at the Federation of Royal Colleges of Physicians. "By itself CME is simply a mechanism to improve competence." Bernard Marlow MD, director of CPD at the College of Family Physicians of Canada, concurred. "Mandatory CME is just chasing credits," he said. "There's no evidence that credits link to performance." He was critical of the efforts of several U.S. states to require specific CME courses, such as one on bloodborne pathogens.
Any defense for mandatory CME? Not from Alfonso Negri MD of the Italian Federation of Scientific Medical Societies. "We have no stick or carrot," he noted. "We should offer financial incentives such as tax deductions -- and keep CME voluntary." Johann Weidringer MD of the Bavarian Chamber of Physicians commented that financial penalties are to take effect in Germany in 2009 for physicians who fail to get sufficient credits -- but agreed that there's no way to prove that mandatory CME results in performance improvement.
So why is mandatory CME so popular? Our view is that that lawmakers see this as a way to prove to citizens that they are ensuring high-quality health care -- because doctors have to keep up. Would it be better if the lawmakers instead required evidence of competence and performance improvement? That's what the UK's revalidation system is supposed to do. What do you think?
In Israel, no CME attendance, no pay!
That's the report of Dr. Pesach Schvartzman, CME leader in Israel, regarding the "voluntary" allocation of 4 hours for CME for doctors working in some HMOs. If they don't attend, there's no pay for those hours. In a sense, he noted at the GAME meeting, this makes CME mandatory for those doctors, though not for all physicians in the country. However, if a doctor doesn't get the 500 required credits in 5 years, he/she must take an exam to be relicensed.
What happened to physician satisfaction around the world? Has it disappeared?
A research study of medical leaders in 7 countries indicates that "satisfaction has been replaced by resignation" among practicing physicians, because of regulation, lack of time, increased workload, low salaries and lack of respect for the profession.
The focus-group study, conducted for GlobalEduHealth, a nonprofit organization chaired by Pablo Pulido MD of Venezuela, sought to identify emerging needs for education in nonclinical areas. In most countries, there appears to be a significant need for education in physician-patient communications skills, in ethics and legal issues, and in leadership, advocacy and healthcare policy. Dr. Pulido included some of the data in his report at GAME on CME in Latin America.
Countries in the study: Argentina, Brazil, Denmark, Mexico, South Africa, Spain and Taiwan.
4 industry companies now reporting grants
Pfizer, Medtronic and AstraZeneca have joined Eli Lilly in the U.S. in decisions to report all grants to CME accredited providers on their websites. All are now available, except for AstraZeneca, which will start August 1; the company is already presenting information on clinical trials, compliance programs and political contributions.
Pfizermade a total of $9.97 million in CME and other education grants, plus charitable contributions, in the first quarter of 2008. The largest grant -- $3.4 million -- was to the California Academy of Family Physicians for a 3-year national professional education campaign to reduce smoking.
BMJ Learning, MSD join forces for European eCME
BMJ Learning will now offer its 350+ interactive learning courses in 20 medical areas through a partnership with MSD's medical portal univadis, it was just announced by Thomas Kellner MD (at right) of univadis and Michael Chamberlain MD of the BMJ group.
BMJ Learning has 80,000 UK and 30,000 international users for its peer-reviewed and evidence-based courses. Univadis is offered as a local portal in 31 countries, has 550,000 registered physicians, and 130,000 accessing the portals per week in several languages. Initially, BMJ courses will be available in English, later in translation -- and free to registered univadis physicians.
For months this column has focused on industry funding of CME. In February Lew said: "There's growing suspicion that CME is somehow being distorted by pharmaceutical funding". In March I called for a reasoned dialogue and in April Lew asked "Can anyone stop Pharma's downhill slide"?
The input continues, as noted at right. As an ex-academic, I am pleased to see the report of the AAMC Task Force on Industry Funding of Medical Education, a thoughtful analysis from a committee of very senior members of academia and industry, chaired by another ex-academic and ex-CEO of Merck. It speaks to standards of professional behavior in multiple areas of industry/academic interaction, including support of CME.
