Continuing medical education across Europe

The vision of a competent medical workforce that can move across Europe to tackle shared health challenges is attractive to a variety of stakeholders. In the linked Analysis article (doi:10.1136/bmj.c4687), Horsley and colleagues argue for harmonisation of the current systems for maintaining professional competence and highlight the barriers that will have to be overcome.1 They recommend that the new system should show improved patient outcomes but acknowledge the uncertainty about how this can be achieved. These recommendations are a major challenge for continuing medical education (CME) in this new system, and all educational providers—from governments and professional bodies to drug companies and other commercial companies—will require a clear understanding of the notion of professional competence and evidence for the effectiveness of different educational approaches. In the current economic climate the cost effectiveness of these different approaches is also an important consideration.

Maintaining competence for doctors requires more than regularly updating medical knowledge and clinical skills. All doctors are expected to act professionally and to display a range of behaviours and relationships underpinned by core values, such as integrity, compassion, and working in partnership with patients and other healthcare professionals.2 Maintaining professional competence across this wide variety of domains is essential for high quality patient centred clinical care.3 A new system for the provision of CME will need to provide opportunities to develop and assess all of these domains that are integrated as professional competence[f1].

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Evidence shows that CME can improve patient outcomes, and several meta-analyses highlight the effectiveness of interactive techniques, such as audit with feedback, academic detailing, and reminders.4 Clinical practice guidelines and opinion leaders are less effective, and the use of didactic presentations and the distribution of printed information have little effect on clinical practice. This evidence can guide the future provision of CME, but the most effective strategies are those that focus on a few specific domains of professional competence, such as approaches to improving the management of hypertension.

Evidence of the effectiveness of CME in the development and assessment of professionalism is less clear. Workplace based assessment has been increasingly used to assess the breadth of professional competence, but often it is also used as a formative and educational approach. However, the linked systematic review by Miller and Archer (doi:10.1136/bmj.c5064) found little evidence that these tools can improve patient outcomes, although it found that multisource feedback seems to improve performance and that the presence of facilitation is an important success factor.5 There is also little evidence of a change in clinical practice or improved patient outcomes for other approaches to developing professionalism, such as reflective practice6 and Balint groups.7

Horsley and colleagues recognise the increasing use of the internet to deliver learning opportunities and consider its potential to deliver CME across Europe.1 An exciting future scenario can be envisaged in which standardised and accredited learning packages could be offered to doctors across different member states, but a recent meta-analysis of internet based learning in the health professions found little evidence that this approach can change clinical practice or improve patient outcomes. 8 Interestingly, it also found no consistent difference between internet based learning and other approaches, although a blended learning approach that has greater interactivity may be more effective.

A clear message from the available evidence that can guide the provision of CME in a new system is that the learner must actively participate in the educational process and that this requires the support of a facilitator. These approaches are highly intensive in both time and resources for the user and the provider. There are few high quality cost effectiveness studies that can adequately justify resource allocation for interactive approaches and further research is needed, although the full costs are likely to be underestimated.9 It is also important to remember the substantial influence of the working context for enabling new learning to be translated into clinical practice.10

A new system of CME should recognise the needs of the learner. For example, most learners who commonly use internet based CME do so because it helps them to balance family and professional commitments.11 Many professionals are also self directed lifelong learners who identify their own learning needs on the basis of their encounters during the course of their clinical practice.12 This approach to learning does not easily align with many of the educational approaches that are offered by various providers. The provision of prepared learning packages may reduce costs, but such packages are not useful to the learner and are not likely to be effective.

A harmonised system that can maintain professional competence across Europe is achievable, but all policy makers and providers will need to appreciate that professional competence is holistic and that it may be difficult to demonstrate the effectiveness and cost effectiveness of different educational approaches. However, this should not hinder the development and implementation of CME that respects the needs of the learner and that uses interactive approaches led by a facilitator.