Continuing Medical Education Participants Research Articles

GP awareness, practice, knowledge and confidence: evaluation of the first nation-wide dementia-focused continuing medical education program in Australia

BackgroundDementia is under-diagnosed in primary care. Timely diagnosis and care management improve outcomes for patients and caregivers. This research evaluated the effectiveness of a nationwide Continuing Medical Education (CME) program to enhance dementia-related awareness, practice, knowledge and confidence of general practitioners (GPs) in Australia.MethodsData were collected from self-report surveys by GPs who participated in an accredited CME program face-to-face or online; program evaluations from GPs; and process evaluations from workshop facilitators. CME participants completed surveys at one or more time-points (pre-, post-program, six to 9 months follow-up) between 2015 and 2017. Paired samples t-test was used to determine difference in mean outcome scores (self-reported change in awareness, knowledge, confidence, practice) between time-points. Multivariable regression analyses were used to investigate associations between respondent characteristics and key variables. Qualitative feedback was analysed thematically.ResultsOf 1352 GPs who completed a survey at one or more time-points (pre: 1303; post: 1017; follow-up: 138), mean scores increased between pre-CME and post-program for awareness (Mpost-pre = 0.9, p < 0.0005), practice-related items (Mpost-pre = 1.3, p < 0.0005), knowledge (Mpost-pre = 2.2, p < 0.0005), confidence (Mpost-pre = 2.1, p < 0.0005). Significant increases were seen in all four outcomes for GPs who completed these surveys at both pre- and follow-up time-points. Male participants and those who had practised for five or more years showed greater change in knowledge and confidence. Age, years in practice, and education delivery method significantly predicted post-program knowledge and confidence. Most respondents who completed additional program evaluations (> 90%) rated the training as relevant to their practice. These participants, and facilitators who completed process evaluations, suggested adding more content addressing patient capacity and legal issues, locality-specific specialist and support services, case studies and videos to illustrate concepts.ConclusionsThe sustainability of change in key elements relating to health professionals’ dementia awareness, knowledge and confidence indicated that dementia CME programs may contribute to improving capacity to provide timely dementia diagnosis and management in general practice. Low follow-up response rates warrant cautious interpretation of results. Dementia CME should be adopted in other contexts and updated as more research becomes available.

A cross-sectional study of learning styles among continuing medical education participants

Purpose: Experiential learning has been suggested as a framework for planning continuing medical education (CME). We aimed to (1) determine participants’ learning styles at traditional CME courses and (2) explore associations between learning styles and participant characteristics.Materials and methods: Cross-sectional study of all participants (n = 393) at two Mayo Clinic CME courses who completed the Kolb Learning Style Inventory and provided demographic data.Results: A total of 393 participants returned 241 surveys (response rate, 61.3%). Among the 143 participants (36.4%) who supplied complete demographic and Kolb data, Kolb learning styles included diverging (45; 31.5%), assimilating (56; 39.2%), converging (8; 5.6%), and accommodating (34; 23.8%). Associations existed between learning style and gender (p = 0.02). For most men, learning styles were diverging (23 of 63; 36.5%) and assimilating (30 of 63; 47.6%); for most women, diverging (22 of 80; 27.5%), assimilating (26 of 80; 32.5%), and accommodating (26 of 80; 32.5%).Conclusions: Internal medicine and psychiatry CME participants had diverse learning styles. Female participants had more variation in their learning styles than men. Teaching techniques must vary to appeal to all learners. The experiential learning theory sequentially moves a learner from Why? to What? to How? to If? to accommodate learning styles.

Reducing Misses and Near Misses Related to Multitasking on the Electronic Health Record: Observational Study and Qualitative Analysis.