The report calls for academic centers to centralize all CME activities, and to institute audit mechanisms to assure compliance with ACCME Standards-- and presumes that industry support will continue, contrary to the view of the recent Macy Foundation think tank report (just released in full) and the even newer AMA Council recommendation to end industry support.
The AAMC report strongly encourages more restrictions on participation in promotional medical education and discourages faculty participation in industry-sponsored speakers' bureaus (two industry CEOs dissented). In many areas it repeats the AMA Ethical Opinion 9.011 on CME (1992) that applies to all physicians.
Unfortunately, in response the NY Times editorialized: "Should They Send a Thank-You Note?" castigating doctors (of course) and the AAMC report for not calling for an end to industry subsidies of CME. Doctors should pay for their own CME, the Times said.
Sometimes I feel as if we're into "Kick CME - and damn the consequences." The attacks on industry support of CME continue not only in the US, but also in Europe. The AAMC and AMA reports are important input into starting a fact-based discussion.
Where do you stand on industry support of CME? What can be done to counter the criticism? Is it best to let industry support phase out? Or create more transparency? Or be tougher in auditing for independence? Let us know your thoughts. We'll summarize these in subsequent columns.
Dear CME colleague,
Once again, the positive and the negative in this issue: Two major organizations in the US are directly opposite each other on industry support of CME. And a European veteran simply says to focus on keeping content free of bias.
Is US CME in crisis? Differing views from the AMA and AAMC
In this topsy turvy world of CME in the US, there is no end of surprises. First, the academic community, represented by a task force of the Association of American Medical Colleges (AAMC), spoke out in favor of "an effective and principled partnership between academic medical centers and ... health industries." Next, the physician community, represented by a council of the American Medical Association (AMA), stated that "physicians and institutions of medicine ... must not accept industry funding to support professional education".
What is a CME professional to do when faced with these opposing views? And what will top executives of pharmaceutical companies do? And, finally, will this debate spread to Europe and the rest of the world? As you ponder these questions, here are the details of these reports:
In late April, the AAMC Task Force on Industry Funding of Medical Education, chaired by Roy Vagelos MD, former academician and later CEO of Merck & Co., acknowledged concerns regarding objectivity in the face of increasing dependence of medical schools on industry support of core educational missions. The report recommended that schools develop audit mechanisms to ensure compliance with Accreditation Council for CME (ACCME) standards, manage all grant requests through a central CME office, and work with accredited providers. Otherwise the CME-industry partnership should continue.
The Task Force further recommended that AAMC and ACCME work together to create a process for spot-reviewing CME offerings "for consistency with ... guidelines and for the presence of inappropriate influence."
In early May, the Council on Ethical and Judicial Affairs, a powerful body, proposed to the AMA House of Delegates that "to deliver scientifically objective and clinically relevant information" to physicians, industry support of CME (and other activities) must end. "Industry support ... has raised concerns that threaten the integrity of medicine's education function," the Council stated.
Neither report has been approved at the final level of authority of the respective organizations. And, if approved, the recommendations are not binding on physicians or medical organizations. Nonetheless, both AAMC and AMA exert substantial influence on the medical community. More in June!
Reader reaction: "The water torture drip"
That's the opinion of Dr. Louis Cooper, former president of the American Academy of Pediatrics, referring to last month's commentary on the attacks on industry support of CME. "Industry remains an important partner for quality unbiased CME, but the drip, drip, drip of revelations threatens even efforts of that kind," he says.
