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versión impresa ISSN 1575-1813
Educ. méd. v.9 n.4a Barcelona dic. 2006
II SESIÓN: RETOS DE LA FORMACIÓN MÉDICA CONTINUADA
Challenges in the CPD and the Regulation of the Profession
Dr. Bernard Maillet
Secretary General Union Européenne des Medecins Spécialistes (UEMS) European Accreditation council for Continuing Medical Education)
Setting the scene
CME/CPD is an important part of the medical practice today. When we look at the training to become a (specialist) doctor, it starts with undergraduate and graduate training at the University followed by the Postgraduate Training that is done in cooperation between the Profession and the University (ideally).
In the past this was the end of the process but it is more than obvious that a long life learning has to be done in order to maintain knowledge and skills for the practitioner. Here CME / CPD is an important factor. It started with Continuous Medical Education where mainly theoretical courses and congresses were organized. Nowadays this is completed by the improvement of communication, IT, managerial and social skills and is more concentrated on the practice of each individual practitioner and his or her needs. The CME / CPD needs and the way it has to be organized is a duty of the National Accreditation Authority in each European Union Member State and can be National or Regional (or a combination of both).
The NAA has to define how many "credits" and which kind of credits are needed each year or each period of time. It is more than obvious that one can not gain all his or her credits by following only one means of CME / CPD, meaning that for instance not all credits may be earned by following Long Distance Learning Programs only. Other means such as Live Events, Enduring Material, like CD-ROMs, or articles have also a certain role to play in the whole picture of the CME / CPD of a (specialist) doctor. It is clear that this remains a responsibility of each NAA.
UEMS has started the EACCME in order to help the European Medical Specialist to have the credits he or she has earned by going to International Meetings approved by his or her NAA in order to avoid a duplication of the process.
For instance when I as a Pathologist go to a meeting organized by the British Division of the International Academy of Pathology and that has been approved for CME by the Royal College of Pathologists of the UK, why should the Belgian Accreditation Authority starts the process of approval again. This was the start of the EACCME where we proposed to have a clearing house where requests for European Accreditation could be sent to.
The aim was to have an approval of both the responsible NAA and the involved UEMS Specialist Section. The responsible NAA is the NAA of the country (or of the region) where the event takes place. The involved Section is the Section of the Specialty that is most involved with the meeting for instance as a target audience. As the Sections are constituted by two delegates representing the Specialty in each EU Member State, they can be considered as giving a quite representative opinion of the field on each evaluation.
UEMS - A short history
On 20 July 1958 - one year after the treaty of Rome was signed -, the representatives delegated by the professional organizations of medical specialists of the six member countries of the very new European Community (EEC), who met in Brussels, created the European Union of Medical Specialists (UEMS). Thanks to the perceptiveness of its founders, the UEMS soon established contacts with the concerned authorities of the EEC and defined the basic principles in the field of training of European medical specialists.
The UEMS tackled straightaway the problem of quality, trying to obtain from the European Commission and the member States a level of training comparably high for the future medical specialists of the Six Common Market countries. This vision of the future resulted in the elaboration of common general criteria, applicable to all specialists wishing to move from one member country to another.
History and political background of EACCME
Continuing Medical Education ("CME") and Continuing Professional Development ("CPD") have always been one of the major key elements of UEMS as it notably promotes the quality of care and the best level of training for medical specialists. This became concrete in 1993 when "UEMS Charter on CME" was adopted. Since then, further work has been laid down in the field of CME and CPD and other declarations and position papers were adopted such as the "Basel Declaration on CME" (2001) or "UEMS Declaration on the promotion of good medical care" (2004).
At the same time, many European countries have been taking steps towards mandatory CME together with legal or professional re-certification or re-licensing, financial incentives or contracts with insurances and hospitals. Even though UEMS defends voluntary CME, it was felt appropriate to help European medical specialists in this respect. Therefore, in October 1999, UEMS Council set up the European Accreditation Council for CME ("EACCME"), with a view to:
- Facilitating access to quality CME for European doctors;
- Contributing to the quality of CME in Europe; and
- Exchanging CME credits in Europe easily.
The quality control of CME activities is a key element in this process. It was thus decided to operate in a decentralised way by using the expertise of existing European and national professional bodies involved in accreditation. The everyday management of European accreditation by EACCME provides this link between European and national levels. One has to remind the political necessity to comply with the political authority of national professional regulatory bodies, as these bodies are responsible for registering doctors CME-CPD and awarding licences to practice.
EACCME was founded in 1999 as a separate entity from UEMS even if it was ruled by its Management Council. In the revised Statutes, it was proposed by the Executive upgrading EACCME as one of the five genuine bodies of UEMS in order to stress the importance of this body.
EACCME management would though remain as it is:
- The governing body is UEMS Council, which is made up of representatives from national associations of each UEMS member country.
- An Advisory Council provides recommendations with regard to the management of European accreditation. This body is made up of representatives from:
- National professional CME authorities, including national CME accrediting bodies;
- UEMS, including its Sections and Boards;
- Professional specialist organisations and societies.
This Advisory Council provides full exchange of expert-knowledge and collaboration between the various partners involved in accreditation at European level. UEMS convenes a meeting of this committee each year as it is committed to the further evolvement of EACCME procedures in cooperation with the members of this advisory committee.
- The daily proceedings of the EACCME are managed by UEMS Executive in its Brussels Secretariat.
