GAME Meetings Archive

2004 Meeting Report
CME around the World: Global Perspectives and Trends

NEW YORK -- Nine international speakers outlined the trends in continuing medical education in various regions and countries around the world here during two related plenary sessions at the Ninth Annual Meeting of the Global Alliance for Medical Education.


Many countries in Europe are shifting from voluntary to mandatory CME, said Dr. Bernard G. Maillet, MD, Secretary General, Union of European Medical Specialists (UEMS) and European Accreditation Council for CME (EACCME), Brussels.

Nevertheless, the UEMS, which now has 28 members, does not support the move toward mandatory CME and regards CME as an ethical obligation of physicians. The UEMS also questions whether mandatory CME improves physician performance. "Our position is that mandatory CME is not effective in weeding out the bad apples," Dr. Maillet said.

Another trend in Europe is the move from continuing medical education to continuing professional development (CPD), which requires different methods of assessing educational activities' effectiveness. Instead of counting the number of attendees, the CME community is exploring peer review, outcomes measurements, practice visitations, and portfolio review. The metric is also changing. "We prefer to measure credits rather than hours," he said.

United Kingdom

Appraisal is now a mandatory requirement for any doctor in the U.K. who is employed by the National Health Service, said Edwin Borman, MB, ChB, Chairman, International Committee, British Medical Association, Birmingham.

Physicians must meet with their clinical directors every year to review their practice, discuss whether they're keeping up-to-date with their CME, and develop a learning plan for the next year. "You'll find it interesting-and perhaps surprising-and that we're expected to look at issues like ethics, diversity awareness, communication skills, and teamwork," said Dr. Borman. These softer skills are critical to maintaining positive relationships with patients. "Actually, patient complaints are more based on those issues than they are on pure medical knowledge," he said.

Under the appraisal system, doctors are no longer trusted to participate in education on their own, but must demonstrate "on a continuing basis that they're actually keeping up-to-date," said Dr. Borman. The appraisal summaries, which include information on the physician's practice and CPD, are linked to the relicensure process, which doctors must go through every five years.

"We have a system in which the inspection and monitoring of doctors has become much more focused than anywhere in the world," said Dr. Borman.

Spain Stays Voluntary

CME is currently voluntary in Spain and is likely to stay that way, said Manuel Garcia Abad, President, Drug Farma Group, Madrid.

As of 2004, there are three bodies that govern CME in Spain: the Spanish Health Department, Spanish Autonomous Regions Health Departments, and SEAFORMEC, which was developed in 2003 and comprises the scientific societies, medical universities, and the National Commission of Medical Specialties. SEAFORMEC has signed a formal agreement with the European Accreditation Council for CME.

Pharmaceutical companies are the major financial supporters of CME in Spain, providing 80% of the support-something that is not likely to change, he said. In fact, he thinks that pharmaceutical companies will increase their investment in CME.

Also on the horizon is LOPS, the Spanish law for regulation of medical professions. Passage of this law will generate interest in CME and possibly in recertification in the future.


Italy is the only European country where a CME system has been implemented for all health care professionals -- more than 900,000 people, said Alfonso Negri, MD., Secretary General CME-Italian Council for Accreditation in Pneumonology, Milan. CME has been mandatory in Italy since April 2002; as of April 2004, 200,000 activities had been accredited.

The system is centralized, with providers applying for credit to the Ministry of Health CME web site. Each activity is evaluated by three experts, who determine a score. The number of credits the activity will earn is based on an average of the three experts' ratings, the number of participants in the program, and the length of the activity. A higher score is given to those events that have fewer participants, because we feel there is a greater possibility of learning in a classroom with 20 people than in one with 500, Dr. Negri explained.

Currently physicians are required to earn 150 credits in five years; the requirement will increase to 150 credits in three years. In another development, the Italian Commission on CME began accrediting providers in mid 2004. Institutions such as universities, hospitals, and scientific societies are eligible. Providers are able to award credit not only for events, but also for distance-learning CME activities.


In Sweden, as in other parts of the world, research has shown that guidelines, standards, and lectures do not motivate doctors to change their attitudes, said Göran Sjönell MD, PhD, Familjeläkare, Medical Director, Familjemedicinska Institutet, Stockholm.

"Doctors don't care about guidelines and standards, and lectures have no effect at all," he said. Rather, small-group, peer-to-peer programs do motivate doctors to change behavior-and 25% of family physicians do participate in small-group sessions. Auditing is also a very effective technique, he said. Nonetheless, 90% of CME in Sweden is lecture-based, with subspecialists speaking to family physicians. "These physicians come and tell us how we should practice."

Another problem in Sweden is pharmaceutical industry influence: Since most doctors in Sweden are publicly employed and employers do not provide funds for CME, "it's heaven for the pharmaceutical industry," Dr. Sjönell said. Eighty percent of CME is funded by industry, and there is little transparency about industry's role.

