CONTINUING MEDICAL EDUCATION IN EUROPE - 2017
Most European CME is carried out on a national basis and is delivered in the language of the host country. The providers are the national medical scientific societies, hospitals/local employers, government health departments and commercial medical communications companies usually funded by the pharmaceutical industry. There is also an emergent “CME provider” community that develops education along the lines of accredited providers in the US, but does not work on any industry-controlled promotional projects.
In recent years the national country-specific specialist societies and associations have to some extent been overshadowed by the development of European specialist societies such as the European Society of Cardiology http://www.escardio.org/Pages/index.aspx, the European Respiratory Society http://ersnet.org, the European Society of Radiology http://www.eurorad.organd many others. All of these societies now organize annual European congresses with numbers of participants often in excess of 20,000. These congresses are held in the limited number of European cities with adequate facilities to accommodate so many doctors e.g. Berlin, Munich, Stockholm, Amsterdam, Vienna and Barcelona. The language is almost always English and most of the funding derives directly and indirectly from the pharmaceutical and device industry. The congresses usually last for 3 or 4 days and have multiple parallel sessions. There is always a large exhibition area. The congresses provide the main source of income for the European societies.
II. Mandatory CME
In February 2014, Dr Len Harvey of UEMS presented the results of his CME survey in Europe. https://www.uems.eu/__data/assets/pdf_file/0004/8149/Session-2-11.05-Len-Harvey-Survey-on-CME-CPD-2014.pdf. In the EU, 18 countries had mandatory CME and 13 countries had voluntary CME. Of those with mandatory CME, sanctions may be imposed only by the profession as in the UK, whereas In France, sanctions may theoretically be imposed by law, but no system has yet been established. In Germany both professional and legal sanctions are in force and a doctor’s license may be withdrawn. The UK has implemented revalidation on a 5-year basis, but Germany and France have no relicensing systems. In the UK, revalidation requires engagement in CME, annual appraisal and multi-source feedback (360 degree assessment). This assessment is largely still valid.
III. Planning and Delivery of CME
Europe is slowly becoming familiar with Moore’s Pyramid of Outcomes.1Almost all professional CME providers now carry out formal needs assessments and are familiar with “backward planning” from the expected outcome level. It is accepted that the design of planned CME should be appropriate to the level of outcome which is desired, as described in Moore’s paper. CME delivery by these providers is seldom didactic and the priority is to create interactive education. These providers are commercial companies who deliver CME usually under contract to a pharmaceutical company. A number of them have formed themselves into the “Good CME practice Group” (www.gcmep.org) which now has 17 members. These providers are familiar with current approaches to CME planning, delivery, and evaluation, whereas the specialist societies and associations are still wedded to predominantly didactic CME and generally do not carry out robust or detailed needs assessment. Content includes both research results and sessions on clinical practice. Research findings may be communicated in spoken presentations, but also as posters which greatly outnumber the former.
There are smaller sessions for discussion some of which are designated as “Meet the Professor” or “Sunrise Symposia”. Industry usually sponsors satellite symposia which often take place in the early evening after the main business of the congress. These sessions are not usually accredited by the EACCME or by the national accreditation authority (NAA).
Many European organisations talk about broadening continuing education to encompass the principles of CPD, but there has not yet been any discernible change in educational material to fulfil that aim.
IV. Industry Funding
The relationship between industry and CME has recently become a hot topic not only in the US, but also now in Europe where CME, as in the US, is largely funded by the industry. In recent years European providers have been expected, as a requirement of the CME accreditation bodies, to be able to demonstrate that their programs are free from commercial control and bias. Supporting companies may offer funding for an educational activity in relation to a disease, in the treatment of which, they have a commercial interest. However they may not choose the speakers or design the program and funding must be directed to a recognized CME provider which is responsible for the organization of the activity. The companies may not pay speakers directly for their contributions. The expression used most often to describe the recommended role of the industry is “at arm’s length”.