BackgroundClinicians’ use of electronic health record (EHR) systems while multitasking may increase the risk of making errors, but silent EHR system use may lower patient satisfaction. Delaying EHR system use until after patient visits may increase clinicians’ EHR workload, stress, and burnout.ObjectiveWe aimed to describe the perspectives of clinicians, educators, administrators, and researchers about misses and near misses that they felt were related to clinician multitasking while using EHR systems.MethodsThis observational study was a thematic analysis of perspectives elicited from 63 continuing medical education (CME) participants during 2 workshops and 1 interactive lecture about challenges and strategies for relationship-centered communication during clinician EHR system use. The workshop elicited reflection about memorable times when multitasking EHR use was associated with “misses” (errors that were not caught at the time) or “near misses” (mistakes that were caught before leading to errors). We conducted qualitative analysis using an editing analysis style to identify codes and then select representative themes and quotes.ResultsAll workshop participants shared stories of misses or near misses in EHR system ordering and documentation or patient-clinician communication, wondering about “misses we don’t even know about.” Risk factors included the computer’s position, EHR system usability, note content and style, information overload, problematic workflows, systems issues, and provider and patient communication behaviors and expectations. Strategies to reduce multitasking EHR system misses included clinician transparency when needing silent EHR system use (eg, for prescribing), narrating EHR system use, patient activation during EHR system use, adapting visit organization and workflow, improving EHR system design, and improving team support and systems.ConclusionsCME participants shared numerous stories of errors and near misses in EHR tasks and communication that they felt related to EHR multitasking. However, they brainstormed diverse strategies for using EHR systems safely while preserving patient relationships.

Online CME Participation by Gastroenterologists Improves Management of Exocrine Pancreatic Insufficiency

Introduction: Management of exocrine pancreatic insufficiency (EPI) can be challenging for gastroenterologists. This study assessed the effect of online continuing medical education (CME) on clinical decision-making among participating gastroenterologists compared to non-participating matched peers. Methods: The American Gastroenterological Association Institute and Medscape, LLC identified performance gaps in management of EPI. An enduring online video-based CME expert roundtable discussion was hosted on Medscape from February 28th, 2013. Clinical case vignettes with assessment questions were administered to CME participants following the CME activity and final data for outcomes was collected by May 30th, 2013. A control group of non-participants that matched the participants' characteristics (e.g., specialty, number of EPI patients treated) was randomly selected and administered the same set of questions. The difference in responses to survey questions between the two groups were analyzed using chi-square tests (P < .05), and educational effect size was calculated using Cohen's d formula, which represented the degree of nonoverlap in answers between the CME participants and non-participants. Results: Gastroenterologist CME participants (n=100) were 37.2% more likely to make evidence-based practice choices than non-participants (n=100) (moderate educational effect size of d=0.58) in the following areas: - 28% more participants ordered a fecal elastase test to confirm EPI (75% participants vs 47% non-participants, P<0.001). - 12% more participants ruled out small bowel bacteria overgrowth in poor responders to enzyme replacement therapy (90% participants vs 78% non-participants, P=.02). - 16% more participants ordered a Vitamin D level for a patient with a history of diarrhea due to EPI (93% participants vs 77% non-participants, P=.002). - 12% more participants accurately counselled patients beginning EPI therapy (88% participants vs 76% non-participants, P=.03). - Most participants (88%) and non-participants (90%) recognized that efficacy of pancreatic enzyme supplementation is influenced by timing of consumption. Conclusion: CME participation in an online video roundtable discussion impacted clinical decisionmaking in gastroenterologists treating EPI, which may translate to improved outcomes in patients. Future education should focus on testing to confirm EPI and patient-clinician communication on treatment adherence and disease management.

Relationship among knowledge acquisition, motivation to change, and self-efficacy in CME participants.

The relationship among an individual's sense of self-efficacy, motivation to change, barriers to change, and the implementation of improvement programs has been reported. This research reports the relationship among self-efficacy, motivation to change, and the acquisition of knowledge in a continuing medical education (CME) activity. The measure of individual sense of self-efficacy was a 4-item scale. The measure of motivation was a 6-item scale following on the work of Prochaska and colleagues. The knowledge acquisition was measured in a simple post measure.The participants were enrolled in a CME activity focused on HIV. The CME activities had a significant effect on knowledge. Preliminary analysis demonstrates a relationship among the self-efficacy measure, the motivation to change measure, and global intent to change. Specifically, as reported earlier, the sense of efficacy in effecting change in the practice environment is predictive of a high level of motivation to change that, in turn, is predictive of formation of intent to change practice patterns. Interestingly, there were also relationships among the self-efficacy measure, the motivation to change measure, and knowledge acquisition. Finally, as expected, there was a significant relationship between knowledge and intent to change practice. Further inspection of the motivation to change construct suggests that it mediates the self-efficacy constructs' effect on intent as well as its effect on knowledge acquisition. This new finding suggests that the proximal construct motivation completely masks an important underlying causal relationship that appears to contribute to practice change as well as learning following CME-self-efficacy.

