The changing face of Continuing Medical Education in Europe
pharmafile | April 28, 2009 | Feature | Medical Communications, Sales and Marketing |Â Â Continuing medical education, EuropeÂ
There is currently no unified approach to delivering Continuing Medical Education (CME) in Europe, and the provision of CME is very fragmented, but is becoming less so. Medical education itself is changing. The past two decades have seen a significant shift in the focus of curricula from the acquisition of knowledge to the achievement of competence – the didactic delivery of old has been shown wanting and the market is crying out for a more innovative and interactive approach that makes demands on the learner. And all this brings opportunity.
The Accreditation Council for Continuing Medical Education (ACCME) defines CME as comprising educational activities that serve "to maintain, develop or increase the knowledge, skills and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession".1
In simple terms, these are the learning activities that follow a doctor's specialist training, primarily as a means of keeping their skills up to date.
These activities can come in many forms, from accredited and non-accredited education in the form of events and courses (both off- and online), to the provision of medical information such as book and journal content, and the contextualisation of that content with news, commentaries, image banks, slidekits and the like.
CME isn't a new concept; the first medical school in Europe was set up in 1AD, although the mainstay of human medical education for the next 2000 years was the research and advances made by doctors on the battlefield. The earliest organised CME in Europe occurred around 1300 in the city of Venice, where a minimum standard of professional competence was ensured by requiring speciality certification for initial medical licensure. Annual refresher courses were also a stipulated requirement for practitioners wishing to keep their licence. (These generally took place around a lavish dinner, which would be frowned upon nowadays!) Corruption, alas, is also not a new concept, and the system was abolished in 1800 because of the ever-increasing trade in counterfeit certificates. 2
Where are we now?
Your view of CME in Europe today depends very much on where you are standing. If you are based in the Netherlands you'll be taking part in a mandatory CME system, with the Dutch government influencing your certification and re-certification on a five-year cycle. You'll be required to show you have been actively working for over 16 hours a week and have gained 40 CME credits each year, and you'll also receive a peer visit by two related specialists every five years, to look at how you carry out your work. Move down to Spain and you'll have no mandatory requirement, with no sanctions if you don't participate, but your peers will likely be actively pursuing their education. In addition the accreditation system uses a 'quality factor' that is at odds with the rest of Europe (although a conversion factor has recently been agreed to allow Spanish credits to be converted to European CME credits). If you're in Albania, no one will recognise what you are doing. 3
So, is there a central body that upholds the standards of CME accreditation across Europe, much like the ACCME does in the USA? No. Is any progress being made in developing a more coherent approach to CME in Europe? Some. CME accreditation in Europe is an incredibly mixed-up affair, with many different systems available; these can loosely be grouped into National Accreditation Authorities (NAAs, responsible for setting the rules to be followed by doctors in their country), European Speciality Accreditation Boards (ESABs, responsible for providing, reviewing, and evaluating accreditation for events in their own specialties), and Accredited Providers. Attempts are being made by the European Accreditation Council for CME (EACCME) to 'smooth out' this mass of incoherent approaches.
EACCME is a part of the European Union of Medical Specialists and is responsible for setting the rules for European CME accreditation and monitoring their application, thus giving nationally accredited CME programmes wider recognition across Europe. They also have an operational role, acting as a clearing house for the accreditation of international events by forwarding all applications to the appropriate NAA and ESAB and then collating the responses and informing the provider.
As with all pan-European initiatives this is a complex process, and although progress is being made it is painfully slow and there are a number of issues that still need to be addressed. Progress will continue though, as CME now has the attention of all the stakeholders – NAAs, ESABs, CME providers, funders, doctors and patients – and the number of accredited events is increasing steadily.
A lot has been made of the general trend towards mandatory CME seen globally, but the importance of this has been exaggerated. Mandatory CME across the whole of Europe is an unrealistic goal, and is unnecessary. There is little evidence to support the idea that forcing doctors to keep up to date works, and it is safe to say that most doctors are professionals who maintain their knowledge level as a matter of pride and to best serve their patients. This doesn't mean that there won't be the occasional doctor who avoids further education at all costs, but forcing them to learn wouldn't do much to improve that.4
Who is funding CME?
It is arguable of course that the majority of CME is indirectly funded by the patient via insurance premiums, hospital bills, fees from doctors and other professionals, taxes, and the prices of pharmaceutical products.
But looking at the more direct funding provided, we see that across Europe as a whole (there are significant variances across countries) pharma funds around half of all CME activities, which is comparable with the situation in the USA. Other funding comes from medical societies, employers (hospitals for example), private institutions, universities and doctors themselves. The pharmaceutical industry has a long history of helping educate the medical community, and has a major contribution to make in CME. High-quality, transparent, pharma-supported CME is necessary, and without it we would see an adverse effect on patient care. The key is in how that CME is delivered, whether it serves the needs of patients rather than a promotional need, and whether it delivers better health outcomes. Medical societies are playing a key role in this, with users generally favouring education endorsed by scientific organisations.
Educational activities can be beneficial to pharma in terms of heightening corporate profile, demonstrating a commitment to supporting a certain disease area, creating an interest within a disease area and increasing awareness among the prescribing community, and improving relations with clinicians and key opinion leaders.5
Physicians are very grateful for high-quality, unbiased education. Web-based educational activities (eCME) have the added advantage of allowing interaction with audiences that may not be reached otherwise.
And the future?
CME in Europe is growing steadily, allowing the rules and working practices to be developed in an atmosphere of discussion and debate. Although it is safe to say that pharma will continue to be involved in providing this education, clear guidelines detailing the appropriate involvement of pharma in CME are needed to ensure that the mutually beneficial relationship between industry and the other stakeholders continues.
Perhaps one of the biggest drivers of change is in medical education itself, and the technology that is available to deliver this education in new and innovative ways. eCME looks set to change the CME landscape over the coming years. In the words of Albert Einstein: "Computers are incredibly fast, accurate, and stupid. Human beings are incredibly slow, inaccurate, and brilliant. Together they are powerful beyond imagination."
The majority of eCME to date has ignored adult learning principles and developments in the field of medical education, but this is also changing. The opportunities that technology brings are immense, and although EACCME has been slow to recognise this trend, it has now stated that it will start accrediting e-learning and enduring materials in 2009.
References
2. Peterson, M.W., Galvin, J.R., Dayton, C., and DAlessandro, M.P. Realizing the promise. Delivering pulmonary continuing medical education over the internet. Chest 1999; 115:14291436.
3. Pozniak, E. European CME Forum: First Annual Meeting. Keyword Pharma Report, November 2008.
4. Pozniak, E. The Changing Face of CME in Europe: Where Are We Now? Keyword Pharma Report, November 2007. Available for free at www.keywordpharma.com
5. Sergeant, E. Should Pharma be Involved in Implementing CME? Ogilvy Healthworld Report, November 2008
Gavin Sharrock is a publisher in the medicine division at Wiley-Blackwell. Contact gsharroc@wiley.com.
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