In 2013, the European Federation of Pharmaceutical Industries and Associations (EFPIA), http://www.transparency.efpia.eu/the-efpia-code-2published a code on disclosure of transfers of value from pharmaceutical companies to healthcare professionals and organizations. This meant that all financial transactions between companies and doctors must be publicly disclosed in a transparent way. It may have been devised because of the Sunshine Act in the US http://www.cms.gov/Regulations-and-Guidance/Legislation/National-Physician-payment-Transparency-Program/index.htmlwhich similarly requires transparency in all financial arrangements between companies and doctors. However there is one major difference in that payments in relation to accredited CME in the US are exempt from disclosure, whereas no similar exemption is included in EFPIA’s code.
The first disclosures were made last year for payments made in 2015. Transfers of value to doctors have increased to more than £116 million a year, but about a third of doctors are still refusing publicly to disclose their earnings, which they are entitled to do because of legal privacy considerations. The NHS has called on pharmaceutical companies to refuse to pay practitioners unless they agree to disclose their earnings, but so far only a few companies, most notably Glaxo Smith Kline, have complied. http://www.telegraph.co.uk/news/2017/06/30/big-pharma-cash-hospitality-doctors-rises-one-three-refuses/.
Last year at the 9th European CME forum, http://europeancmeforum.eu/wp-content/uploads/2016/12/Skopowski_Session-4C.pdf, EFPIA divided CME into 4 categories:
Company-Driven, Product Specific education;
Company-Initiated Professional Development,
Collaborative Partnerships and
Independent Medical Education.
Of these only the last is considered accreditable, because it is organised on an arm’s length basis. Thomas Kellner from UCB Biosciences in Germany, has submitted a paper on this topic on behalf of a consortium of pharma companies to the Journal of European CME (JECME) and this will be published later this year. His paper endorses the EFPIA view. It is certainly true that in Europe, pharma is involved in many, but not all CME programs and at the moment, only a minority of programs can be described as “independent medical education”. That is however the direction of travel which is favored by the Good CME Practice Group. “Independent medical education” is preferred to “sponsorship” in which an advantage to the company is expected.
A “Position paper on current aspects of sponsoring in accredited CME” by Daiana Stolz and colleagues has recently been published in JECME http://www.tandfonline.com/doi/full/10.1080/21614083.2017.1312062. This was followed by a Commentary entitled “Roles and Responsibilities in the Provision of Accredited Continuing Medical Education/Continuing Professional Development” http://www.tandfonline.com/doi/full/10.1080/21614083.2017.1314416. At present most pharma companies no longer pay physicians to attend meetings.
Despite these various initiatives, it is likely that European pharma is still considerably more active in funding CME than in the US
V. European Union of Medical Specialists
The European Union of Medical Specialists (UEMS) http://www.uems.netwas founded in 1958. It comprises representatives of the medical professional associations in Europe. These associations are political or organizational rather than academic or scientific. For example in the UK, the British Medical Association, which is the doctors’ trade union provides representatives for the UEMS.
In 1999, the Management Council of the UEMS established the European Accreditation Council for CME (EACCME) http://www.eaccme.euwith the aim of assuring the quality of CME activities and facilitating the international exchange of CME credits for medical specialists in Europe. The EACCME’s main function is to award a CME credit value for European rather than national educational activities. The latter are accredited by the NAAs. In the UK this function comes under the aegis of the Academy of Medical Royal Colleges http://www.aomrc.org.ukwhich is the umbrella organization of the colleges of physicians, surgeons, pediatrics, radiology etc.
The EACCME and almost all the NAAs in Europe carry out Activity Accreditation rather than Provider Accreditation which is predominantly used in North America. In other words, each activity (live event or e-learning module) is assessed individually, whereas in the US and Canada, there is a split system where in some cases programs are accredited, for example FP organizations, but in all others, providers are accredited.