In contrast: Simple lessons from a veteran European CME professional
When the Union of European Medical Specialists (UEMS) celebrated its 50th anniversary last month, Dr. CC. Leibbrandt, former secretary-general and founder of the European Accreditation Council for CME (EACCME) offered these lessons regarding CME from 15 years of involvement:
Keep it Super Simple
Reach consensus, do not dictate
Avoid bureaucratic structures; use grass roots structures when possible
Use existing expertise, including from professional organizations; don't reinvent the wheel
Remember that the main goal of structured CME is facilitating access to quality CME for individual doctors
Focus on improvement of knowledge and skills, not on a smooth running system
CME is just a part of professional development
Respect the dedication of individual doctors and take care that they are enjoying CME; avoid detailed regulation
Avoid structures in which doctors act as policemen
Pursue the ongoing battle between quality CME and commercial interests; the latter should be welcomed only when the education is free of commercial bias; avoid petty regulations.
Indications are favorable that EACCME is filling these requirements, Dr. Leibbrandt concluded.
At last, UEMS proposes accrediting eCME for European doctors
After several years of discussion, the Union of European Medical Specialists (UEMS) has released a draft set of requirements for approving electronic-based CME/CPD programs for European-wide credit through the European Accreditation Council for CME (EACCME). The draft, prepared by a UEMS vice-president, Dr. Edwin Borman (left), covers not only online CME, but also that in any recorded format.
The criteria are similar to those for live meetings, but do encourage task-based interactive learning and performance improvement, and should be suitable for an international audience. The proposal also recognizes that there may be differences with national recognition of eCME credits, which control what doctors in individual EU countries may claim. Italy, for example, only accepts eCME in one region, Lombardy, at the moment; France has yet to announce its position.
Major events ahead
May 29-31, CME Congress 2008, under the auspices of leading international educators, Vancouver, Canada
June 8-10, Global CME Harmonization 2.0: Strategy for the Future, Jersey City NJ, sponsored by the Global Alliance for Medical Education (GAME)
June 13-30, inaugural certification exams for CME professionals at 200 testing centers across the US. Go to NCCME for details.
Several readers cheered Dennis Wentz's call for reason regarding the industry's support of CME last month. One said "the noise level is not helping". We were cheered by the accompanying report from Australia, indicating that positives in our industry relationships can occur.
But unfortunately, in the US the noise level is increasing. In an
April 15 NY Times article, several US academic scientists announced they would no longer accept payments from drug or medical device companies -- whether for speaking or for consulting.
"It's easy to offer subtle statements that would favor a drug," said Dr. Kelly Brownell, an obesity expert at Yale. Dr. Peter Libby, top lipid researcher at Harvard, said he thought he was safe from accusations of bias because he consulted (for pay) for so many companies. But now, as a result of blogger attacks, he will no longer accept payment. "It is not worth it to be under suspicion," he said.
The next day, JAMA published an editorial, "Impugning the integrity of medical science: The adverse effects of industry influence". It is based on accusations in 2 related articles that Merck "apparently manipulated dozens of publications to promote one of its products", a charge Merck vigorously protested.
Among the editors' recommendations: "To maintain a healthy distance from industry influences, professional organizations and providers of [CME] should not condone or tolerate for-profit companies having any input into the content ... or providing funding or sponsorship for medical education programs" (italics mine).
We are now in an age in which respect for ethical behavior has vanished, to be replaced by fear and overreaction. Remember the biblical lesson: "Let he who is without sin cast the first stone." The pharmaceutical industry is not intrinsically evil, nor are medical scientists, educators and the media without sin. Let's restore a climate in which we can work together for good.
Dear CME colleague,
The positive and the negative in this issue: Pharma in Australia is pioneering transparency in its support of CME. But in the US, attacks on the industry continue. Many in the industry are getting weary of being scapegoats. The result may be their withdrawal from support of CME. Your thoughts?
A global first: Pharma in Australia reports details of medical education funding
Medicines Australia, the industry association, has published a report showing that in the 6 months ending 31 December 2007, 42 member companies held or sponsored 14,633 educational events for doctors and other healthcare professionals at a total cost of Au$31 million.
Of the total, 52 events are under review for possible breaches of the Medicines Australia Code of Conduct. The results of an independent committee investigation will be made public. "The Code is clear," said Ian Chalmers, CEO. "Personal gifts are banned. Entertainment is banned. Lavish meals are banned." Companies can be fined up to $200,000 per breach.
