In a policy letter issued last spring, the American Medical Association (AMA) stipulated that international conference sponsors wishing to have their meetings designated for Category 1 credit toward the AMA Physician's Recognition Award (PRA) apply directly to the AMA. Previously, sponsors obtained such designation through their U.S.-accredited sponsor counterparts.

To meet the new criteria, conferences will have to adhere to the AMA PRA standards, which reflect the language and concerns of the Accreditation Council for Continuing Medical Education (ACCME) Essentials and Standards, a set of guidelines for creating and providing industry support for CME activities. Like the Essentials and Standards, the AMA policy letter sets forth rules for developing meeting content, disclosing commercial support, and preventing commercial influence.

The purpose of the directive is "to help physicians who go abroad and who want CME credit for worthy CME activity," says Dennis K. Wentz, MD, director, division of CME, American Medical Association in Chicago.

The new procedure is actually a revision of a policy set in place in 1989. At that time, Wentz explains, physicians told the AMA Council on Medical Education that U.S. specialty societies had dropped joint sponsorship of international conferences because it was impossible for them to comply with the ACCME's joint sponsorship requirements. As a consequence, physicians had lost the opportunity to receive credit at important meetings.

"Our members were saying, 'These international meetings are great conferences,'" Wentz recalls. "'They are state of the art, on AIDS, in vitro fertilization, a whole host of things. They are the place to present the newest medical knowledge.'"

The AMA listened, and developed rules allowing physicians to receive credit at these conferences. Now, the AMA has revised the rules, based on its experience and physicians' feedback.

What's Different? Under the old policy, an international conference had to be endorsed by a specialty society that held a seat in the AMA House of Delegates. The American College of Cardiology (ACC), for example, endorsed the educational activity of the European Cardiology Society (ECS). As a condition of the endorsement, the specialty society had to send an observer, a requirement Wentz says many societies found onerous. Under the new policy, those provisions have been removed, and the ECS and other societies like it will apply directly to the AMA, which will send an official representative to the conference.

As under the previous rules, U.S. physicians attending international conferences will be responsible for complying with the AMA Ethical Opinions on CME and Gifts to Physicians (guidelines for choosing meetings, claiming credit, and accepting corporate gifts). Although the rules are different in other countries, Wentz says, "We expect American physicians who claim credit to uphold the American standards."

Wentz stresses that the new protocols do not replace joint sponsorship, but apply only to conferences that an ACCME-accredited sponsor cannot jointly sponsor and designate for AMA PRA Category 1 credit-conferences whose multinational scope precludes the level of participation required of American sponsors by the ACCME. To meet the AMA's eligibility criteria, congresses must be international in sponsorship, planning, faculty, and attendance, and must be either a joint effort of independent medical organizations from numerous countries, or sponsored by a medical specialty society with chapters or active membership in many nations. "This is a special situation where, because of the number of countries [involved], it's extremely difficult for the American sponsor to retain the level of control joint sponsorship requires," Wentz explains.

Will It Work? The bottom line is that now international congresses will in effect have to follow the same procedures as their accredited U.S. counterparts for the AMA's approval. The difference is that the payoff will be important only to that fraction of their attendees who come from the U.S. and want Category 1 credit. Will they do it?

"I believe they will be willing," says Marcia J. Jackson, PhD, associate executive vice president, education, ACC. "Although the criteria will be new for them, they will be able to do it."

The rules concerning industry support and faculty disclosure may be problematic, Jackson cautions, because those requirements are not the norm in other countries. "Just as when [those rules] were introduced in the U.S. four years ago and we were unaccustomed to them, it took getting used to," Jackson says. "We had the backing of the accreditation groups saying we had to do it." On the other hand, Jackson says, international groups do not have accreditation agencies to support their efforts. Jackson adds, "I'm hoping the AMA will be flexible."

Wentz acknowledges that there may be difficulties at first but thinks they will be overcome. "When we explain what [disclosure] means, that the audience has a right to know, to be informed, [international organizers] say, 'Is that all?'" Wentz says. "We think there are a lot of folks interested in our system."

Insisting that international congresses follow AMA PRA standards if they want accreditation is a positive move, adds Bruce J. Bellande, PhD, executive director of the Alliance for Continuing Medical Education. "I don't know that it would be prudent to offer a double standard," Bellande says. "It's a voluntary process. If you are interested in having an international education opportunity accredited, I think you should be held to the same standards that accredited providers are [held to], regardless of where the [program] is offered."

Nevertheless, Jackson predicts that European groups will be most interested in the new procedure, since they are working on establishing their own accreditation standards. "I don't know how much interest there will be in Pacific Rim countries, or in South or Latin America," Jackson says. "I don't know if they will be willing to meet all that criteria."

Globalization of CME Wentz underscores that the directive is intended to facilitate the process of U.S. physicians obtaining CME-not complicate it. He points out that the revised procedure is only one step in efforts by the AMA and ACCME to develop more flexibility in the international arena. Currently, the ACCME is revising Essential 7-the rules about joint sponsorship-to make it easier for accredited and nonaccredited organizations to work together. All these changes are aimed at achieving one goal, notes Wentz.

"We hope to open up international dialogue," Wentz says. "We want to recognize that CME is evolving into new forms. The world is becoming a smaller place. We're a global village. This is a step in that direction."

These changes are important, says David A. Davis, MD, CCFP, associate dean, continuing education, University of Toronto/Faculty of Medicine and head of the Alliance for CME's international liaison committee, reiterating the reason the AMA developed the initial 1989 policy. "I think it's a good movement," Davis says. "Increasingly, research findings are disclosed internationally. The more we can learn from each other, the better."

And so, 1997 will be the year in which the AMA and the international medical meeting community discover whether international organizations will comply with the new rules-and become proficient at faculty disclosure forms-or turn their backs on offering CME credit to American physicians. What's the bottom line for U.S. meeting planners? If the policy is accepted by international medical conference organizers, expect the issue to sink with barely a ripple. But if it isn't, there may be new opportunities for U.S.-accredited sponsors to meet the needs of American physicians who want to go abroad to learn about new medical developments and also earn Category 1 credit.