Learning is like rowing upstream; not to advance is to drop back.
-Chinese Proverb
The crown jewels of neurosurgical continuing medical education are the annual meetings of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. These meetings are the primary vehicles through which neurosurgeons fulfill the obligation to acquire contemporary knowledge for the benefit of those entrusted to their care. It is difficult to imagine that this was not always so.
 |
| Robert A. Ratcheson, MD |
To this point, neurosurgery was a lonely and isolated field, practiced by only a very few pioneers who had been groping their way beset with difficulties that one can only imagine today. Craniotomies were performed and frequently tumors were not found. Few young men had sufficient courage to embark upon a specialty in which the results were so discouraging and which seemed to offer so little chance of success.
Spurred by his reception at the College of Surgeons meeting, Cushing suggested to Ernest Sachs of St. Louis the formation of a club that would meet regularly to discuss neurosurgical problems and compare results. It was left to Sachs to organize the first meeting. Eleven men were invited to attend, and only one, Walter Dandy, refused, likely because of ongoing animosity with Cushing. The first meeting of this group, the Society of Neurological Surgeons, the SNS, took place in the spring of 1920 in Boston. The organization met twice per year at each other’s clinics, where patients were presented and operations observed and discussed. After each of the first three meetings, Sachs, as secretary and at the instruction of the members, wrote to Dandy again inviting him to join. After that, even as late as 1926, Dandy was approached personally by Cushing, but never became a member.
This organization was the beginning of neurosurgical CME, and in this instance, it is Dandy’s absence that underscores its importance. Sachs considered Dandy’s refusal to participate as being particularly unfortunate. In 1918, Dandy made his most important contribution to neurosurgery, ventriculography, which likely would have found earlier acceptance had he been able to promulgate his invention to other neurosurgeons through the meetings of the SNS. Because of Cushing’s antipathy, its acceptance was retarded. Prior to its advent, less than 50 percent of tumors were found at operation, whereas afterward 95 percent could be located. The toll on neurosurgical patients, which occurred between ventriculography’s invention and its ultimate acceptance, was truly unfortunate.
The founding of the SNS was a huge advance for neurosurgery. It had the results of cementing friendships and standardizing surgical procedures and methods. A growing correspondence among its members addressed technique, equipment, possible trainees and pathology. Sachs considered that his attendance at SNS meetings was an important factor in improving his results due to the insight it gave into what others were thinking and doing and also in preventing one from becoming self-centered and self-satisfied. Major advances such as “the Bovie” were first introduced at these meetings and neurosurgery continued to prosper and grow.1,2
Continuing medical education is lifelong learning for the purpose of keeping us up to date. Most of our licenses are tied to having obtained CME credits, and in the near future, our ability to become recertified by the American Board of Neurological Surgery will clearly involve participation in and documentation of these efforts. Significant changes in medicine occur all the time. The half-life of medical information is less than five years and the average physician practices 30 years. The neurosurgeon must be able to incorporate into his skills new technology, sophisticated surgical techniques and improvements in the treatment of neurosurgical and neurological disease. With new knowledge and growing complexity, there is a potential for errors, a fact that has not escaped American’s lawyers.
CME, as opposed to residency training, is specifically for the practicing neurosurgeon. Its elements include self-direction, internal motivation and a quest for specific knowledge, whereas traditional medical training is rigidly structured, lecture based and focused on the memorization of facts. Learning for the mature student is most successful when focused upon practical applications that allow information to be placed in a contextual framework. One of the major responsibilities of the AANS is to organize and provide a framework for these educational experiences that promotes the independent judgment and professionalism of our members and, most importantly, provides objective and balanced information. The AANS has the responsibility to require that its members participate in the continuing education processes, and thus, have in place requirements for membership which will complement those of the ABNS in their Maintenance of Certification efforts. There is in place a process to track CME activity for each neurosurgeon and also to review and approve neurosurgical CME. The AANS has the ability to sponsor and jointly sponsor category I CME, a process carried out under the auspices of the Accreditation Council for Continuing Medical Education.
An important service to society and for the quality of neurosurgical education is specialty-specific CME. We must guarantee to the public that neurosurgeons are receiving appropriate neurosurgical CME. The responsibility for educational content must be firmly in the hands of neurosurgery and not under the direction of some quasi-governmental agency or those with conflicting interests. Neurosurgery’s educational leadership must ensure that the policies put in place by the ABNS’ Maintenance of Certification and the AANS and CNS are fully married in order to prevent confusion and maintain and support the standards which society expects of us.
There are some challenges to contemporary CME. A great deal has been said about the role of industry and its influence upon CME programs. Industry spends in excess of $11 billion or between $8,000 and $13,000 per physician each year on education and marketing, and the difference between the two is not always clear.3 Industry, an abundant source of medical advances, plays a crucial role in disseminating up-to-date medical information. Although industry information fills an important need, it is often biased.4 It is not difficult to see why this may be so.