Last year, Vassilios Papalois, the new Secretary-General of UEMS presented an updated accreditation system, EACCME 2.0 https://www.uems.eu/__data/assets/pdf_file/0016/40156/EACCME-2-0-CRITERIA-FOR-THE-ACCREDITATION-OF-LEE-Version-6-07-09-16.pdf, in which EACCME promises faster and more efficient handling of applications, a brand-new IT platform to support the process and assist providers, new educational material - e.g. e-platforms and recognition of CME/CPD activities beyond live events and e-learning material - e.g. publishing, reviewing and lecturing. They also plan to embrace a much broader spectrum of healthcare professionals.
One of the more important features is the introduction of Trusted provider Statusin which:
the evaluation process is reduced to 4 weeks.
COI (conflict of interest) forms do not need to be submitted at the time of the application, but must be available at the time of the event for possible monitoring. This applies to the members of the scientific organisation committee and to the faculty.
applications will be sent for review before receipt of payment. However, the payment must be received before the finalisation of the procedure.
Trusted Provider Status may be awarded to major providers who submit at least 10 applications annually and have a good record of compliance with UEMS-EACCME rules.
UEMS-EACCME are at pains to point out that this initiative is in no way a concession to provider accreditation to which they remain implacably opposed. They state that “The EACCME does not support the concept of accredited provider status as it offers no assurance regarding the robustness and fairness of the process when a provider has the right to accredit its own educational activities; this by itself undermines the quality of accreditation.” Anyone who has experience of the US ACCME system will find this a curious statement, given the almost exhausting robustness which must be exercised in submitting an application to become an accredited provider in the US.
Recent UEMS documents donot include details of accredited events. The latest document was from 2015 and showed the data from the preceding 3 years:
The figures for the last 2 years are likely not much different. The striking feature is how few activities are accredited by the EACCME, perhaps only 1 - 2% of the total European activity. A total of 13,311 past CME events have been accredited since January 2008.
The principle of subsidiarity in the EU means that the EACCME cannot usurp or supersede the NAAs. Therefore all educational activities for which EACCME accreditation is sought must be assessed both by the EACCME and by the NAA of the host country – dual accreditation. In practice, this means that when a submission for accreditation is made to the EACCME in Brussels, it must be forwarded by the EACCME for both European and national assessment.
VIII. European Accrediting Agencies
The UEMS Specialty Sections have CME accreditation sub-committees. A few UEMS Sections have formed European Specialty Accreditation Boards (ESABs) which comprise representatives from the Section and from the corresponding medical scientific society. These are the European Boards for Accreditation in cardiology (EBAC) http://www.ebac-cme.org, pneumology (EBAP) http://www.ebap.org, urology (EU-ACME) http://www.eu-acme.org and infectious diseases (EBAID) https://www.escmid.org. Oncology does not have a UEMS Section, but the European CanCer Organization has set up the Accreditation Council of Oncology in Europe (ACOE) http://www.acoe.bewhich is recognized by the UEMS and works within its structure for accreditation in the same way as the other ESABs. There are other accrediting agencies in Europe that accredit programs, but do so independently of the UEMS structure, such as the European Hematology Association (EHA) http://www.ehaweb.org(EHA-CME Unit), the European Society for Medical Oncology http://www.esmo.org(ESMO-MORA), the European College of Neuropsychopharmacology (EFNS) http://www.efns.organd in neurology, the European Accreditation Council in CNS (EACIC) http://www.eacic.eu.
Accreditation of cardiological CME has been experiencing recent problems. The European Board for Accreditation in Cardiology (EBAC) has fallen out with UEMS-EACCME which claims that it is owed substantial moneys by EBAC. This claim is denied by EBAC and legal proceedings have been instituted. At the moment, it seems that most cardiological applications for accreditation are being handled by the UEMS Cardiology Section rather than by EBAC.
