Education and debate

Continuing medical education and continuing professional development: international comparisons

Cathy Peck, director of continuing professional development ^a,  Martha McCall, executive officer ^b,  Belinda McLaren, research assistant ^b,  Tai Rotem, research assistant ^b. 

^a health-media.net, London EC1R 3DB, ^b Royal Australasian College of Physicians, Sydney NSW 2000, Australia

Correspondence to: C Peck cathy_peck{at}hotmail.com

Continuing professional development is the process by which health professionals keep updated to meet the needs of patients, the health service, and their own professional development. It includes the continuous acquisition of new knowledge, skills, and attitudes to enable competent practice. There is no sharp division between continuing medical education and continuing professional development, as during the past decade continuing medical education has come to include managerial, social, and personal skills, topics beyond the traditional clinical medical subjects. The term continuing professional development acknowledges not only the wide ranging competences needed to practise high quality medicine but also the multidisciplinary context of patient care.

	Methods

We obtained information from an assessment of the relevant policies, and interviews with directors of continuing professional development of the UK medical royal colleges, the UK Joint Centre for Education in Medicine, the European Union of Medical Specialties, the Royal College of Physicians and Surgeons of Canada, the American Medical Association and other American specialty societies, and the US Accreditation Committee for Continuing Medical Education. We also assessed research by the Australian and New Zealand Committee for the Maintenance of Professional Standards.

	Common features of systems for professional development internationally

Although there are wide variations across systems for professional development in different countries and healthcare systems, there are some common features: most are based on an hours related credit system, in which one hour of educational activity equates to one credit; educational activities tend to be divided into three categories: (a) "live" or external activities (courses, seminars, meetings, conferences, audio and video presentations), (b) internal activities (practice based activities, case conferences, grand rounds, journal clubs, teaching, consultation with peers and colleagues), and (c) "enduring" materials (print, CD Rom, or web based materials, possibly based on a curriculum, with testing or assessment); and where there is mandatory recertification or revalidation, showing an ongoing commitment to continuing professional development is a major component of the process.

	Continuing professional development and recertification in Europe

A survey of 18 countries in Europe illustrated the diversity of systems operating within the territory (box 1).¹ No European country has followed the US model of examination for recertification. Only the Netherlands has a legislated recertification system, but several other countries, including the United Kingdom and Ireland, are considering introducing compulsory revalidation or recertification. Several incentives for undertaking continuing professional development also exist (box 2 and table A on website).¹

Credit points
Half the countries surveyed used an hours based credit system to quantify educational activities, in which one hour of educational activity equates to one credit. Different countries have either three or five year cycles, and the number of credits required varies from 50 to 100 per year. Other countries are considering introducing an hours based system, but there is much debate as to whether this system of accumulating hours of educational activity is a valid measure of such activity. Changes in behaviour or outcome measures are more valid, but their objective measurement is difficult.²

European accreditation
Although there are legislated common features of medical undergraduate education in Europe, mutual recognition of credits for continuing medical education or continuing professional development across Europe is beyond the remit of the European Commission. Plans are, however, being developed by the European Union of Medical Specialties for European accreditation of different systems.³ This European accreditation committee will act as a clearing house for accreditation to allow mutual recognition of credits between European countries, different specialties, and the European and North American credit systems. The American Medical Association is anxious to recognise European credits for continuing medical education for its members, and in September 1998 it signed a letter of intent with the European Union of Medical Specialists to develop a mutually recognised system of international activities and credits.⁴ The aim is to establish a system of reciprocal exchange or recognition of credits according to agreed quality requirements between the participating countries. The European accreditation committee, however, will not itself award credits or trespass on the local responsibilities of national professional authorities.

• A consensus on basic quality requirements for international educational activities
• The assessment of the quality of international providers by national and relevant European professional societies
• The commitment of national professional authorities
• A compatible system of accreditation and awarding continuing medical education credits in Europe; the European Union of Medical Specialties has recommended that the common unit be the credit per hour
• The channelling of national professional continuing medical education through the European accreditation committee.
• The first pan-European accredited system for continuing medical education in oncology, developed by the Federation of European Cancer Societies, was launched at the European cancer conference in Vienna, Austria in September 1999.

