Continuing medical education funding and management in Europe: room for improvement?

Introduction

The need to keep clinical competence up to date has become more and more important in recent decades, since biomedical science has progressed with a speed never seen before. While the benefits of rapid technological development for society are obvious, fast innovation is inevitably associated with the need for continuous updating by health professionals, who are ultimately responsible for making scientific discoveries available to populations. In this context, continuing medical education (CME) programmes have been rapidly increasing in many developed countries.

Although the idea that doctors should attend CME programmes on a regular basis is not questioned, the debate on modalities is still wide open^1,2. Questions on whether and to what extent current CME programmes improve physicians' performance and healthcare outcomes are hard to answer, because of the weaknesses in the reported validity and reliability of evaluation methods. The accreditation of medical education and communication companies and the way CME courses should be organised and financed raises controversy too³. In many countries their funding mostly stems from commercial support by pharmaceutical companies and medical device manufacturers⁴, casting doubts on the integrity of their real educational function^5,6.

The situation in Europe, compared to the USA, is complicated by factors such as multiple languages and the mixed roles of public authorities and medical associations^7,8. A major concern is the lack of common European rules and quality criteria for CME^9,10.

In order to understand how CME is organised in Europe and to envisage desirable future trends, we tried to compare the main country-specific institutional settings in Europe, and then formulated suggestions for speeding up the progress of CME.

Methods

We selected a group of European countries according to the following variables: type of CME participation (compulsory or voluntary), population density (low or high), cultural background and geographic location (northern or southern). Austria, Belgium, France, Italy, Norway, and the UK were included. Information was drawn by desk research, i.e. analysis of local documents and literature. Both the supply and demand aspects of the CME market were analysed.

Results

CME management in northern Europe is mainly the responsibility of medical associations (Austria, Norway, and the UK), so doctors themselves are responsible for continuing education.

Voluntary participation for specific categories of physicians (such as GPs) is encouraged in Belgium and Norway by financial incentives, usually a premium on consultation fees. Compulsory involvement appears more formal than practical in the southern countries where CME is mandatory (Austria, France, and Italy). In general, no sanctions are foreseen: even when penalties are set by law, little seems to be done if a doctor does not reach the required number of credits. CME credits are linked to licence maintenance – but limited to specialised GPs – in Norway only, where participation is explicitly on a voluntary basis. The main criterion for quantifying CME credits is time devoted to medical education (generally 1 hour corresponds to one credit). Four countries have 3/5-year cycles, the total number of credits required being on average 50 per year.

The range of activities includes traditional congresses and conferences, on-line courses, and reviews or publications. In Belgium and France, GPs and non-hospital specialists are obliged to attend CME carried out by local small groups (respectively GLEM, Groupement Local d'Evaluation Médicale, and EPP, Evaluation des Pratiques Professionelles). These very economical programmes are expected to have a major impact on individual performance and health care outcomes, and are aimed at achieving targets defined in guidelines issued by national health authorities.

Proof of expertise and (self-) certification of lack of conflict of interest are the two main criteria for accreditation and certification of public and private CME providers. In all countries except Norway, commercial sponsorship is permitted; in Austria, Belgium, and France companies can promote their products during CME too, promotion being banned only for CME carried out by the GLEM and EPP in Belgium and France.

Discussion

Our desk research confirmed that regulations still differ substantially across European countries confirming the results of a previous study⁸. This appears to be a difficult hurdle, given the perspective of pan-European CME harmonisation. While awaiting common EU guidelines, it would be of interest here to discuss the key issues for building up a national CME system, in the light of the different national experiences.

Should continuing medical education be compulsory or voluntary?

The ‘compulsory approach’ is largely a formality in the countries that have adopted it, since in practice nothing happens to health professionals who do not achieve the required CME hours. This is likely to become a ‘false problem’ once the need for medical education to continue beyond university is universally accepted as a life-long unavoidable process by physicians as well^11,12. Hence, the question could be rephrased as follows: ‘What are the simplest tools currently available to ensure that doctors continue their medical education?’.

If moral persuasion is probably not enough on its own to convince reluctant physicians, continuous updating of evidence-based medicine might end up being favoured due to the increases in malpractice disputes in Europe^13,14. According to this scenario, it seems quite reasonable to devolve CME management to medical associations that are responsible for continuous development and defence of their members. However, to limit the discretion of medical associations towards their members and control potential conflicts of interest, health authorities should set minimum rules to defend public interests. At present, this seems to be achieved in two ways only: (1) by assessing whether doctors' performance is in line with national guidelines (e.g., in France), or (2) by linking CME to physicians' revalidation or recertification (e.g., in Norway for specialised GPs).

