Fall 2000

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The Booming Business of
Keeping M.D.'s Current

By Mat Edelson | Photographs by Bill Denison

What started out as a cottage industry among a few Hopkins professors in the early '70s has blossomed into the nation's largest self-supporting continuing medical education enterprise.

A lie Ghazal laughs at his own naivete. It only took him two years of practice to realize that earning an M.D. was no guarantee of lucrative employment. "I started realizing in my second year out of medical school how hard it is to get a job," says Ghazal, who speaks in a soft, musical voice that carries just a trace of his childhood roots in Lebanon. Despite a fine record at Loma Linda Medical School and a residency in internal medicine at Kettering Medical Center in Dayton, Ohio, Ghazal found himself facing a saturated job market in the Dayton area, where he wanted to practice. Finally, he turned to a temporary physician placement agency that found him a job at a 50-bed hospital in tiny Circleville, Ohio.

For all his ability to diagnose and treat, when it came to understanding how to market himself as a physician, Ghazal was a tabula rasa. His lack of business knowledge was limiting his possibilities just at the point his career was ready to take off. He didn’t know where to look for a position or how to assess the economic implications of the different roles available to MD’s today, everything from working for a managed care organization to joining a private practice to taking a job at a nursing home. Had it not been for a new concept in continuing medical education, in fact, he could easily have spent years figuring out how to secure a financially sound, fulfilling position amid the chaotic health care scene of the 21st century.

Elie Ghazal (above) in
Cincinnati tuning into a
weekly session of the Online
Hopkins Business of
Medicine course.

But last year, Elie Ghazal took his future in hand. Several days a month, when he ended his 12-hour hospital shift, he made the 80-mile drive to the Cincinnati suburbs. There, in a Caliber Learning Network classroom, he met several other physicians who’d traveled there for the same reason as he—to link onto the Internet for a satellite broadcast emanating from Baltimore. Five hundred miles away at Johns Hopkins, a group of faculty and administrators had found a way to give these MD’s the information they needed to practice medicine in today’s data-driven, competitive market. Each week, as the welcome slide came down and the show began on the large screen TV in the center of the classroom, the futures of Elie Ghazal and his classmates took shape... "Good evening, and welcome to the next session on Managed Care, Perspectives and Practices in The Business of Medicine Program from Johns Hopkins" it read.

Instituted by most states in the ’70s as a way of ensuring that doctors kept abreast of the latest technology and information in their fields, Continuing Medical Education was initially seen by many in medicine as an unwelcome burden... and sometimes even a joke. 60 Minutes once skewered the concept by showing a course at a plush winter resort where a VCR played to a classroom full of empty seats. Physicians in the course were out skiing or shopping but still receiving full credit.

In an Online Hopkins
Business of Medicine course,
participants speak with
Frank Herlong about his
lecture Liver Disease and

Not surprisingly, the history of CME at Johns Hopkins has been quite different. It is—and always has been—serious business, aimed at doctors and health professionals intent on self-improvement while fulfilling their state-mandated CME hours. But what started out as a cottage industry among a few Hopkins professors in the early ’70s has blossomed into the nation’s largest self-supporting CME department, topping other notables such as Harvard and the Mayo Clinic. Last year the Hopkins Office of Continuing Medical Education ran 480 programs for over 18,000 registrants, offering curricula as wide ranging as medicine itself: Grand Rounds, board reviews, clinical research conferences, symposia ranging from Ophthalmology to Dysphagia, even an MBA program for doctors...all these courses fall under the auspices of Hopkins’ Office of Continuing Medical Education.

As courses have evolved, so, too, has the audience to which they’re delivered. What once was seen as primarily an in-house service for Hopkins staff has become a worldwide educational force. Today, many out-of-town physicians plan working vacations around Baltimore City to attend annual seminars that attract the superstars of their specialties. Hopkins also takes its CME on the road, running conferences around the country. And often this doesn’t mean having to pack an overnight bag. Utilizing satellite and computer technology, physicians like Elie Ghazal can access vital medical information. Increasingly, that material is being formatted to fit physicians’ schedules. For those who can’t make regular classes, Hopkins has an Internet innovation: www.johnshopkinswebcast.net (see sidebar), that will eventually offer the latest pharmacological, diagnostic and surgical information just a mouse click away.

As CME continues to expand, the office that began a quarter-century ago almost as an afterthought has turned into a cash cow for Hopkins, returning well over $2.4 million to various departments last year. But there’s more to the enterprise than dollars and cents, says David Heaphy, Ph.D., the associate dean for Continuing Medical Education. "It’s the confidence it brings a doctor, knowing that no matter where she practices she’s on top of her game."

The pale blue pamphlet is a tale of past, present and future...

September 16–18, 27th Annual Current Topics in Geriatrics: A Board Review ...September 17–19, 28th Annual Diagnostic Ultrasound in Obstetrics and Gynecology and Abdomen Conference...September 22–23 National Conference on HIV/AIDS Prevention in the African-American Community...September 25–26, Fifth Annual Johns Hopkins Hepato-Biliary Update...