	Canada

In Canada, the maintenance of competence programme encourages clinicians to manage their own continuing medical education by focussing on what can be learnt from every day practice. From 1 January 2000, specialists are required to report on their activities for continuing professional development on the basis of a five year cycle. The Royal College of Physicians and Surgeons of Canada, with the national specialty societies, will set educational standards and criteria for each specialty.⁵ Specialists who successfully complete the programme will receive a certificate, and their names will be published. Names and credentials of specialists will also be accessible on the college's website.⁶

A range of activities forms the framework of educational options (table B on website). Fellows will be required to earn 400 credits during five years of active practice by participating in the educational activities of their choice. In common with other systems, credit is mostly based on one hour's activity, but there is a weighting towards activities that recognises that some forms of educational activity are more effective than others at changing practice.⁷

The new programme will also offer doctors the tools to document their professional development, including the learning tools used in the maintenance of competence programme. The college has developed an electronic diary to enable physicians to define their learning needs and to keep a portfolio of learning generated from, for example, practice, reflection on clinical experiences, educational meetings, reading of journals, and informal consultation with peers and colleagues. A searchable database is generated from entries in the diary to produce a "question library" available on the internet that allows physicians to compare their learning needs and practices with those of their peers. However, of the 11 088 college fellows registered in the maintenance of competence programme in 1998, only 554 used the electronic diary.⁵

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	United States

Continuing medical education in the United States is closely related to recertification. Not all the 24 medical specialty boards require regular recertification, but recertification may be required, for example, by medical societies and associations, health maintenance organisations, insurers, and partners in medical practices. The medical specialty boards set the standards for recertification, but the colleges, associations, academies, faculties, and societies of the various medical specialties, state medical societies, and commercial companies provide educational resources and materials for recertification and continuing medical education. There is a rigorous programme of quality assurance of providers of continuing medical education administered by the Accreditation Council for Continuing Medical Education, which accredits more than 600 organisations.

Many educational programmes are based on a curriculum, with multiple choice questions, self assessment, or other tests. The American Medical Association's physician's recognition award defines the type of activities a physician may undertake to gain credit.⁸ Educational providers want to designate activities for category 1 of the award because this has become the benchmark for quality in formally organised educational programmes. Category 1 activities include such formal programmes, journal based or enduring materials, international conferences approved by the American Medical Association, and passing a recertification examination. Category 2 comprises other activities (for example, consultation with peers and experts, reviews, small group discussions, journal clubs, teaching, writing) that are now thought to be of greater educational value for adult learning.⁹ A similar programme of continuing medical education and accreditation for family physicians exists, administered by the American Association of Family Physicians.

	Australia and New Zealand

Programmes in Australia and New Zealand are managed by the respective medical colleges and faculties and provide a mechanism for members to show participation in both continuing medical education and quality assurance activities.

A survey of 16 medical colleges and faculties associated with the Australian and New Zealand Committee for the Maintenance of Professional Standards was conducted in June 1998.¹⁰ The survey showed that all programmes encourage self directed learning and allow for different learning styles and practice environments. All the programmes commenced after 1992 except those for obstetricians and gynaecologists (1986) and general practitioners (1987).

The programmes of the medical colleges surveyed are based on self reporting by physicians. Programme cycles are continuous, and the length of a cycle is either three or five yearsexcept for pathologists who submit every six months. Points are allocated for both continuing medical education and quality assurance activities, using an hours related credit system, and many programmes allocate defined points for certain activities such as publications and presentations, regardless of the hours involved. Quality assurance is a component of all the colleges' and faculties' programmes, with the exception of those for dermatologists, radiologists, and pathologists. A separate quality assurance programme for laboratories is offered for pathologists.