Implementing direct access to low-dose computed tomography in general practice--method, adaption and outcome.

BackgroundEarly detection of lung cancer is crucial as the prognosis depends on the disease stage. Chest radiographs has been the principal diagnostic tool for general practitioners (GPs), but implies a potential risk of false negative results, while computed tomography (CT) has a higher sensitivity. The aim of this study was to describe the implementation of direct access to low-dose CT (LDCT) from general practice.MethodsWe conducted a cohort study nested in a randomised study. A total of 119 general practices with 266 GPs were randomised into two groups. Intervention GPs were offered direct access to chest LDCT combined with a Continuing Medical Education (CME) meeting on lung cancer diagnosis.ResultsDuring a 19-month period, 648 patients were referred to LDCT (0.18/1000 adults on GP list/month). Half of the patients needed further diagnostic work-up, and 15 (2.3%, 95% CI: 1.3–3.8%) of the patients had lung cancer; 60% (95% CI: 32.3–83.7%) in a localised stage. The GP referral rate was 61% higher for CME participants compared to non-participants.ConclusionOf all patients referred to LDCT, 2.3% were diagnosed with lung cancer with a favourable stage distribution. Half of the referred patients needed additional diagnostic work-up. There was an association between participation in CME and use of CT scan. The proportion of cancers diagnosed through the usual fast-track evaluation was 2.2 times higher in the group of CME-participating GPs. The question remains if primary care case-finding with LDCT is a better option for patients having signs and symptoms indicating lung cancer than a screening program. Whether open access to LDCT may provide earlier diagnosis of lung cancer is yet unknown and a randomised trial is required to assess any effect on outcome.Trial RegistrationClinicaltrials.gov NCT01527214

Continuing medical education in Saudi Arabia: Experiences and perception of participants

Introduction: Continuing medical education (CME) is important in developing competencies of medical practitioners with all the different influencing factors that have impact on their opinions and preferences. Despite the broad range of work on CME, very few studies have examined participants' opinions and attitudes towards CME. However, understanding them is critical in improving the practice of CME. Purpose: The purpose of this study was to explore attendees' perception of CME in Saudi Arabia regarding the different aspects of its practices and preferences. Materials and Methods: A survey composed of demographic questions, frequency of reading habits and 24 other related items was developed for CME participants. Participants were asked to indicate the extent to which they agreed or disagreed with each of the 24 items on a 5-point Likert scale. In total, 601 surveys were analysed. Results: The response to each item in the questionnaire was compared on the basis of demographic variables. The results showed that healthcare practitioners acknowledged the importance of CME in improving their knowledge, attitudes, clinical and academic skills, as well as improve their clinical practice outcome. Differences of opinion were categorised by gender, profession, nationality and age. Conclusion: The study showed that opinions related to CME varied among different disciplines and nationalities. Moreover, it raised questions related to the system of sponsoring participants to attend CME events and its consideration for ethical issues. There is a need to embed the concept of lifelong learning into the education of basic health professions. In addition, the policies related to sponsoring and accrediting CME in Saudi Arabia should be improved. We recommend further research into this matter.

Using Social Media to Improve Continuing Medical Education: A Survey of Course Participants

ObjectiveTo determine continuing medical education (CME) course participants' use of social media (SM) and their attitudes about the value of SM for enhancing CME education and to examine associations between participants' characteristics and attitudes toward SM. Participants and MethodsWe conducted a cross-sectional survey and validation study of 539 participants at a Mayo Clinic Internal Medicine CME course in November 2011. The Social Media Use and Perception Instrument (SMUPI) consisted of 10 items (5-point Likert scales) and categorical response options. The main outcome measures were psychometric characteristics of the SMUPI scale, course participants' use of SM, and their attitudes regarding the importance of SM for enhancing CME. ResultsOf 539 CME course participants, 327 (61%) responded to the SMUPI survey. Most respondents (291 [89%]) reported using SM, with the most common types being YouTube (189 of the 327 participants [58%]) and Facebook (163 of 327 [50%]). Factor analysis revealed a 2-dimensional assessment of course participants' attitudes. Internal consistency reliability (Cronbach α) was excellent for factor 1 (0.94), factor 2 (0.89), and overall (0.94). The CME course participants' favorable attitudes toward SM were associated with younger age (20-29 years, mean score 3.13; 30-39 years, 3.40; 40-49 years, 3.39; 50-59 years, 3.18; 60-69 years, 2.93; and ≥70 years, 2.92; P=.02), using SM frequently (never, mean score 2.49; less than once monthly, 2.75; once monthly, 3.21; weekly, 3.31; and daily, 3.81; P<.0001), and professional degree (PhD, mean score 3.00; MD, 3.05; DO, 3.35; PA, 3.42; and NP, 3.50; P=.01). ConclusionWe describe the first validated measure of CME course participants' use of and attitudes toward SM. Our results suggest that CME course directors should guide SM strategies toward more youthful, technology-savvy CME participants and that SM will become increasingly worthwhile in CME as younger learners continue to enter the profession.