IX. Practical operation of the EACCME
When an educational activity is submitted to the EACCME for accreditation, it is forwarded to the appropriate accrediting agency (relevant UEMS section or ESAB) and also to the NAA of the host country when the activity is a live event. For e-learning, there is no obvious host country, but the submission nevertheless is forwarded to one or other of the NAAs. The accrediting agencies have to scrutinize the application forms and decide whether the criteria are satisfied. If so, they calculate how many credits should be awarded on the basis of the duration of the learning activity. If both agencies agree, the EACCME issues a formal accreditation certificate with the agreed number of credits. If the agencies award different numbers of credits, the EACCME seeks agreement on a compromise with them.
For a live event the educational content and quality can only be judged from perusal of the program and details of the speakers, whereas e-learning is actually experienced by the reviewer who goes through the module from beginning to end. It is therefore more difficult to assess a proposed live event than an e-learning module which has been fully examined by the reviewer. For that reason, there is a higher rejection rate for e-learning applications than for live events. After the educational activity has taken place, the learners apply to the provider for their CME certificate which includes the number of European CME credits (ECMECs) which have been awarded.
EACCME scale of fees for live events:
From 1 to 100 participants: € 175 (accreditation fee = € 150 + processing fee = € 25)
From 101 to 250 participants: € 375 (accreditation fee = € 300 + processing fee = € 75)
From 251 to 500 participants: € 675 (accreditation fee = € 600 + processing fee = € 75)
From 501 to 1,000 participants: € 1,000 (accreditation fee = € 900 + processing fee = € 100)
From 1,001 to 2,000 participants: € 1,300 (accreditation fee = € 1,200 + processing fee = € 100)
From 2,001 to 5,000 participants: € 2,550 (accreditation fee = € 2,400 + processing fee = € 150)
More than 5,000 participants: € 4,400 (accreditation fee = € 4,200 + processing fee = € 200)
EACCME scale of fees for e-learning modules:
€ 500 For 1 module
€ 1,000 for up to 10 accredited modules
€ 1,500 for up to 20 accredited modules
€ 2,000 for up to 30 accredited modules
€ 3,000 for up to 40 accredited modules
€ 5,000 for up to 50 accredited modules
€ 7,500 for up to 100 accredited modules
€ 10,000 for more than 100 accredited modules
X. Reciprocity and Mutual Agreements
The UEMS-EACCME has signed mutual agreements with many of the NAAs of European countries in which signatory NAAs agree to recognize ECMECs and convert them to their own credit currencies in keeping with the principle of subsidiarity. The countries which have signed agreements are:- Austria, Belgium, Croatia, Cyprus, Finland, Georgia, Greece, Hungary, Ireland, Regione Lombardia, Luxembourg, Malta, Norway, Poland, Romania, Slovakia, Slovenia, Spain, Sweden, Turkey, United Kingdom.
An agreement with the American Medical Association (AMA) http://www.ama-assn.org/amawas signed in 2002, and renewed on several occasions, by which the AMA agrees to recognize ECMECs as equivalent to PRA Category 1 credits for American doctors attending European events and vice versa for European doctors attending meetings in the USA. Since 2010, this also applies to e-learning. However an American activity delivered in Europe by an ACCME-accredited provider does not allow European doctors to receive ECMECs. For that the provider must apply for EACCME accreditation. Similarly an EACCME-accredited activity delivered by a European provider, but held in the US does not allow learners to receive PRA Category 1 credits.
The last few years have seen some improvement in the understanding and provision of CME in Europe. The role of pharma remains problematic. The pharmaceutical companies themselves seem keen to regulate their activities more rigorously, but European doctors show no signs of being prepared to finance their own CME. It may be that European governments are quietly acquiescent to the present situation, since otherwise they may have to pay for CME themselves. There is no indication that Europe is prepared to consider changing to provider accreditation, despite many providers being favorably disposed to it.
1. Moore DE, Green JS, Gallis HA. Achieving the desired results and improved outcomes: Integrating planning and assessment throughout learning activities. Journal of Continuing Education in the Health Professions2009; 29:1-15.