The total number of attendees was 385,221, with an average hospitality cost of $43 per person. But in one case, a firm paid $514,000 to host a symposium for 226 gastroenterologists -- at $2,275 a head.
"The Australian pharmaceutical industry is now the global leader in terms of transparency and accountability", Chalmers said. "I hope this report gives the community a better sense of the contribution the industry makes to our healthcare system by saving, improving or prolonging lives."
Medicines Australia was required by the Australian Competition and Consumer Commission to publish these reports on a regular basis.
US CME appears to work for neurologists in the developing world
In the US, the American Academy of Neurology (AAN) has documented that its problem-based interactive course, Continuum, has changed behaviors of participating doctors. Under the auspices of the World Federation of Neurology (WFN), the course has now been provided in 36 developing countries around the world, ranging from Cyprus to Russia to Yemen.
A recent article by Abi Sriharan of University of Toronto in the Journal of Neurological Sciences reviewed the success of the program, based on a survey of coordinators in 16 countries. Her findings:
The content is relevant to a great extent, and evidence based
Neurologists would not otherwise have had access to these learning materials
Residents who took the course had improved performance on exams
System level improvements were noted, including an increase in number of neurologists and an increased awareness of the importance of CME
Critical to success were ownership by local societies and committed coordinators
No evaluation was made of changes in physician knowledge or behavior. Translation and adaptation were among the roadblocks in some countries.
Update on CME in Germany: Recognition of the growth of interactive learning
Recognizing the increasing importance of long-distance learning -- particularly web-based education -- the German Federal Medical Association has eliminated its previous maximum limitation on number of credits allowed for interactive learning, according to a report just delivered to the Union of European Medical Specialists by Dr. Leonard Harvey. "Some of the regional medical chambers and professional boards are considering an intensified offer of web-based CPD to increase the effective and efficient use of e-learning," he said.
Since the 17 regional chambers are primarily responsible for issuing credits, these bodies are expected to accept the change in the near future. German physicians must show proof of 250 credits every five years; hospital specialists must collect 150 points in their own specialties. Failure to produce such evidence can result in a 10% reduction in fees for a year, and if failure still exists, a 25% reduction for the next year; after the 2-year period, a physician is liable to lose his license to practice.
Since the first 5-year period expires June 30, 2009, no penalties have yet been put in place. Dr. Harvey noted that 5-10% of physicians have declined to participate, "so lawyers loom".
Major conferences ahead
May 4-6, Canadian Conference on Medical Education, Montreal, sponsored by the Assn. of Faculties of Medicine of Canada (AFMC)
May 29-31, CME Congress 2008, under the auspices of leading international educators, Vancouver, Canada
June 8-10, Global CME Harmonization 2.0: Strategy for the Future, Jersey City NJ, sponsored by the Global Alliance for Medical Education (GAME)
In the February Newsletter Lew Miller said: "There's growing suspicion that CME is somehow being distorted by pharmaceutical funding".I too have been thinking about this - and it is time to address the issues with the voice of reason. Some of the loudest voices being heard are almost histrionic and this will get us nowhere. We need a renewed debate that includes practicing physicians, the best teachers (not all faculty qualify), all of the organizations and professionals involved in CME.Reducing or eliminating commercial support will not give us more quality in CME.
In the US, the National Task Force on CME Provider/Industry Collaboration was formed 19 years ago to focus on these issues and on solutions. It has contributed the widely adopted 1992 Guidelines on Commercial Support of CME for Accrediting Bodies, and later a national campaign to rekindle awareness of the AMA Ethical Opinions on Gifts to Physicians. Now the Task Force is developing "fact sheets" to clarify the issues that are being raised daily.
The 1993 "Ethical Opinion 9.011 on CME" from AMA's CEJA says: "Physicians should strive to further their medical education throughout their careers, for only by participating in CME can they continue to serve patients to the best of their abilities and live up to professional standards of excellence."