Men's Sexual Health: Evaluating the Effectiveness of Print- and PDA-based CME

Personal digital assistant (PDA)-based continuing medical education (CME) activities have become widely available. To evaluate the effectiveness of print- and PDA-based CME materials in erectile dysfunction (ED). CME materials describing links between ED and comorbid medical conditions, effects of certain lifestyle modifications on ED, and treatment of ED with phosphodiesterase 5 (PDE5) inhibitors were distributed as a print supplement and as electronic modules, viewed with PDAs. We evaluated how effectively these materials improved evidence-based clinical choices, using survey questions about case vignettes and comparing responses of CME participants (N = 85) and matched nonparticipants (N = 94). Effect size, measuring the difference in evidence-based clinical scores between participants and nonparticipants. CME certificates were awarded to 3,557 participants (459 print, 3,098 PDA). Among survey respondents, significantly more CME participants recognized that ED was associated with greater risk for myocardial infarction (61% participants; 34% nonparticipants; P <or= 0.001) and was a strong marker for diabetes mellitus (37% participants; 9% nonparticipants; P <or= 0.001). In contrast, participants and nonparticipants both displayed a good understanding of the relationships of smoking, obesity, and sedentary lifestyle with ED and of using PDE5 inhibitors to treat ED in patients with prostate cancer or benign prostatic hyperplasia; this likely reflects a good baseline understanding of these topics. Participants and nonparticipants each displayed a poor understanding of the recommendations regarding nonarteritic anterior ischemic optic neuropathy and PDE5 inhibitor use. Patient reluctance to discuss sexual concerns was perceived as the most significant barrier to optimal ED management. Given patient reluctance to discuss sexual concerns, future CME activities should focus on educating health-care providers and patients that ED is a risk factor for cardiovascular disease and diabetes. Both print- and PDA-based CME on ED were effective; the large number of lesson completers suggests a trend toward on-demand, self-selected CME is positive.

A standardized approach to assessing physician expectations and perceptions of continuing medical education

Rapidly expanding science and mandates for maintaining credentials place increasing demands on continuing medical education (CME) activities to provide information that is current and relevant to patient care. Quality may be seen as the perceived level of service measured against consumer expectations. Standard tools have not been developed to determine how well CME activities meet consumer expectations. A widely used approach for evaluating perceptions of service quality in other fields, SERVQUAL, was adapted for CME by eliciting perspectives from physician consumers of CME and CME providers through nominal group techniques. These perspectives were used to develop a CMEQUAL evaluation survey instrument. Feasibility testing was conducted. Data were analyzed and items were tested for internal consistency. CME participants were individuals willing to complete items related to expectations before participation and perceptions after participation in a CME activity. Of the CME activity participants who provided CMEQUAL rating data for the study, 43% rated their overall perceptions of the CME activity below their overall expectations. CME activities most clearly met participant expectations in providing fair and balanced evidence-based content. Areas of lower priority for participants included opportunities for self-assessment, solving cases, and interactive learning. Two areas highly valued by participants but not adequately addressed by CME activities were (1) translating trial data to patient seen in practice and (2) addressing barriers to optimal patient management. Developing standards for evaluating physician perceptions of the quality of CME activities may assist CME providers in improving the effectiveness of CME activities in meeting physician learning needs.

What constitutes commercial bias compared with the personal opinion of experts?