The most radical option – generalised recertification – is a sensitive issue¹⁵ whose legal implications must be addressed properly. However, if continuing education is recognised as helping to maintain doctors' necessary knowledge, keeping their licences should depend on CME fulfilment too. Linking CME to premium fees only, like for non-hospital physicians in Belgium, seems problematic from a societal perspective. If doctors failing to accomplish CME requirements receive lower fees for service but go on practising as before, this does not seem to support the general interest of patients.

What education and how?

This question is closely related to CME content. It seems obvious to state that the main need is to keep physicians informed of and trained on the latest medical and organisational evidence that could improve their professional activity. Accordingly, educational targets should be planned by national health authorities in agreement with professional bodies; objectives could be tailored for each medical category by setting an educational path over a 3–5-year period. The main advantage of this approach, already in place in the majority of the countries we surveyed, is to limit physicians' discretion in choosing among hundreds of different CME activities, which risks focusing their attention on how to collect the yearly number of credits more easily (rather than on the educational content).

Published studies^1,16 suggest that CME is more likely to improve medical performance and, to some extent, healthcare outcomes if it focuses on interaction and promotion of practice-enabling strategies. Accordingly, it seems reasonable to expect that small groups (like GLEM in Belgium and EPP in France) can cope with problems close to daily practice more effectively, offering more scope for interaction than traditional conferences and congresses. Moreover, these local activities are not costly. Internet-based learning may offer another effective¹⁷, low-cost tool that could be successfully managed by health authorities.

What accreditation and how?

Scientific societies, academic centres, professional organisations, and private and public medical institutions are the most common providers, usually accredited by either medical associations or ad hoc public authorities. Although these bodies are often well-equipped for organising CME, many of them are also subject to different types of economic pressure and are often encouraged to acquire visibility and prestige through multiple programmes. It is important that health authorities are fully aware of this critical issue. A sound strategy might be to accredit each single event separately, rather than broadly certifying providers' quality. To avoid the trap of work overload for the authorities dealing with accreditation, this might be more effective once the current excess offer of CME in many countries is successfully tackled by clear rules on commercial support (see next section).

Credit assignment could be standardised according to a common ‘One Hour/One Credit’ criterion, easy for physicians to understand and for CME authorities to apply. This would substantially limit the present discretion in countries like Italy in evaluating conventional events. More innovative activities whose duration cannot be measured easily, like e-learning, could be promoted by providing credits for more than the expected number of hours required to complete them.

How to fund continuing medical education?

Current debate is highlighting the well-known risk that medical education may be significantly biased by commercial funding and is warning the medical community about the need to find more credible alternatives. Although commercial funding should be avoided in principle to defend CME from confounding factors, it is nevertheless realistic to recognise that many CME activities rely on commercial support, and that this will continue in most countries until health authorities can fully fund them, which is unrealistic in the light of the financial problems endemic in most healthcare systems. At present, promotion is banned only in Norway, which can boost a unique combination of factors: a wealthy economy, an efficient public sector, and a low density of physicians.

Despite economic constraints, overwhelming private funding for CME raises considerable concern in many continental European countries. We think that health authorities could achieve rapid improvements through more transparency in this field. The simple declaration of lack of conflict of interest is clearly insufficient. Full disclosure of financial details (e.g., speakers' fees) should help make attendants more sensitive towards potential bias. Another measure to limit the current proliferation of conferences and symposia in many countries could be to cap commercial support at a fixed amount of money (e.g., a lump sum per participant).

How to increase public funds is the ultimate question in order to offer real alternatives to commercial support. Although it may seem unfair to ask industry to contribute, the successful Italian experience of funding independent research through a yearly tax paid by pharmaceutical companies of 5% on their promotional expenditures suggests that this might be an acceptable and feasible ‘co-payment’ for education too, at the same time tackling the risk of widespread bias in CME, by cutting commercial budgets.

Conclusions

The substantial variability in the organisation and accreditation of schemes and participants across Europe indicates that much could be done to improve effectiveness. Common European regulation of CME activities offers the prospect, if correctly done, of rectifying this situation. Advances from clinical research will only prove helpful in the management of patients if key findings are appropriately implemented.

Acknowledgements

Declaration of interest: The authors have declared no conflict of interest and have received no payment in the preparation of this manuscript.