A company’s primary obligation is to obtain maximum benefit for its shareholders. Medical professional societies such as ours have the altruistic duty to advocate and act in the best interest of the patient and society and are expected to serve as independent and trustworthy sources of objective and balanced healthcare information and education for members and the public. While seeking to achieve these goals, professional associations frequently seek external funding to defray costs and risk arrangements that can result in dual commitments or conflicts of interest, and they therefore must follow specific guidelines when dealing with industry sponsorship to ensure that unbiased information is presented in a scientific program.
The AANS has established policies that require complete control of program planning, content and delivery by the organization in its programs. Our interactions with industry have been harmonious and supportive and present little in the way of a problem. However, society has deemed it appropriate that this relationship be further clarified in order to ensure that the material presented by medical associations, such as ours, is unbiased and accurate. The AANS has charged a task force to review guidelines and interactions with commercial and corporate sponsors in an effort to further the continuation of appropriate relationships. These guidelines will ensure that industry’s presence does not detract from the annual meeting’s focus on professionalism and other organizational goals.
With a professional organization such as ours, the appropriate role of sponsors and industrial contributors has been easy to maintain. However, this becomes much less clear when dealing with commercial support for smaller organizations and individual physicians. In such situations companies have been known to help organize and advertise educational events, prepare teaching slides and curriculum materials, compile lists of possible speakers as well as indirectly pay speakers. Attendees are often rewarded with free meals and other amenities.
Anthropologists have looked at the cultural significance of gifts. They recognize that the central importance of gift exchange is a means of initiating and sustaining relationships. In our society we are not taught to accept gifts without accepting certain obligations and only the very callous would do so. This makes things far less clear for the individual physician accepting gifts, such as hospitality and travel expenses. The obligations established are minimized when gifts are institutional rather than personal as no personal relationship and no obligation to respond in any way are established between the individual physician and the company. Nevertheless, some might argue that issues of justice and influence by promotion still remain and that institutions can also be corrupted. However, for an institution, full disclosure, avoidance of extravagance and the primary goal of improving patient care by physician education make these activities ethically acceptable and laudable.
The neurosurgeon’s primary concern must be with the quality of the CME that is offered, and not just with the accumulation of credits of any conceivable merit. Although current guidelines for organizational CME appear appropriate and effective, there are other dangers to unbiased content.
I suspect there is a more insidious threat to neurosurgical CME that resides within our own house. Conflict of interest is an obstacle to the honest exchange of information that has been heightened by the increasing involvement of neurosurgeons with commercial ventures. Teachers, who also function as CEOs of their own companies, or stock or option holders of others, or paid consultants, are asked to carry a difficult burden in providing unbiased evidence regarding their products and inventions. The disclosure of a conflict of interest, by itself, does not guarantee that the information provided will be without prejudice, and there must come a point when the requirement for unbiased educational content should restrict certain individuals from participating in specific educational venues.
One should also be wary of personal marketing. We have all been at CME venues where colleagues have claimed remarkable successes through the use of technology or vastly superior surgical skills that only they can provide. While in some cases this may be true, the desire to enhance one’s practice can also lead to the delivery of biased and compromised information.
| “The AANS organizes and provides a framework for educational experiences that…provide objective and balanced information.” |
These issues should be looked at with the appropriate perspective. I would assure you that the problems of CME represent a much less significant threat to the practice of medicine than the pressure exerted by those who wish to directly influence how we practice for their financial gain. The influence of HMOs, physician joint ventures, proprietary hospitals and federal constraints on best practice along with the effect of medical liability issues, when measured against threats to CME, are the proverbial giant to the gnat.
I have been involved with the organizational aspects and the delivery of neurosurgical CME for over 25 years. I recall the first CME meeting I attended on behalf of neurosurgery. It was in 1978 and attended by no more than 150 individuals; I also recall the second which had closer to 400, and the last, just a few years ago, which was attended by thousands. I have observed CME become a giant bureaucratic industry with arcane rules. What has been learned? The majority of knowledge that I have gained beyond my residency, my reading and my role as a program director has been learned at neurosurgical meetings. It has been gleaned from colleagues and friends who have provided new ideas that I have been willing to try because of my trust in and respect for them. The ability to interact with my peers has been the cornerstone of my CME. When one considers the missed benefit to early neurosurgical patients which resulted from the lack of communication and conviction about Dandy’s ventriculography, society can be grateful that our small part of the medical profession has evolved differently.
Irrespective of the progress that will be made in communication of information through electronic and other formats, the ability of neurosurgeons to communicate with each other about their mutual problems, and as Sachs said, “its benefit in preventing us from becoming too self-satisfied or self-important,” will remain the most effective CME of all.
Robert A. Ratcheson, MD, is the 2004-2005 AANS president. He is the Harvey Huntington Brown Jr. professor and chair of the Department of Neurological Surgery at Case Western University and at University Hospitals of Cleveland.
This article is adapted from Ratcheson, RA. “Neurosurgical Continuing Medical Education.” Clinical Neurosurgery. 2004;51: 36-38.
Notes
1. Sachs, Ernest: Fifty Years of Neurosurgery. 1958, New York, N.Y.; Vantage Press.
2. Historian/Executive Council of the Society of Neurological Surgeons. The Society of Neurological Surgeons 80th Anniv