A national accreditation system is under development in Sweden, but one of the barriers is that the pharmaceutical industry is not interested in funding "softer" subjects, such as courses about patient-doctor relationships, although this education is necessary, he said.

In contrast, the pharmaceutical industry has much less influence on CME in Norway, in part because CME is funded by the state and the medical profession. In addition, pharmaceutical company-sponsored CME programs do not qualify for CME credit, said Dr. Sjönell.

Norway also recognizes the importance of small-group education, which has been mandatory since 2000. Fifty out of the 300 CME credits physicians are required to earn every five years must come from small-group sessions. CME and recertification are mandatory in Norway. Physicians who fail to meet the CME credit requirements are penalized with a 30% reduction in their income-a system that works quite well, he said.

Financial incentives to participate in CME worked well in Denmark, increasing participation from 60% to 90%, he noted. To manage pharmaceutical industry influence, doctors attend ten days per year of CME organized by the medical professional, and two days per year of CME sponsored by drug firms.

Dr. Sjönell said that Denmark expects to develop a mandatory CME system soon, due to government pressure.

United States

In the future, there must be an emphasis on practice-based, evidence-based CME, said Daniel J. Ostergaard, MD, Vice President, International and Interprofessional Activities, American Academy of Family Physicians, Leawood, Kansas.

While evidence-based CME has become almost a cliché, it's important to remember the role of patient preference. "In many cases, there isn't any good evidence, and given that fact, the patient's desire becomes much more important than before-when we thought we were gods," said Dr. Ostergaard.

One trend in evidence-based, practice-based CME is point-of-care learning, which occurs when the doctor and the patient are together, and the patient presents a problem for which the doctor doesn't have the answer. "It is the nirvana of needs assessment," said Dr. Ostergaard. "You identify the clinical question and you go right to the computer to search the evidence for the answer, and then you decide whether or not to implement that answer for the patient." The physician can later document behavior change based on that experience.

To assign credit for point-of-care learning, the credit metric must change, he said. "The new metric will be based on practice impact, not just on time. The challenge is come up with the right measurements."


Despite all the discussion in CME about the importance of incorporating adult learning principles and developing interactive activities, attendance at large conferences is up by 50 percent or more in Canada, said Bernard A. Marlow, MD, Director of CME/CPD, College of Family Physicians of Canada, Mississauga, Ontario.

The increase in meeting attendance appears to date from the Sept. 11, 2001 tragedy; another driver for the trend might be that doctors are under increasing time pressure and can get the most credits in the least amount of time by attending large conferences, said Dr. Marlow.

Regardless of the reasons, "the reality is that 800 to 1,000 doctors are sitting in a large lecture hall for the entire day listening to speakers," Dr. Marlow said. The trend is also seen as occurring in the U.S. and Mexico. "We need to see how we can introduce some of the better forms of education, such as small group learning, into really big conferences."

Another type of learning that can be incorporated into those large meetings to make them more effective and meaningful is reflection-an old education idea that is back in vogue again, said Dr. Marlow.


There are a multitude of problems with CME in Mexico, said José Luis Arredondo, MD, PhD, Chief, Clinical Research, National Institute of Pediatrics, Mexico City.

The CME system is not well-organized or supervised by academic authorities, and there is wide variety in the quality of CME courses and in general practitioners' level of knowledge. While board certification and recertification are well established, with most of the 50 boards recertifying their members every five years, there are no consistent procedures for obtaining credits for recertification.

However, Mexico is trying to make improvements, Dr. Arredondo said. The country is trying to spread CME across the country for both general practitioners and specialists. While it will take time, he is optimistic about CME's growth in Mexico.

One positive trend is the growth in the number of certified physicians: in 1990 there were about 22,000, by the year 2000 there were 60,000-a growth of 139% in ten years. Another factor influencing the growth of CME is the strong collaboration between the U.S. and Mexico. Many Mexican opinion leaders have graduated from U.S. medical colleges, he pointed out. Mexico offers good opportunities for web- and print-based CME suppliers to work with government health bureaus, medical schools and institutions, and private CME companies.


Malaysia has taken an interesting approach to managing drug industry influence on CME. Pharmaceutical companies are allowed to develop 25% of the content for CME events, explained Dr. P. Krishnan, President, Commonwealth Medical Association, Kuala Lumpur.

"We recognized that it was important for the pharmaceutical industry to present information on drugs and their efficacy," he said. However, pharmaceutical firms cannot register as CME providers with the Malaysian Medical Association Secretariat, the body that has overseen CME since 1995.

Like other countries, Malaysia is debating the question of whether CME should be mandatory. The government wants to make CME compulsory, while physicians are fighting to keep it voluntary. "We are trying to come to consensus between the medical profession and the government," said Dr. Krishnan.

Meanwhile, CME is growing in popularity, with almost 10,000 doctors-or 42% of the physician population-participating in CME in 2003. That is a huge increase from 1995, when only about 1,500 doctors participated, stated Dr. Krishnan.

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