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Continuing medical education provides lifelong learning

A dozen years ago, a colleague approached Apostolos (Paul) Dallas, M.D., Carilion Clinic’s long-tenured director of Continuing Medical Education, and made what was, to Dr. Dallas, an intriguing observation. “You know, nobody’s teaching portable ultrasonography in the United States,” Dr. Dallas recalls the colleague saying. “I think we can be the first people to teach it.”

Ultrasonography, a technique that uses the echoes of soundwaves to create images of what’s inside the body, is perhaps best known for helping obstetricians track what’s happening in the womb during pregnancy. Yet its use in medical practice is far-reaching. Since its introduction in the United States in the 1960s, ultrasonography has been adopted by fields as disparate as cardiovascular medicine, urology, emergency medicine, and dermatology to help make diagnoses and guide treatment. And, by ditching cumbersome machinery for more mobile, handheld devices, portable ultrasonography has opened up more applications for this powerful tool.

The portable devices can be dispatched in the field quickly—inside or outside the hospital—making them especially useful in critical care and emergency medicine, where cases are delicate or life-threatening and time is of the essence. The notion that portable ultrasonography devices, which were widely available by the late 1990s, were not being used to their full potential because of a lack of training was disconcerting. And it’s exactly the type of gap that CME, which is designed to keep physicians updated on the latest technologies and practices, was meant to address. To Dr. Dallas, it was a perfect opportunity for Carilion doctors to fill an unmet need in medical education.

“It’s one thing to do something that everyone else is doing and try to do it incrementally better,” Dr. Dallas says. “It’s another thing to do something no one else has done. It was exciting.”

There’s Always More to Learn

Mandatory CME programs began to pop up across the United States back in the 1930s, once it was recognized that the initial training of physicians wasn’t enough to sustain them through their long careers. Patients would be better served, it was thought, if their doctors continued to learn over the years. That philosophy has proven ever more relevant as the responsibilities of modern physicians have mounted. Physicians today not only care for the sick and injured, but also find themselves with additional responsibilities, most often as teachers, administrators, researchers, and advocates. Learning all these skills—on top of those needed to treat patients—would be impossible during the relatively short term of medical training. And new information and procedures always arise.

Without CME, it would be difficult for physicians to keep fresh and updated. Shari Whicker, Ed.D., director of the Office of Continuing Professional Development, of which CME is a part, looks at the issue from the perspective of health care delivery. “While it may be imperceptible to them, CME matters to patients,” Dr. Whicker says. “They expect the level of expertise that CME helps provide. When they come in, they expect their physicians and health care team to have answers. While providers are never going to be all-knowing, it’s absolutely critical for them to stay up with the latest technologies and information so they can provide the best possible care.”  

“One would hope that if you’re educating a physician on a new technique or practice,” Dr. Dallas adds, “then on the very next opportunity the physician has to see a patient with a relevant condition, there’s the potential that the patient will benefit.” He offers the emergence of new medications as an example. If a physician learns during a CME course that a new anticoagulant has come onto the market that causes less bleeding and is better at preventing clots than older therapies, then that doctor can immediately switch patients to the better agent. Similarly, if physicians learn that a new antibiotic is available, they’ll know they can prescribe it if other treatments fail. Carilion’s portable ultrasonography course provides additional instances.

Dr. Dallas notes that one student used the tool days after taking the course to identify the location of a dangerous clot. Anotherdiagnosed fluid buildup around the heart of a woman who was suffering from low blood pressure. “There have been cases,” he says, “where a physician has been able to help a patient in a significant way by having attended one of our CME courses.”

TEACH to Learn

With physicians’ responsibilities increasing, and with medical and scientific knowledge growing at exponential rates, CME has had to keep pace.Dr. Dallas reports that, in his time as CME director, Carilion has gone from offering 7,000 credit hours each year to more than 80,000 hours—an increase of about 20 percent each year.