That's what the dialogue has to be about around the world - helping bring that best quality CME to our physician colleagues, involving them in the decisions. Of course there must be balance, objectivity, rigor and lack of bias in CME certified for credit.Most CME systems require it. Why does a conversation with industry automatically make for bad CME? We've got to move beyond the polarizing rhetoric and stand up for what is right for doctors and patients.
Dear CME colleague,
In this issue, a preview of a major new research report on CME funding. Related to that report, we resume the discussion on the role of the pharmaceutical industry in supporting CME. Plus what's happening in Singapore!
CME and industry: A new report focuses on trends in Europe, North America
Where are CME decisions made within pharmaceutical companies? How does spending compare from the US to Europe? What are the trends in industry support? These and other questions are answered in a major new research report from Best Practices, LLC.
The report is based on responses from executives in 26 North American pharma and biotech companies, 18 European companies, and a handful of others, including WentzMiller. The key findings:
Decentralized management styles prevail; most companies do not centralize CME management but rather oversee regionally or nationally so as to reflect local market requirements. Only 18% of respondents centralize the function.
CME internet usage is on the rise -- fostered by a fractured CME marketplace in Europe, especially in an effort to reach smaller markets. It is estimated that up to 50% of all CME will be delivered online within 5 years.
CME program heads must manage a paradox: live meetings are most common but are often least effective; resources are limited; regulation is increasing. Targeting change-ready physicians is a growing new tactic.
Savvy CME leaders are developing informal best-practice sharing networks inside and outside their companies to accelerate innovation.
Use of basic management tools is emerging as part of the CME toolkit for the first time, with more emphasis on strategy and measurement.
The average CME investment in Europe is about 20% of that in North America.
CME in Singapore: Mandated but lightly regulated
A report from KM Tan MD, Kaiser Permanente
Ten years ago,on a visit to Singapore where I grew up, I asked several friends about CME activities in an attempt to compare with the US. I was met with blank stares, my friends acknowledging the availability of educational opportunities but thoroughly puzzled by the extensive CME network in the US.
But in 2003 CME became compulsory and was mandated for license renewal in 2005.The program is run by the Singapore Medical Council (SMC), a statutory board under the Ministry of Health, which maintains the Register of Medical Practitioners in Singapore and regulates professional conduct and ethics.
The SMC-CME committee reviews and accredits individual programs. Representatives from universities, the Singapore Medical Association and large national hospitals serve on this committee. Professional organizations may produce CME activities following approval of an application, provided attendance records are maintained and submitted immediately. An application is approved by in a relatively quick and unencumbered process.Commercial groups such as drug companies may also present educational opportunities for credit provided they are co-sponsored by a recognized entity.
Physicians must have 50 points per every 2 years in order to renew their licenses, obtained from the usual range of educational activities, including internet CME. An activity must be a minimum of one hour; if less than 2, only one point is granted. Per activity lasting more than 2 hours, up to 3 days, points range from 1-12, regardless of the actual duration.
There are no significant restrictions on activities of potential commercial supporters. They financially support physicians attending conferences. In summary,CME is now mandatory but activities, including commercial support, are lightly regulated.
An Aussie objects to industry funding -- and other comments
Ray Moynihan, author and lecturer at the University of Newcastle, New South Wales, adds his voice to the growing chorus of those who would end direct drug company sponsorship of CME. In a feature in the British Medical Journal, he suggests that "invisible influence may be flowing through ... sponsored seminars -- even those accredited by august associations -- far more often than many of us realize. ... it is not uncommon for drug company sponsors to suggest speakers" for sessions whose attendees assume are totally independent, not only in Australia but also in the UK.