The presence of commercial messages in continuing medical education (CME) is an ongoing cause of concern. This study identifies actions perceived by CME participants to convey commercial bias from CME faculty. A questionnaire listing actions associated with CME activities was distributed to 230 randomly selected participants from 7 CME activities designated for AMA PRA Category 1 Credit. The activities were held over an 8-month period. Participants were asked to complete the questionnaire before participating in the live activity. Nine actions identified by over 50% of all respondents were perceived to convey commercial bias. The most critical ones reflecting commercial bias were speaking about only one agent, not providing a balanced presentation of all agents, and faculty relationships with commercial supporters. Ten actions identified by over 50% of the respondents were perceived to convey personal opinion of the faculty. The most prevalent actions were the influence of mentors or teachers, relating general practice habits from the faculty member's own experience, and cultural differences among patient populations. More than half the respondents who indicated they perceived commercial bias in certified activities attributed this perception to an overall impression, instead of 1 or 2 specific actions. Actions were identified that conveyed differences between commercial messages and personal opinion. CME providers should define commercial bias for participants, faculty, and planners and provide education about that definition.

Learning associated with participation in journal-based continuing medical education

Medical journal reading is a standard method of increasing awareness among physicians of evidence-based approaches to medical care. Theories of physician learning and practice change have suggested that journal reading may be more influential at some stages of behavioral change than at others, but it is not clear how journal reading may influence the learning process that can lead to behavioral change. A random sample of 170 continuing medical education (CME) participants who had read three journal articles and completed a CME evaluation form received a CME credit certificate with a brief survey appended. The survey asked participants to report their stage of learning on each article topic before and after reading the three articles. Of the 170 CME participants, 138 (81.2%) responded to the survey. Most (106 of 138; 76.8%) reported a progression in stage of learning on the topic of at least one of the three articles read for CME credit. More than one-fourth of the respondents (37 of 138; 26.8%) made a commitment to change practice related to the topic of one or more articles. CME participants were more likely (relative risk 1.14; 95% confidence interval 1.06-1.22) to report a progression in stage of learning if they had recorded a commitment to change practice related to the same article topic on the CME evaluation form. Journal-based CME activities may be educational at all stages of the learning process, and journal-based learning episodes may result in commitments to change practice.

Using a quasi-experimental research design to assess knowledge in continuing medical education programs

The objectives of continuing medical education (CME) programs include knowledge acquisition, skill development, clinical reasoning and decision making, and health care outcomes. We conducted a year-long medical education research study in which knowledge acquisition in our CME programs was assessed. A randomized separate-sample pretest/past-test design, a quasi-experimental technique, was used. Nine CME programs with a sufficient number of participants were identified a priori. Knowledge acquisition was compared between the control group and the intervention group for the nine individual programs and for the combined programs. A total of 667 physicians, nurses, and other health professionals participated. Significant gain in knowledge was found for six programs: Perinatology, Pain Management, Fertility Care 2, Pediatrics, Colorectal Diseases, and Alzheimer's Disease (each p < .001). Also, the intervention group differed from the control group when the nine programs were combined (p < .001), with an effect size of .84. The use of sound quasi-experimental research methodology (separate-sample pretest/post-test design), the inclusion of a representative sample of CME programs, and the analysis of nearly 700 subjects led us to have confidence in concluding that our CME participants acquired a meaningful amount of new knowledge.

Increasing the satisfaction of general practitioners with continuing medical education programs: a method for quality improvement through increasing teacher-learner interaction.

BackgroundContinuing medical education (CME) for general practitioners relies on specialist-based teaching methods in many settings. Formal lectures by specialists may not meet the learning needs of practitioners and may cause dissatisfaction with traditional CME. Increasing learner involvement in teaching programs may improve learner satisfaction.MethodsA quality improvement program for CME for 18 general practitioners in the Tel Aviv region was designed as a result of dissatisfaction with traditional CME activities. A two-step strategy for change was developed. The CME participants first selected the study topics relevant to them from a needs assessment and prepared background material on the topics. In the second step, specialist teachers were invited to answer questions arising from the preparation of selected topics. Satisfaction with the traditional lecture program and the new participatory program were assessed by a questionnaire. The quality criteria included the relevance, importance and applicability of the CME topic chosen to the participant's practice, the clarity of the presentation and the effective use of teaching aids by the lecturer and the potential of the lecturer to serve as a consultant to the participant.ResultsThe participatory model of CME significantly increased satisfaction with relevance, applicability and interest in CME topics compared to the traditional lecture format.ConclusionsIncreased learner participation in the selection and preparation of CME topics, and increased interaction between CME teachers and learners results in increased satisfaction with teaching programs. Future study of the effect of this model on physician performance is required.

