Leaders explore the status of continuing medical education around the world.
The future of CME is here in this room,” said Paul Piché, president of HIT Global and president of the Global Alliance for Medical Education, addressing the 140 participants who came from around the world to attend the 15th Annual GAME Meeting in Montréal in June. While the quality and quantity of healthcare available varies from country to country, the need for high-quality continuing medical education is shared around the globe. That's why it's essential to understand different countries' CME systems, and to find ways to harmonize — not homogenize — these systems to form a more effectiveCME community, he said.
Speakers from North America, Europe, Asia, and Latin America shared information about their respective healthcare systems, regulatory environments and structures, and the role CME can have in enhancing healthcare provider competence and performance.
CME Moving Toward CPD in U.S., Canada, Europe
North American and European countries are working on where and how commercial supporters should be involved in CME; on how to allot credit for CME in an era of exponential growth in alternate forms of education beyond the traditional meetings model; and on identifying the metrics, strategies, and tools needed to shift the focus of HCP education from a knowledge-based CME process approach to continuing professional development, which starts with outcomes and is ongoing throughout a physician's career.
United States: In the U.S., there are many signs that CME is moving toward CPD, said Alejandro Aparicio, director, CPPD, American Medical Association, Chicago. For example, the AMA's credit system is moving away from counting hours of participation (except for live activities, where one hour still equals one credit) and toward awarding credit based on the achievement of goals. Aparicio pointed out that the future of CME in the U.S. will likely include an increase in performance-improvement-based CME, point-of-care learning, education becoming part of physician order-entry products, and patient-care team learning. Technology will continue to play a key role in CME's evolution, and simulation use in CPD also will be on the rise. However, the total number of CME providers and available commercial support dollars for CME will likely decrease.
Canada: Though CME has only recently begun to be required in some provinces, more provinces are expected add mandatory CME requirements in the near future, said Bernard Marlow, director, Continuing Education, College of Family Physicians in Mississauga, Ontario. Canada, which has four accrediting systems, is considering a new proposed credit system under which physicians would be required to earn 250 points over three years, with more points being awarded for activities with higher-level outcomes (improvement in performance, patient health, and community health). Canada also is seeing a rise in e-CME: 90 percent of physicians surveyed recently said they had tried it, and 50 percent said they used e-CME on a regular basis, Marlow reported.
Europe: Having traditionally viewed CME as a way to maintain academic knowledge and skills, Europe is moving toward CPD as well, said Bernard Maillet, MD, secretary general of the European Union of Medical Specialists-European Accreditation Council for CME. The push in Europe, he said, was to have the EACCME act as a clearinghouse for CME accreditation and credits in Europe. It would help harmonize the CME efforts of its member countries, but not standardize them.
In Europe, the future of CME will stress the systematic evaluation of activities by participants as well as long-distance learning, said Maillet. Unlike his counterparts in the U.S. and Canada, Maillet said that Europe still does not believe that mandatory CME is a good solution to the problem of ensuring that healthcare providers stay up-to-date — CME should remain voluntary while moving in the CPD direction.
CME in Asia
The focus in Asia is more on developing accreditation systems for CME and post-graduate education in general than on shifting from CME to CPD. The three panelists also said that, when it comes to measuring outcomes, Asia is generally still measuring at level 1, which charts attendance, rather than at higher levels of competence, performance, or patient health.
Japan: Hikaru Matsuda, MD, president of Hyogo University of Health Sciences in Kobe, Japan, explained that while there is no mandatory recertification system, the Japan Medical Association conducts its own CME program and recertifies those who clear its requirements every three years. Approximately 70 percent of its membership is certified. The Japanese Board of Medical Specialties sets the standards for quality control and certification, similar to the Accreditation Council for Graduate Medical Education in the U.S. In 2002, the Ministry of Health, Labor, and Welfare, which regulates medicine in Japan, set up its own medical specialty accreditation system, separate from that of JBMS. Now both organizations are working to refine the specialty society accreditation and certification systems.
India: “We hardly have a CME system in our country,” said Saurabh Jain, MD, director of CME Solutions, Indegene Lifesystems, Bangalore. Three states — Maharashtra, Punjab, and Kerala — have mandatory CME systems that require physicians to complete 30 hours of CME every five years. However, these programs have been in place for only a year, so it will be four years before the first doc has to reregister. The state of Delhi also has a voluntary system, he said. The biggest CME issue in India, Jain said, is finding ways to establish a credible and objective CME system. While live symposia still make up more than 50 percent of the CME offerings in India, Internet-based CME already constitutes more than 20 percent of the total and is growing rapidly.
Malaysia: There are two key players here: the Malaysian Medical Council, which registers physicians for practice and provides certificates for completion of CPD; and the Malaysian Medical Association, which accredits education from CPD providers. Providers submit details of their program to the MMA in advance and then receive points allocated on a grading system. While CPD is voluntary for private doctors (it is mandatory for government physicians), “it's a very competitive environment,” said Lisa Sullivan, group managing director, In Vivo Communications, Singapore. “The more certificates they can hang on their walls, the more their patients like them.” While Malaysian docs have access to several online CME systems through the MMA, Internet access in rural areas, where many practice, is limited.
The MMC has had a grading system in place for 10 years, but many private docs still don't use it because they don't have to. There are plans to make it mandatory to acquire a certain number of points through the grading system to get the annual practicing certificate. However, when Sullivan asked the president of the MMA CPD Committee how long it would be before it was compulsory, he replied, “It has taken us 10 years to get this far, and I expect at least another 10 before CME/CPD is compulsory.”
CME in Latin America
Specialty societies play a large role in Latin American CME. While societies in Argentina and Mexico are beginning to require continuing education and/or professional development participation for certification and recertification, there still is a long way to go before CME or CPD becomes mandatory for licensure.
Argentina: The government and social security employ most docs in Argentina; only 15 percent are in private practice. CPD is not mandatory. Until the pediatric society began a formal program in 1987, CPD programs were informal in Argentina, said Angel Centeno, MD, chair of the Department of Biomedical Education Committee, Universidad Austral, Buenos Aires. The cardiology society then followed suit; now roughly 60 percent of pediatric physicians and 25 percent of cardiologists have been certified, he said.
While most of the CPD has fallen to medical societies, medical schools now are recognizing the need to get involved, especially since the societies' accrediting agency wants to add conducting CME to its requirements. “We need to lobby for an organized system, and to involve all stakeholders,” said Centeno.
Mexico: Forty-six more specialty boards have become engaged in the certification and recertification of medical specialties since the first Specialty Board on Clinical and Surgical Pathology was established back in the 1960s, said Enrique Wolpert, MD, coordinator, National Normative Council of Medical Specialties, Academia Mexicana de Medicina, Mexico City. While certification remains voluntary for licensure, more specialty societies require it for their certifications. The Mexican Senate and House of Representatives also are considering making certification a requirement. In addition, hospitals, medical schools, and the private sector in general are also beginning to require physicians to have a valid certificate.
The National Normative Council of Medical Specialties believes in the power of CPD to improve healthcare delivery while reducing medical errors and costs. However, said Wolpert, the CME requirements need to be made more homogenous across the specialty boards.
Lewis Miller, principal, Wentz Miller & Associates, Darien, Conn., who moderated the Latin American panel, also talked about the need to create a Latin American Council of CME. This council, he said, would bring together leaders from medical societies, academia, and governmental agencies to define CME terms and common goals among HCPs in the region, and to develop a map for the future.