Will a credit exchange program between the U.S. and Europe increase opportunities or competition for American medical conference organizers?

"We can't run the world, although we try to sometimes," says Lewis A. Miller, chairman, Intermedica, Inc., Darien, Conn.; president of the Global Alliance for Medical Education; and co-chair of the Alliance for Continuing Medical Education's International Strategies Subcommittee. Spoken as he was about to fly to Linkoping, Sweden, to attend the Association for Medical Education in Europe conference, along with representatives from the American Medical Association (AMA) and the Alliance for CME, Miller's statement succinctly sums up what U.S. providers need to remember as they enter a new era of globalization.

"New era" is not an overstatement. After 10 years of debating the pros and cons of CME accreditation, Europe's medical education community has now taken the first step toward establishing a credit system. Launched in July, the European Accreditation Council for CME (EACCME) aims to establish Europe-wide standards for medical education and serve as a credit exchange clearinghouse. Under the proposed Euro-CME system, French physicians, for example, attending a congress in Italy that has been approved by the EACCME, will know that they can get credit with no hassles.

The ambitious project reaches farther than Europe--3,000 miles farther. The European Union of Medical Specialists (UEMS)--EACCME's parent organization--and the AMA have signed a letter of intent; the goal is to develop a mutually recognized CME credit system. U.S. physicians would then have an additional incentive--easy access to CME credit--to attend overseas conferences.

That means Americans are no longer the sole players in the accreditation field. As Miller observes, educators need sensitivity and awareness to take advantage of the dramatic changes currently unfolding.

"U.S. providers [should] stay on top of what's happening," Miller says, "and think about how to deploy resources and do joint programming in Europe."

Why Now? A confluence of forces is fueling the CME movement in Europe. For one, the medical profession is under an uncomfortably hot spotlight in Europe now; there have been well-publicized cases of alleged physician malpractice, and the public, press, and governments are demanding action. There is a push to make CME mandatory, something that the medical profession opposes.

The European Union has ruled that physician competence is not within its purview--so if the medical community doesn't develop its own system for maintaining physician competency, then, perhaps, individual governments or other national institutions will take over and regulate physicians.

Sound familiar?

The Europeans are responding much as Americans did back in the 1990s when Senate hearings run by Senator Edward Kennedy (D-Mass.) exposed industry-run junkets held in the name of physician education. Rather than face government interference, the U.S. medical community got behind an existing organization, the national Accreditation Council for CME, (ACCME) and charged it with developing self-regulation sufficient to keep the Food and Drug Administration (FDA) at bay. And that's what the EACCME is now attempting to do. "We would like a system that we are running ourselves," says Cees Leibbrandt, MD, liaison officer, UEMS.

Home Rule If the European medical profession is to succeed in regulating itself, and in setting quality standards for CME, there must be a multinational, multidisciplinary body, say European CME leaders.

Easier said than done. Much easier. A multitude of parties are already proposing and implementing CME systems throughout Europe. Even before the EACCME was formed, specialty societies took the leap on their own and set up pan-European systems. The Federation of European Cancer Societies (FECS) launched its system this past February, and the European Federation of Neurological Societies (EFNS) initiated its program a year ago.

Within individual countries, institutions known as national professional CME author- ities oversee medical education. In countries where there is no such authority, national specialty societies take on that role. There's even a for-profit corporation in the U.K. proposing to oversee European CME. For the EACCME to succeed, it must get buy-in from all the players, just as the ACCME had to do in the U.S.

Buy-In That's where diplomacy comes in. The EACCME will not trespass on the various national authorities or specialty societies, says Leibbrandt. Here's how it would work: If a society accredited by its own governing body (such as a national authority) were planning a conference of interest to foreign doctors, it would apply to the EACCME for accreditation. If the event complied with EACCME standards, the EACCME would decide the number of credits the program merited. All the participating national and European societies would have to agree to award those credits.