In a March issue of BMJ, 2 US doctors debate: Has the hunt for conflicts of interest gone too far? Thomas Stossel of Harvard says Yes: "Conflicts of interest ideology purports to promote scientific rigor, yet is far from rigorous itself." Kirby Lee of UCSF says No: "Gifts of any size from drug companies create feelings of obligation and reciprocity." And in JAMA in March, Dr. Robert Steinbrook of Dartmouth Medical School writes: "Commercial funding may inherently distort education and practice to the detriment of physicians and patients, regardless of ... safeguards to protect integrity."
There's growing suspicion that CME is somehow being distorted by pharmaceutical funding.
For many years, we have promoted the idea of collaboration between industry and CME providers. Critics, not only in the US but also in Europe, are now suggesting that doctors are not intelligent enough to recognize bias when they see it in a CME program -whether the bias comes from pharma funding or a faculty member.
In the free economy of the Western world, we believe that consumers can make appropriate decisions about purchases or lifestyles, even when exposed to TV or magazine advertising.
As noted in the adjacent article, a drug company can be an accredited provider of CME in France; no longer the case in the US. In Europe, pharma funding supports a majority of physicians attending a major congress; no longer in the US. And many in Europe worry that the US "hands-off" approach will spread.
We hope not. There is a legitimate role for the industry to play in support of physician education. It is up to CME providers to ensure that programs are evidence based and free of bias. Accreditation bodies have the responsibility to police this. Exclusion of industry is not the answer.
Dear CME colleague,
In this issue, we present reports from the Alliance for CME annual meeting on trends toward integration of CME activities in Europe. Our commentary focuses on the sources of CME funding and its implications. We invite your comments!
Europe's approach to CME: Is it becoming more integrated?
Yes and No! That was the mixed response presented last month at the International Day sessions of the annual meeting of the Alliance for CME held in OrlandoFL. A survey of the 2500 members of the Alliance showed that an amazing 68% wanted to learn more about CME internationally!
Specialty boards coming aboard
Bernard Maillet MD, secretary general of the European Union of Medical Specialists (UEMS), provided a positive report on negotiations with European specialty accreditation boards. The European Board of Accreditation in Cardiology (EBAC) has agreed to work within the European Accreditation Council for CME (EACCME) system, and talks are being held with similar bodies in infectious diseases and genetics. In addition, Dr. Maillet mentioned ongoing discussions with the European Union of Omnipractitioners (UEMO) regarding integration of GP CME credits. EACCME would then serve as the conduit for such credits to the national authorities, a final required step in assuring that doctors get credit for their CME against any mandatory requirements.
Provider vs. program accreditation
There's less integration on the question of how CME is accredited, however. For the most part, activities are accredited, one by one, reported Alfonso Negri MD of the Italian Federation of Medical Societies. In his own country, one region -- Lombardia -- is moving to accredit providers. So is France in its new system. EACCME, the specialty boards and other countries remain wedded to individual program accreditation. In France, a pharmaceutical company can become an accredited provider; Pfizer has done so. Elsewhere, providers must be academic or medical organizations.
Increasing use of the internet
Despite slow acceptance of Web-based CME for credit, eCME is spreading rapidly throughout Europe. Thomas Kellner MD, manager of MSD's univadis site, described this and several others worth visiting: Diabetes education modules, Elwis-MED, BMJ Learning, PONE (for cancer in youth), and World Forum CPD. Some have offerings in several languages; most are in one language only. There's an emphasis on interaction and self-assessment. Dr. Kellner noted. While funding is still primarily from the pharmaceutical industry, some sites are seeking other sources.
That is the theme of the forthcoming meeting of the Global Alliance for Medical Education (GAME), scheduled June 8-10, 2008 in Jersey CityNJ. Keynote speaker will be Dr. Dave Davis, vice-president for continuing health care education and improvement at the Association of American Medical Colleges (AAMC). Other speakers will cover Europe, Latin America, Israel and India in presentations and interactive discussions.
Our organization recently embarked on a major strategic effort to assist a European eCME client determine how and when to expand not only throughout Europe but also into the U.S. Dennis Wentz MD, Lew Miller and Edwin Borman MD(right), our UK associate, play significant roles in this project. To learn how we can help your organization, contact Dennis (email@example.com) or Lew (firstname.lastname@example.org).
