CME in an HMO: Fifty Years of Experience | to pdf >>
By M. Rudolph Brody, MD

The evolution of the Kaiser Perman-ente Southern California (KPSC) 50-year experience in continuing medical education (CME) is reviewed. The current program consists of in-house, specialty-specific half days of CME; annual one- to two-day symposia; various specialty, subspecialty, and interspecialty conferences; and an extensive graduate medical education (GME) program. The support structure and budget show strong commitment to the educational program. Future challenges include using new technology to enhance the program, developing programs suited for individual needs, and showing the value of KPSC's commitment to education.

Currently serving about 2.8 million Kaiser Foundation Health Plan (KFHP) members, the Kaiser Permanente (KP) Medical Care Program in Southern California (KPSC) is a prepaid, group-model, nonprofit HMO with 50 years of experience in continuing medical education (CME). Indeed, development of an educational program always had a high priority at KPSC, which currently contracts with the approximately 3000 physicians of the Southern California Permanente Medical Group to provide medical care at 12 different KP medical centers and numerous KP medical offices throughout Southern California. KPSC's philosophy from its inception has been that the opportunity for continuing professional growth was necessary, first to attract outstanding physicians and then to maintain their excellence. The evolution of this educational program is detailed below.

Integral Part of KPSC's Founding Philosophy
Given the philosophy that the opportunity for continued professional growth was necessary, KPSC, during its formative years of 1945-1957, granted its physicians up to two half-days per week for bona fide educational activities (ie, medical meetings, organized rounds at various hospitals, teaching, and research). Physicians were encouraged to use this time, and many actively participated in the teaching programs of neighboring universities. In 1957, these educational half-days were changed: one half-day was allocated to education, and the other was used as time off. Physicians were encouraged to combine the half-day off with educational time to maintain their teaching commitments. In addition, if a teaching commitment required three half-days, the chief of service was authorized to allow that time to meet such a commitment.

In-house and Beyond: Growth of Educational Programs
As KPSC grew, it became apparent that in-house departmental programs must be developed. Most large departments and many smaller departments have developed specialty-specific conferences, and most departments in each medical center have a departmental educational chair who develops and coordinates that particular departmental specialty's educational program.

As subspecialties have evolved and grown, major subspecialties such as cardiology, gastroenterology, and nephrology have also developed their own in-house educational programs. Each medical center's director of medical education and departmental educational chairs meet periodically to administer and evaluate the educational program, to share innovative ideas, to discuss important issues, and to participate in faculty development. (One physician coordinates these meetings and represents the educational program within the organization and nationally.)

Budgets are allocated for development and support of these educational activities, and an organizational structure has been developed.

The in-house educational staff conferences usually meet for a designated half-day per week and consist of two or three main segments. The conferences include visiting professors from neighboring medical schools as well as from universities around the country. KPSC physicians lead case presentations and discussions, in-depth reviews of selected topics, radiology conferences, specialty-specific pathology conferences (including clinical pathology conferences). Recently, the conferences have begun using video- and teleconferencing. Before the conferences are held, a needs assessment is done and objectives are set. After completion, the conferences are evaluated by participants, and feedback is given to the speaker. Category 1 CME credit is given for attendance at these activities. Each medical center's director of medical education is responsible for maintaining overall quality and California Medical Association (CMA) accreditation for the CME program. In 1997, KPSC offered more than 5000 hours of Category 1, CMA-accredited medical education to its physicians.

In addition to these half-day in-house programs, KPSC recognized the need to have extended educational programs. One- and two-day symposia in major specialties were thus instituted, beginning in about 1955. Speakers at these symposia include academicians from the United States and abroad as well as our own Permanente physicians. The symposium program has grown to the point where we now sponsor annual symposia in nearly 50 different specialties and subspecialties as well as a varying number of cross-specialty symposia on such topics as women's health and doctor-patient communication.

Contributions to Academic Training
An important part of KPSC's educational program has been the intern, resident and fellow training programs. Since the formation of an Obstetrics and Gynecology Residency Program in 1955, KPSC's Graduate Medical Education (GME) Program has grown to include approximately 300 trainees in residency and fellowship programs. These programs include five separate Family Medicine Residency Programs. KPSC strongly believes that the residency and fellowship programs stimulate the attending staff, attract high-quality physicians to the KP Medical Care Program, improve patient care, and contribute to the community by helping to train the next generation of physicians. The GME training programs are administered departmentally by a physician coordinator and a residency or fellowship director.

Other aspects of the educational program include providing clerkships for 400 to 500 medical students per year. The questions and fresh approach of these students provide another educational stimulus for our physicians. In addition, a school for training nurse practitioners was begun in 1972 and provides an opportunity to train nurse specialists in several primary care disciplines.

The approximate budget for the combined CME and GME components of KPSC's educational program, exclusive of physician administrative time but including house staff salaries, is approximately $20,000,000.

Future Challenges
The future for KPSC's educational program holds many challenges. These challenges include incorporation of new technology, development of programs suited to individual needs, and--especially in this time of increasing concern about cost-effective medical care--finding ways to show the value of KPSC's extensive commitment to education. The educational programs should show that they are improving the quality of care we deliver to our members. The programs must also be better coordinated with the quality management program. In addition, the educational programs must be in alignment with KP's organizational goals without losing their independence and objectivity.

Acknowledgment: Over the years, we have worked with a number of people without whose energy, support, and creativity KPSC's educational program could not have been developed. We especially thank Raymond Kay, MD, dec.; Samuel Sapin, MD; the physicians who both administer and participate in these programs and to those who have supported the physicians: Shirley Gach, Cheryl Tsieprati, BA, Valerie Riggs, BS, Peggy Stone-Barclay, MA, Denise Lenore, BA, and their staffs.