Janet Hardy, MD, takes one look at the Johns Hopkins Continuing Medical Education Calendar for 1999–2000 and shakes her head in wonder. To say she never dreamed of the day when Hopkins would put on more conferences in a week than she used to in a year wouldn’t exactly be true, for as Hopkins’ first CME director she certainly saw the possibilities. But the realities? Hardy recalls CME before it even had a formal name.

The year was 1974, a time when "if you had your (medical) license...that was it. You never had to crack another book," says the emeritus professor of pediatrics. That bothered Hardy, and at a Hopkins social gathering she got on her soapbox. "I was shooting my mouth off, saying there was a need to do something about CME, and if prestigious universities like Hopkins took the lead, so much the better," she remembers. "A couple of days later, (Dean) Russ Morgan called me up...he happened to overhear part of my conversation. He’d been thinking about this also, and wondered if I had any interest in developing a formal program."

Bringing The Classroom Home

At www.johnshopkinswebcast.com, the future of continuing medical education is taking shape. The brainchild of associate dean for CME David Heaphy, the website is the delivery system for Heaphy’s Center for Distributed Medical Education, which will utilize the Internet to make medical information instantly accessible to physicians anytime, anywhere in the world. "I’ve always known this is going to be something big," says Heaphy, noting that Hopkins’ CME office has long advertised conventional courses on the Internet, "before many people thought the Net was really a valuable tool."

CME head David Heaphy, an
avid sailor.

Though in its infancy, the website already offers cutting-edge courses. For $795, physicians can access 70 lectures and support material that make up the Johns Hopkins Internal Board Review Course. Completion of the course earns physicians 53 hours of Category 1 CME credit. But the real benefit is the flexibility the Internet course offers. Whether it’s during a coffee break on the overnight shift or a few precious minutes after the kids are put to bed, doctors can now bring the classroom home. With a click they can listen—and watch—experts discuss arrhythmias, glomerular disease, myelodysplasia / myeloproliferative disorders...a vast panoply of internal medicine concerns. On the techno-side, with the coming of affordable DSL lines and higher baud modems, occasional video problems (jumpy pictures) on the Net should soon disappear; even now, 56K modem owners will find the audio quality satisfactory for learning purposes.

At the time, internist Phillip Tumulty, pathologist Jack Frost, gyn/ob specialist Don Woodruff, pediatric neurologist John Freeman and pediatrician Ed Sills were running their own successful ad hoc seminars. "They were quite apprehensive that their entrepreneurship would be interfered with," recalls Hardy. She says they listened to her only because she was a colleague. "If Hopkins had brought in an educator type to run the CME program, it wouldn’t have worked. Because the faculty would have been put off." Instead, Hardy made a deal: You come up with the course ideas, and we’ll handle the logistics for a 15 percent cut of the course fees. "If we flubbed it, [CME] would have died a miserable death. But [the faculty] very quickly saw the advantages.

By the time Hardy turned over the reins to the late Carol Johns in 1981, CME was running 80 courses and the office was $100,000 in the black. Johns, a pulmonologist, brought to the post a unique perspective as an outstanding physician and administrator (she had spent a stint as interim president at Wellesley College). During her 12–year tenure, Johns boosted CME’s annual income over the $1 million mark. She focused on how physicians learned and geared courses to offer a variety of educational modalities. Quick-paced multimedia presentations are the norm now, but in Johns’ time every seminar was trial and error, figuring out what worked and what failed.

When Johns left CME in 1993, it was clear the baby was maturing. It fell to Heaphy to bring it to adulthood. Heaphy is the first non-M.D. to head CME, and though he jokes that he only came to Hopkins so he could sail the Chesapeake, his background in continuing education is impressive. For a quarter-century, Heaphy ran the adult education programs for CUNY and later Long Island University. "I called myself Dr. No when I first got here," Heaphy chuckles, recalling that when he first came to Hopkins, faculty were so used to getting their own way that they often issued dictums to CME’s staff. With the backing of former Vice Dean Catherine DeAngelis, Heaphy began negotiating with physicians, upgraded the office’s computer capabilities (they’re now on their fourth generation), then turned his considerable energy to educational innovation.

"Every time I had an idea, Cathy [DeAngelis] let me do it," says Heaphy. Those ideas include the Business of Medicine program, a series of four core business courses so well-received at Hopkins that it led to a satellite version run nationwide with Caliber Learning Centers and a full-scale medical MBA degree program at Hopkins. "Doctors who felt like they’d been trying to read their budget and had no idea what was going on flocked to the course," says Heaphy.

In his seven years as director, Heaphy has gone on to find new revenue streams, create a detailed data base of CME’s registrants and develop CME’s Office of Funded Programs. Under the guidance of Victor Marrow, Ph.D., that office partnered with pharmaceutical and medical device companies to produce 92 CME programs (and $11 million in gross revenue) in FY 1999.

Those revenues, though considerable, may just be the beginning. Heaphy’s latest brainchild, the Center for Distributed Medical Education, is gearing up to create a medical school without walls, accessible to physicians over the Internet anywhere in the world.