Some of that increase can be traced to the growth of the Virginia Tech Carilion School of Medicine, which has brought more students, residents, and fellows into the system, creating an even greater demand for instruction. In tandem, and through collaboration with the Virginia Tech Carilion School of Medicine and Jefferson College of Health Sciences (now Radford University Carilion), Carilion has recognized the importance of support for quality teaching. That commitment is exemplified by the Teaching Excellence Academy for Collaborative Healthcare (TEACH). The program, which Dr. Whicker directs, brings together faculty and other professionals at Carilion united by the common thread of teaching within the health professions.

The academy provides organizational support, opportunities for networking and collaboration, and recognition for medical experts whose educational roles are too often overlooked. It’s hoped that some additional CME programming might continue to come out of the collaborations and training provided by the academy. Still more stems from existing trainings offered by individual departments.

“Almost every department has a requirement to teach residents and fellows. If their trainees can benefit from it,” Dr. Dallas says, “then we ask: why not make it so other physicians can benefit from it also and get CME credit?” Additionally, Carilion’s CME program offers various conferences and symposia, including a spring symposium that has, for the past 70 years, offered a concentrated mix of interdisciplinary training for interested Carilion physicians.

“We conduct regular needs assessments to see where our gaps are and what our faculty and professionals need to learn more about,” Dr. Whicker says. “Once we establish what those needs are, we seek experts who can provide that training internally and, if necessary, we’ll bring in outside experts to fill those gaps. This is true when it comes to teaching, as well as a variety of other developmental needs that reach our physicians and other health care providers.”

Dr. Whicker adds that topics include basic research, quality improvement, communication skills, team-building, well-being, and anything else that will improve the patient and learning experiences throughout the organization.

Crossing Borders

In Virginia, physicians are required to accrue 60 hours of CME every two years. Although requirements vary by state, it’s safe to say that demand for training nationally is high. Carilion is doing its part. While most of its offerings cater to physicians within the Carilion system, many courses allow physicians from all over Virginia, neighboring states, and the country to train as well. Past conferences have even attracted doctors from abroad. And Carilion has projected outward. Some courses—particularly those that are unique or in high demand—are taught outside of Carilion’s walls.

The portable ultrasonography course that Carilion designed—a detailed, hands-on, CME program first offered to critical care physicians at Carilion—proved so popular that it gained national attention. In addition to extending the program to primary care physicians and others, the experts who taught it were ultimately asked to design a portable ultrasonography course for the Society of Critical Care Medicine and, later, the American College of Physicians. Carilion faculty also teach courses nationally that weren’t developed through the CME program, yet depend on a faculty member’s unique expertise. Joseph Moskal, M.D., chair of Orthopaedics, for example, teaches courses on an anterior approach for total hip replacement surgery that he helped pioneer. Surgeons from across the globe have visited Carilion to learn the procedure, which allows access to the hip socket without cutting through major muscle groups, potentially speeding recovery. Dr. Moskal has also taught the technique in Europe. Similarly, Carilion’s chief of Otolaryngology, Benjamin Cable, M.D., is one of only three experts nationally who teach surgeons how to performsialoendoscopies in children.

The minimally invasive surgery has been shown to be a safe and effective treatment for obstructive salivary gland disorders. And the reach of Carilion’s program extends even further. Classically, CME has been defined as “by physicians, for physicians.” Yet the Carilion program has, over the past several years, committed to extending offerings to other health care professionals, such as nurses, physical therapists, and physician assistants.

“So many of the courses we offer are valuable for other health care professionals, and we don’t see a reason we should ever limit it,” Dr. Whicker says. She emphasizes that, as health care professionals increasingly work together on teams, it’s essential that they work from a shared knowledge base. “As health care evolves, interprofessionalism becomes even more critical to patient care, and if we’re not learning in the same way we’re practicing, we’re losing a lot,” she says. “It’s important to tear down the walls, engage in conversation together, and learn from one another.”

By Veronica Meade-Kelly