The EACCME can supervise the process, but "at the end of the day, one country has to accept what has been determined [acceptable] in another country," says Leibbrandt. "That's a sensitive point."

He's concentrating on getting Germany and the United Kingdom to sign on. Those two countries, he says, are key players because of the volume and quality of their CME. He asserts he's close to gaining their commitments. "I expect the [EACCME] will be functioning next year," he forecasts, "between some of the European countries, not all."

Leibbrandt has also gained the support of the two pan-European bodies that have established their own systems, the FECS and the EFNS. However, Eileen J. Barrett, education manager, FECS, acknowledges the potential obstacles. "Whenever you bring together two things that were developed independently, there are bound to be some issues of discord," she says. "But in the interests of harmony, we will tackle each problem as it arises."

Enter the U.S. "Not bad for a colony." That's what one CME leader told Murray Kopelow, MD, executive director, ACCME, when he was in Europe recently offering support to his colleagues. "[Europeans] have a profound respect for our [accreditation] system," Kopelow says, "for its longevity and our experience."

That's good news, because to establish a viable credit exchange system between the U.S. and Europe, American providers will want to ensure that the ACCME's Essentials and Standards, and the AMA's Ethical Opinion on Gifts to Physicians from Industry, are upheld.

The EACCME, the FECS, and the EFNS are working closely with American organizations to develop ethical and quality standards. A perusal of the EACCME's proposed guidelines reveals familiar elements: Providers must demonstrate the programs are not influenced by commercial organizations; there must be no strings attached to education grants; faculty must disclose potential conflict of interest.

There are some major differences, however, between European and American CME, mostly in the arena of industry/provider relations. In Europe, phar- maceutical companies can pay all expenses for physicians to attend conferences; that practice--at least on paper-- is forbidden here. Industry symposia are intermingled with congresses in Europe, while in the U.S. they are kept separate. In Europe, industry is free to promote off-label use of devices and drugs--verboten in the U.S., at least until recently. (See Court Muzzles FDA, page 12.)

The Money Trail Will Europe give up its traditions to comply with U.S. regulations in the interest of establishing a credit exchange? Not completely. While the EACCME is dedicated to ensuring that education is nonbiased, and its guidelines state that industry-run education should not be scheduled concurrently with CME activities, Leibbrandt does not agree with every aspect of the hard-line American approach.

"The U.S. standards are too strict," he says, referring to the rule forbidding industry to underwrite physician attendance at meetings. His colleagues agree. "Many young people can only afford to go to meetings if a company supports them," says Wolfgang Grisold, MD, chairman, EFNS Task Force for CME. "If companies stopped supporting physicians, congresses might be half-empty."

Given those differences, it is up to the U.S., says Intermedica's Miller, to "decide the degree to which we are willing to be accommodative, in order to have some reciprocity."

So far, reciprocity is winning out.

Sharing Values Even though American doctors attending overseas programs are expected to adhere to the AMA's Ethical Opinion on Gifts to Physicians, the AMA has no intention of dictating ethical policies to Europe.

"The last thing the AMA wants to do is say, 'This is the right way.' This is not our business. It's their business," says Dennis K. Wentz, MD, director, CME, AMA. "If our standards can be declared equivalent, then we can go the next step."

The U.S. is not the world's CME police officer, agrees Kopelow. "The ACCME has been very clear that its role is not to accredit organizations all over the world. The most important thing is not to get Europeans to follow our system but to identify values that we share. The systems can be different, autonomous, but can be built on the same values."

American CME providers make their judgments based on solid experience. The Bethesda, Md.-based American College of Cardiology, for example, has put on joint symposia with the European Society of Cardiology (ESC) and national cardiology societies in Europe for years, says Elizabeth Wilson, ACC's vice president, marketing and new business development. "Industry does play a large role in their education systems," she acknowledges, "but they are concerned with providing the best possible education. [Based on my experience], I have every confidence that [these issues] would be sorted out properly."