Continuing education in the health professions (CE) is in disarray, says a new report from a conference of U.S. and Canadian educators sponsored by the Josiah Macy Jr. Foundation. The key problems:
* Inadequate focus on improving clinician performance and patient health
* Too much emphasis on lectures, too little on enhancing competence
*Accrediting organizations are too bureaucratic
*Too little scientific study of the value of CE
*Pharma support is hurting objectivity
It is hard to disagree with these findings. We have been relying too long on CE practices that no longer keep pace with today's healthcare environment.
The report recommendations are sound, for the most part:
*New metrics to assess quality, based on enhanced outcomes
*Improved information technology tools for CE
*Creation of a CME Institute to advance the science
But the report treads on dangerous ground when it suggests that all pharma funding stop within 5 years, to be replaced by funding from health professionals and their employers. The authors believe there is no way that pharma funding can be managed to produce unbiased CE.
We don't accept these assumptions. We need good research to determine the truth before changing the financing methods based on perception. Do you agree?
Dear CME colleague,
In this issue, the trends toward more use of the Internet and more emphasis on performance improvement are clearly delineated. The future is upon us. The Alliance for CME annual meeting later this week is also looking ahead -- it is the largest such conference of CME professionals in the world. This year, most of one day is devoted to international issues. We'll bring you the results in the February newsletter.
UEMS-EACCME is finally moving into the Age of the Internet
CME and the Internet haven't fit well in the past in the European Union of Medical Specialists (UEMS) and its affiliate, the European Accreditation Council for CME (EACCME). But in 2008 change is taking place, in two directions:
1) Starting this month, UEMS-EACCME are launching a new website to facilitate accreditation. No more paper applications! "Through this single portal," UEMS says, "CME providers from all over the world will be able to apply for EACCME accreditation electronically, track their applications, ... and advertise their event to the medical and scientific community through the UEMS-EACCME database".
2) Before year end, UEMS is likely to approve accreditation of long-distance learning (LDL), a topic that has been debated vigorously for several years. Some members of the UEMS Working Group on LDL have been fearful of an invasion of U.S. commercial CME providers, but others recognize that LDL is inevitable. eCME is already accepted in the UK, Spain and Germany, and may also be recognized this year in Italy and France.
England is developing its first pay-for-performance program
Taking a leaf from the U.S., NHS North West, England's largest strategic health authority, will implement the country's first pay-for-performance (P4P) program to improve care for hospital patients. NHS North West will utilize the Hospital Quality Incentive Demonstration project developed by Premier Inc., a US provider working with the Federal government.
In the November 2007 issue of this newsletter, we raised the question: Can performance improvement be the only basis for continuing medical education, as some have suggested? Or is it more of a systems tool for redesigning medical practice? It will be interesting to see the extent to which the NHS North West project affects revalidation of staff physicians.
New health portal appears in Spanish and Portuguese -- including CME
Spanish and Portuguese speaking physicians now can find up-to-date medical news, conference coverage and CME in their own language on a new portal, Medcenter/Medscape. The new site combines offerings from Medscape, a longtime US website visited by thousands of health care professionals in the U.S. and elsewhere, with those of Medcenter, a multinational pharmaceutical marketing company with offices in the U.S., Spain and Latin America.
Our organization recently embarked on a major strategic effort to assist a European eCME client determine how and when to expand not only throughout Europe but also into the U.S. Dennis Wentz MD (right), Lew Miller and Edwin Borman MD, our UK associate, play significant roles in this project. To learn how we can help your organization, contact Dennis (email@example.com) or Lew (firstname.lastname@example.org).
SEARCHING THIS SITE: PRESS CONTROL F AND ENTER YOUR SEARCH TERM. YOU CAN SEARCH ANY SECTION LISTED TO THE LEFT, ONE SECTION AT A TIME.