Right from the start, it was clear that national professional regulatory bodies would approve a structure, such as EACCME, which would make CME credits in Europe exchangeable. The only condition was that these bodies would remain in charge of events in their own country and would have a major input in the process of EACCME. This is a political reality. Moreover, it is expected that within a few years mandatory recertification would apply in several countries. CME credits would then be the instrument used in this respect.
EACCME received its mandate from national regulatory bodies together with several distinct conditions.
a) National authorities are maintained. EACCME does not become a supranational body, but a link and clearing-house between national regulatory bodies.
b) The final word concerning accreditation of each activity remains the decision of the national regulatory body in the country where the activity takes place.
c) The Brussels administration should be as lean as possible.
d) Quality assurance and determination of number of credits of separate CME activities would be decentralised, EACCME relying upon the expertise of professional bodies in each specialty (such as the UEMS Sections and/or Boards and European Speciality Accreditation Boards). This aims to avoid duplication of quality assurance proceedings.
e) There would be no accreditation of commercially biased activities, internet activities and for the time being each activity should be judged separately. So providers are not accredited for series of activities stretching over years.
f) Administrative expenses of EACCME are borne by the providers of activities applying for European accreditation. Expenses would be limited, avoiding duplication in Brussels of work already done by other accreditation bodies.
The recognition of EACCME credits (ECMECs) is only guaranteed by national authorities within the framework of these conditions. EACCME strictly complies with this set and operates according to the procedure:
The accreditation process in Europe involves two partners, on the one hand the National Accreditation Authorities and on the other hand the UEMS Specialist Sections and/or Boards. The responsible National Authorities are determined according to the place where the meeting is organized and the involved Specialist Sections are determined based on the specialty that is most involved or to the target audience of the event.
Let us now look how the process works in practice.
The organizer of an event send the request form with all the relevant and needed documents to the UEMS- EACCME Office in Brussels or fills in the web-based request form. Here the request form will be distributed to the two partners. The relevant UEMS Section and/or Board assess the scientific value of the CME activity. This evaluation strictly follows UEMS Quality criteria defined in D-9908. Both partners are requested to give in a well determined time scale an approval or a refusal for accreditation, the number of credits being determined by UEMS EACCME.
As the different National Accreditation Authorities apply different credit systems, the European CME Credits ("ECMEC") were introduced in order to harmonise the number of credits on the following basis:
1 ECMEC per hour;
3 ECMEC for half a day; and
6 ECMEC for a full-day event.
National authorities can then convert these credits into national units, following the National rules.
When both partners agree on the approval, the organiser will receive a letter confirming the approval of the European Accreditation. This letter contains three sentences: the first stating the approval and precises which partners have been involved. The second sentence gives the number of ECMECs granted to the event (and eventually the number of National Credits granted following the rules of the National Accreditation Authority of the country where the event takes place). The third sentence informs about the mutual recognition of credits between UEMS EACCME and AMA PRA Class 1 credits.
CME CPD : Voluntary or Mandatory?
There is a shift in Europe from voluntary CME to mandatory. Is this really worthwhile and will this move achieve its aims? The aim of making CME mandatory is to assure the patients that the health care professionals and in our case the (specialist) doctor that he or she maintains his or her competence and skills. The question here is if mandatory systems are more efficient. In some systems in Europe incentives are given rather than coercion. Is the carrot not a better tool rather than the stick?
When repression is used people will automatically find ways to cross the system while with incentives they feel a drive to follow the rules on a spontaneous way. May-be we have to consider this (psychological) aspect also.
Evaluation of events.
It is very difficult (if not impossible) to fully evaluate an event before it is held based on documents that are provided by the organizer. Therefore in the future efforts will be concentrated to ask the organizers to have an evaluation of the event by the participants. This evaluation can be quite simple because at the end a too much detailed evaluation will be problematic to analyze. The main questions could be:
- was the event well organized.
- did I learn something from the event.
- will what I learned from the event change my practice.
- did I felt any bias.
The evaluation can be graded from "fully agree" to "fully disagree" by five steps for instance. The principal aim of this evaluation is not to retrospectively throw away the allocated credits but rather help in the evaluation of the next meeting of the same kind organized by the same people. EACCME is mostly involved in the evaluation of big international events that are recurring events so this will help in the process.
Which added value?
As shown, the added value of EACCME lies in the link set up between the professional societies, the CME providers and the national regulatory bodies. Any change to this procedure would need the consensus of national regulatory bodies. Any deviation from this consensus would defeat the purpose of the EACCME and it would also mean loss of the agreement with the American Medical Association concerning mutual recognition of EACCME and AMA credits. From the point of view of the organizers of events, the added value sits in the international dimension that would be given to an event. More participants from abroad and also from the USA would be interested in joining their meetings. The agreement with the American Medical Association has been renewed and is now valid from July 1st 2006 for a period of four years.
The long term benefit is the link with the national regulatory bodies. These bodies are very keen to preserve their national authority in the awarding of credits to the doctors in their own countries. The EACCME offers an institution in which they participate and have authority. In this way the profession facilitates exchange of CME credits in Europe in a similar way as postgraduate diplomas are mutually recognised according to European law.
At the end it is the National Accreditation Authorities together with the National Licensing Authorities that gives to license to practise.
The ultimate goal is to develop a system that makes life easier for our colleagues and to provide them with recognised quality CME with the guarantee that they can use their CME credits to meet national requirements.