"My job is to support the desires of faculty and make clear to the world what Hopkins can do," says Heaphy.

Physicians from around the country traveled to Baltimore in September for the Internal Medicine Review course. These two talked with course organizer Redonda Miller, of Hopkins internal medicine faculty.

Three days, 43 speakers, 44 different lunch topics to choose from, a two-inch thick binder filled with study aids, lecture notes and published works. The 25th Anniversary Topics in Gastroenterology and Liver Disease Conference is not CME for doctors looking for mindless credit. That’s why it appeals to physicians such as Gordon Marson of Greeneville, Tenn. "I started coming here a number of years ago," says Marson, a gastroenterologist. "There’s several reasons I come to Hopkins. This is a world-renowned place with a lot of expertise, and it’s intellectually stimulating listening to these guys. I mean you can read it in books, you can take a course in home study, but it’s not the same as being able to interact or hear discussions."

The setup is a bit like an educational a la carte menu, and Marson came to Baltimore knowing what he wanted to order: A full dish of talks on HPylori, the bacteria associated with peptic ulcers, esophagitis and a whole host of gastric conditions...in short, "a thing we’re faced with every day" as GI physicians, Marson says. A blue-ribbon panel including Hopkins’ Thomas R. Hendrix and Dallas VA Medical Center’s Walter L. Peterson addressed Marson’s HPylori concerns, giving him plenty of food for thought while he awaited another lecture on the use of photodynamic therapy to eradicate abnormal cell growth in the esophagus.

"It’s useful to be able to say to patients that last October at Hopkins they were doing this," Marson says. "That’s very impressive to patients, at least where I practice. A lot of patients travel to the big [medical] centers to get the latest technology and information, but if you can bring that information to them, they’d just as soon stay home."

And that in a nutshell is the goal of CME here, says course director and radiologist Elliot Fishman, MD, who puts on five CME courses a year. To keep the courses fresh, Fishman often mixes Hopkins speakers with guest faculty from other schools, providing registrants with groundbreaking practical knowledge. "They’re in private practice," says Fishman of registrants. "They don’t want the academic theory. They want to know what they can use in practice. You could be a Nobel Prize winner and get up there, explain the theory of everything, and people would hate the talk."

The route from course conception to realization is rigorous on both physician and CME’s support staff. This includes peer-reviewing proposed courses, marketing the course, designing and mailing advertising brochures, registering applicants, finding facilities...literally hundreds of details.

For Carlita Kearney, senior conference coordinator in the CME office, the process is one of constant growth and refinement. After 25 years in the business, she’s still in search of the perfectly run course. She recently fielded some complaints following a board review course, comments that the course didn’t properly prepare registrants for the upcoming boards. "We don’t say that as a result of taking this course you’ll pass the board. They expect more than what we can really offer from that type of conference," says Kearney. Yet while another administrator might dismiss such gripes as sour grapes, Kearney sees an opportunity for improvement. Did we miss something in the marketing piece? That’s where the coordinator works hand-in-hand with the course director. This is the type of comment we need to work on for next year’s conference.

Still, judging by the exploding numbers, Hopkins’ CME participants are satisfied customers. For physicians like Anita Holloway, MD, the medical MBA program has been a godsend. The clinical director at the Hopkins Center for Occupational and Environmental Health, Holloway says a class full of physicians wrangling with serious business concerns is more practical for her than taking an MBA program with bean counters and widget entrepreneurs.

Two hotel settings where Hopkins CME Courses take place:
Lake Tahoe (left) and Mont-Tremblant, Quebec.

"One of the best things you can get out of an MBA is the ability to foster new collaborative relationships based on the principles and issues you learn," says Holloway. "Everyone in my class has a health care focus. It might be to set up a new business, a new industry. It might be to better lead their organization. So I’m fostering relationships and projects that are all based on health care."

Former Hopkins undergrad J. Michael Casparian, MD, completed the 40-week satellite Business of Medicine course at Caliber’s Kansas City center, and before he was even finished, a dean at Kansas University Medical Center asked him to design and co-teach a Cliff Notes version of the course. "They said they thought some of the foundational issues would help faculty throughout the medical school, the school of nursing and school of allied health. We were successful beyond our hopes," says Casparian, adding that his newfound business knowledge convinced another administrator not to cut staffing in his dermatology department.

Elie Ghazal, meanwhile, was so turned on by his first Hopkins Business of Medicine course that he intends to take all four. And the course did for Ghazal what he’d hoped it would. He used what he gleaned in class to land himself a job in a small private medical group at 250-bed Fort Hamilton Hospital outside Cincinnati. Today, he’s cut his commuting time in half and is working with a cadre of superbly trained specialists. He’s also developing a data base from the CME information that will quantify the results of the care his group provides to patients. It’s the kind of hard information that will not only reinforce the practice’s standing with Fort Hamilton administration but also attract business from managed care.

"What I got out of that CME course," Ghazal says, "is much more than book knowledge. It’s about empowering yourself."

For your personal copy of Hopkins’ CME calendar, call the office at (410) 955-2959 or sign on to http://www.med.jhu.edu/cme.