Only five of the colleges or faculties surveyed did not indicate any mandatory components of their programmes. The mandatory components of the other colleges' and faculties' programmes are listed in box 3.

In New Zealand, participation in a recognised programme has become mandatory in order to hold vocational (specialist) registration. The New Zealand Medical Practitioners Act (1995) states that unsatisfactory completion of recertification or competence programmes may result in a doctor's registration or practising certificate being subject to conditions or a doctor's vocational registration being suspended, in which case the doctor will be deemed to hold general registration and therefore will be required to work under supervision.

In Australia, current legislation does not require clinicians to participate in formal professional development programmes. In recent years, however, the renewal of employment contracts in public hospitals, particularly in Western Australia, has required demonstration of participation in education and quality assurance activities and, in some cases, specific college or faculty programmes. For general practitioners, government legislation imposes financial disincentives for non-compliance in that college's professional development programme.

Most of the colleges' programmes are voluntary, except those provided by the colleges of surgeons, obstetricians, and gynaecologists, and in emergency medicine. To address non-compliance these colleges use fellowship review committees, vocational registration, and random audits of returns. Participation rates in colleges offering voluntary programmes range from 30% to more than 70%. Participation rates for general practitioners and physicians are over 90% and those for obstetricians and gynaecologists currently 100%.

The Royal Australasian College of Physicians has also reviewed the maintenance of professional standards programme to assess whether it is achieving its objectives. Its objectives are promoting activities likely to improve quality in patient care and providing a means of showing participation in education and quality assurance activities. The review taskforce reported in late 1999 that the structures and procedures of the programme were still broadly suitable for the present needs of the college and the community. Some changes were made to the weighting of activities, and certain areas require improvement, such as the use of electronic communications and strategies to assist the professional development of college fellows who are either isolated, living in rural areas, or working part time.¹⁰

	Conclusion

Legislated revalidation and recertification of practitioners are driving the profession towards mandatory professional development programmes internationally, covering a spectrum of clinical, professional, and managerial activities. Approaches differ widely around the world, but most rely on professional self regulation. Even where there is no mandatory system, many doctors are already active participants in the process. Increasingly there are common features between specialties and across borders and recognition of such between national and international bodies. Whatever system is adopted or legislated, however, every doctor has a personal responsibility to participate in continuing professional development and has a choice of a wide range of accredited educational activities to fulfil that responsibility.

	Footnotes

Competing interests: None declared.

website extra: Educational options in the maintenance of certification programme and requirements of the UK royal colleges appear on the BMJ's website www.bmj.com

	References

1.	Joint Centre for Education in Medicine. Good CPD guide. Sutton, Surrey: Reed Healthcare, 1999:23.
2.	Grant J, Stanton F. The effectiveness of continuing professional development. Joint Centre for Education in Medicine, , 1998:21-24.
3.	The European Union of Medical Specialists European Accreditation Council for Continuing Medical Education. No EF 34, 1998-9. www.uems.be/cme.htm (Accessed October 1999.)
4.	The European Union of Medical Specialists. Letter of intent continuing medical education, 1998. www.uems.be/intent.htm (Accessed October 1999.)
5.	Royal College of Physicians and Surgeons of Canada. 1998 Annual report of the Royal College of Physicians and Surgeons of Canada. Ottawa: RCPSC, 1999.
6.	Royal College of Physicians and Surgeons of Canada. www.rcpsc.medical.org (Accessed October 1999.)
7.	Parboosingh J, Gondocz T. Townhall session on maintenance of certification. Attachments 1 and 2. Ottawa: Royal College of Physicians and Surgeons of Canada, 1999.
8.	American Medical Association. The physician's recognition award. Chicago: AMA, 1999.
9.	Fox RD, Bennett NL. Learning and change: implications for continuing medical education. BMJ 1998; 316: 466-468[Free Full Text].
10.	Royal Australasian College of Physicians. Review of the maintenance of professional standards program, 1999. www.racp.edu.au (Accessed October 1999.)

(Accepted 2 January 2000)