More Opportunities A particularly positive aspect of the European guidelines for MM readers is the emphasis on face-to-face activities. In its draft proposal, the EACCME recommends that physicians obtain 250 credits over a five-year period, and that at least 100 of the credits should be earned in "external, formally planned CME," which includes conferences. The EFNS is approving only live programs.

"They really believe in the value of people coming together," says Wentz.

U.S. providers can, of course, partner with their counterparts overseas to set up credit exchanges. But to do that, either a U.S. society must jointly sponsor a conference with a European group, or the foreign organization must apply directly to the AMA for credit. Both systems can be unwieldy, time-consuming, and expensive.

The proposed mutual recognition system between the AMA and the EACCME would remove some barriers, thus "encouraging more cooperative programming," says Wilson. "No doubt about that."

More Competition, Too? But if U.S. doctors can get credit abroad with ease, will European conferences become more of a competitive threat to American providers?

"The ESC meets in Vienna, Barcelona, Stockholm. We meet in Atlanta, Anaheim," says Wilson. "You could think those [foreign] cities are more of an inducement. Doctors' time is much more precious than it was even a few years ago. I think they're taking fewer trips, and trying to combine CME activities with vacations--so there may be some effect."

On the other hand, Wilson points out that obtaining credit is not the main reason members attend the ACC annual meeting--it is high-quality content and faculty that draw them. And, her members can already get credit overseas, and that hasn't affected attendance at domestic meetings. Members have not crossed the Atlantic in droves. The ESC attracts only about 1,800 U.S. attendees out of a total of 25,000, she says.

Join Forces A credit exchange system can increase both opportunities and competition, says Miller. The best approach for U.S. societies, he says, is to partner with their European counterparts. "If U.S. societies are part of [overseas conferences], and agree to do promotion in the U.S and provide some of the faculty, that would enhance the program for U.S. physicians," he says. "American physicians are more likely to attend meetings [overseas] if U.S. societies or medical schools are involved."

Right now, societies are the major deliverers of CME in Europe, he says, but there are often a number of societies within one specialty. "Deciding which one or ones to work with can be difficult," he says. Before collaborating, get to know a society's leaders, he says, and talk to other groups that have worked with them.

The benefits of having a credit exchange system far outweigh any of the obstacles, agree CME players on either side of the Atlantic.

"We have a huge amount to gain from this," underscores Kopelow, envisioning the possibility of not only a pan-European body, but an Australian-Asian one. "It would be like a United Nations, with a table at which everyone talks about important [CME] issues."

The free flow of information will improve education for physicians and raise the bar on CME, say Barrett and Wilson. Because Europeans can promote off label uses, U.S. doctors can get information overseas they can't get here, says Wilson.

Adds Barrett, "One could surmise that any competition will be healthy, as people won't make the trip unless it is worth it. Can we defend not making an effort to learn about each others' recent advances in medicine?"

For updates on the European CME movement, visit the following Web sites:

* The European Union of Medical Specialists (www.uems.be),the parent organization of the European Accredi- tation Council for CME, features the letter of intent between the American Medical Association and the UEMS on its site, as well as the EACCME's proposed standards for CME.

* When you visit the European Federation of Neurological Societies' site at www.efns.org, click on Approval of CME Meetings, and you'll find background information on the EFNS' Europe-wide system and its guidelines for accrediting programs. An interesting aspect: There is a U.S. member on the CME subcommittee, Eva L. Feldman, MD, University of Michigan. Her role is to offer an outside perspective when the other members can't agree on whether to approve a program.

* When you click on "Education" at the Federation of European Cancer Societies' site (www.fecs.be), you'll find a series of reports, including the results of an audit of European oncology societies' CME efforts. The survey found that "European countries have not been able to benefit from each other's experiences and mistakes," a finding which strengthens the case for multinational systems. There is also a section on relations with the U.S.; the FECS has discussed establishing a credit exchange system with the AMA and the ACCME.