Physician Education Intervention Influenced Prescribing for Otitis Media

OBJECTIVE: To assess the impact of a continuing medical education (CME) program on frequency of diagnosis of acute otitis media (AOM) versus otitis media with effusion (OME) and adherence to national guideline recommendations for antibiotic management. STUDY DESIGN: Intervention study comparing CME participants to nonparticipants for frequency of AOM versus OME diagnoses and associated costs of care for a Rochester-based health maintenance organization (HMO). METHODS: Frequency of use of ICD-9 codes in the OM group and associated costs of care were compared. Designed to influence physician prescribing, a 3.5 hour CME course was taught that utilized video, interactive instruction, and an audience response system, obliging providers to commit to decisions about diagnosis and treatment. RESULTS: After the CME, intervention physicians (n=9) more frequently diagnosed otitis media with effusion (OME) (28% of all OM diagnoses) compared to nonintervention physicians (n=90) (11.1% OME diagnoses) (p =0.003). Analysis of 1938 OM episodes showed CME intervention physicians wrote prescriptions for 59% (95% confidence Interval (52%-66%) of episodes compared to 88% (95% CI = 82-90%) of episodes in the nonintervention group; pless than0.0001. CME-attending physicians wrote an average of 109 (95% CI = 78-132) fewer prescriptions, resulting in an average total savings of $914 to the health care plan (95% CI = $604-$1,052) per doctor for OM over the 16-month study time-frame. CME attendees less frequently wrote prescriptions for macrolides and sulfonamides (pless than0.001 for both) and more frequently for aminopenicillins and cephalosporin antibiotics (p=0.006 and less than0.001, respectively) compared to the nonintervention group, in keeping with national guideline recommendations. CONCLUSIONS: A favorable prescription cost impact on management of OM can be achieved through a well-designed, interactive, technology-driven CME intervention provided to physicians.

Prescribing controlled substances in Tennessee: progress, not perfection.

In the 1980s, Tennessee ranked among the top 10 states in per capita consumption of several controlled substances. We describe efforts designed to reduce non-criminally motivated misprescribing in Tennessee, present Tennessee's recent Drug Enforcement Administration (DEA) rankings, and suggest how physicians may reduce misprescribing. Tennessee's Board of Medical Examiners (BME) consults with Tennessee Physician Health Program (PHP) and refers selected physicians to a continuing medical education (CME) program offered at Vanderbilt University School of Medicine. The BME has also published a clear set of prescribing guidelines. Of more than 160 CME participants, only two have reappeared before the BME for prescribing infractions. Tennessee's overall DEA ranking improved from 7th highest to 17th from 1994 to 1997. The reasons the rankings improved cannot be established, but the changes occurred at the same time as the BME, PHP, and Vanderbilt CME collaborations. We will continue to promote professional and patient health throughout the region.

Comparison of face-to-face versus interactive video continuing medical education delivery modalities

The challenge to provide accessible continuing medical education (CME) programs for physicians and other health care providers in rural communities is ongoing. One possible solution to facilitate physician access to CME is through distance instructional media such as interactive video (ITV). A review of the literature revealed that there is a dearth of research investigating the differences in effectiveness between CME programs delivered through ITV and CME delivered in the traditional classroom setting. The purpose of this study was to compare physician perceptions of the effectiveness of CME programs delivered by ITV and CME programs delivered in the traditional classroom setting. Results from the survey indicate that ITV and traditional face-to-face CME participants did not feel that the majority of attributes related to the content, speaker, and program were significantly different between the two delivery modalities. The implications from these findings are also discussed.

Evaluation of continuing medical education by resort-based participants

In recent years our society and the medical profession have demonstrated growing interest in the quality of continuing medical education (CME). The present paper provides data concerning resort-based CME recipients' views about CME. From 442 physicians' responses to a questionnaire administered during CME at a resort site, data were examined with regard to two research questions: (1) What constitutes a good CME experience, in terms of 17 attributes of CME? (2) What characteristics of good CME experiences seem to be associated with the resort site, in comparison with other possible CME settings, from the standpoint of resort-based CME participants?