An Overview of Continuing Medical Education/Continuing Professional Development Systems in Europe: A Mixed Methods Assessment

ABSTRACT

The aims of this assessment were to describe the requirements for European physicians to engage in CME/CPD; explore perceptions of their CME/CPD systems; interprofessional continuing education (IPCE) and independent CME/CPD and provide recommendations that may be adopted to improve quality and effectiveness. This assessment used a mixed-methods approach that included 1:1 interviews with in-country subject matter experts (SMEs) and an electronic survey capturing qualitative and quantitative data from practicing in-country physicians. Our analysis reflects countries with CME/CPD systems that are quite mature when compared to other areas of the world. Almost all the European countries have CME/CPD systems that are professionally self-regulated and have implemented policies or laws to limit the influence of pharmaceutical or device companies over content in CME/CPD. Several countries have incorporated a learning sciences framework into their systems, including self-assessment/self-reflection and evaluation of professional practice gaps. Overall quality of CME/CPD systems was described as high, with education focused on knowledge and practice change. Opportunities for improvement are focused on increasing innovation, improving transparency and consistency, and decreasing administrative burdens. About half the countries have and support IPCE, which is likely also a marker of a more mature CME/CPD system. This mixed-method assessment demonstrates that the CME/CPD systems in the 15 European countries reflect elements of mature systems globally. Physician participation is mandated or strongly encouraged and supported. Physicians have access to a wide variety of opportunities to participate in CME/CPD, and they do participate even if not required by regulation. There are mechanisms to ensure the quality of CME/CPD even when pharmaceutical or device companies are permitted to provide education. Suggestions for improvement focus on quality and not basic elements of structure.

Introduction

Globally, healthcare professionals (HCPs) engage in continuing medical education (CME)/continuing professional development (CPD) to ensure they remain competent to deliver high-quality, evidence-based care that supports positive patient and population health outcomes. It is critical that stakeholders, including those participating in and financing those systems, understand the elements that best support their desired outcomes; however, the systems that support HCPs to regularly and actively participate in CME/CPD vary widely.

This manuscript is one in a series of four assessments that describe CME/CPD systems in different regions of the world. This manuscript supplements a summative, comparative manuscript of four different regions (China, Europe, Latin America, and the Middle East/North Africa) and complements two previously published manuscripts using the same mixed methods methodology describing CME/CPD systems in Japan and seven countries in the Asia-Pacific region [1,2]. In this overview, Europe is defined as the 46 member states belonging to the Council of Europe [3]. We have included the following 15 countries in our assessment that included subject matter experts (SMEs): Austria, Bulgaria, Croatia, Finland, France, Hungary, Italy, the Netherlands, Norway, Poland, Portugal, Spain, Sweden, Turkey, and the United Kingdom as they responded to the request for participation in the qualitative portion of the assessment. Survey responses expanded this analysis to another 12 countries.

Overview

The countries in this assessment vary greatly in population size and geographic range (Appendix A). Croatia is the smallest country by population at 3.9 million, while Turkey is the largest at 84.8 million (The World Bank Group, 2021).

Physician Capacity by Country

There is wide variation across countries when comparing the number of physicians per 1000 people and population size. Of the countries included in our analysis, Turkey and Poland have the smallest ratio of physicians per 1000 people at 1.8 and 2.4, respectively, while Italy, the United Kingdom (UK), Portugal, and Austria have the largest and most robust physician workforces at 8.0, 5.8, 5.3, and 5.2 physicians per 1000 people, respectively [4,5].

Medical Education Systems

Academic preparation for physicians in these European countries is relatively congruent. Entry into the medical profession begins immediately following the completion of secondary school, and medical school lasts for 5–6 years depending on the country system. Interestingly, in France, all HCP students enter through a common track then branch to pursue different professions (e.g. medicine, nursing and physiotherapy). All countries here have the opportunity for academic progression through a residency (internship) and/or fellowship programme and the majority require candidates to successfully pass a national licencing examination to practice medicine. Medical schools may be public or in some cases private, and in many countries medical education is free. In all countries, there is a regulatory body responsible for the practice of medicine, most often the Ministry of Health through the country’s medical council.

CME/CPD Requirements for Physicians

In this analysis of 15 European countries, seven require all physicians to participate in CME/CPD as a condition of licensure and the ability to practice medicine and one requires specialist physicians to participate. In the other seven countries, participation in CME/CPD is encouraged and often supported but is not mandatory. In France and Poland, although participation is mandatory, failure to participate is not regularly enforced. Austria, in contrast, has the strictest enforcement policies with non-compliance resulting in actions that range from a reprimand and fine to a ban from practicing in the profession. In Finland, participation is not mandatory as tied to licensure; however, physicians are legislatively required to engage in CME/CPD and may be required if safety issues are identified for a specific practitioner.

Points or credits are defined by the individual regulatory body and are generally based on the type of educational activity and/or length of time engaged in the educational activity. More points and/or credits are awarded to educational activities that are perceived as more valuable/impactful or those that are longer. For example, more points may be awarded to a physician who participates in a medical symposium as compared to reading a journal article or teaching. More credits may also be awarded for an educational activity lasting 8 hours as compared to one lasting 1 hour. In countries with mandatory participation in CME/CPD, the greatest number of credits (points or hours) is 50 annually; Croatia requires the fewest hours annually at 20.

In most countries, the regulatory body with oversight for CME/CPD requirements for physicians is the same as the regulatory body for the practice of medicine. However, the regulatory body for the practice of medicine may delegate this authority to a more specialised branch that focuses on education/continuing education. In France, a national agency governs CPD for all professions, consistent with its health care education system that is more integrated across the health professions as compared to the other countries.

CME/CPD Provider System

The CME/CPD provider systems, defined as organisations that develop CME/CPD educational activities, in these European countries are also regulated by the regulatory body for the practice of medicine or a more specialised branch that focuses on education/continuing education. In all 15 countries, CME/CPD providers include colleges/universities, professional medical and speciality associations, hospitals and health care systems, and governmental agencies. In Croatia, most CME/CPD is provided by pharmaceutical or device companies, which could influence and develop content. In the Netherlands, Spain and the UK, pharmaceutical or device companies may provide CME/CPD, but they are subject to strict regulations. In the other countries, pharmaceutical or device companies may financially support but not control or influence CME/CPD. In all countries assessed, physicians can participate in various formats of CME/CPD delivered by a CME/CPD provider, such as live and web-based educational programmes, conferences and scientific meetings, simulation, and skills or practice-based education, as well as education that is self-directed by the individual physician learner. In all countries, even if not mandatory, CME/CPD providers may award credit via hours or points based on the country’s system and activity type.

CME/CPD Accreditation Systems (Pan-European and European)

This assessment of CME/CPD systems in Europe incorporated survey items that reflected awareness of pan-European and European accreditation bodies, types of organisations from which respondents collected CME/CPD credits, and whether the respondent had converted or applied for reciprocity after receiving CME/CPD credit issued by a provider or accreditor outside of Europe. The following European accreditation systems were included:

• European Accreditation Council for Continuing Medical Education (EACCME)

• European Board for Accreditation of Continuing Education for Health Professionals (EBAC)

• Royal College of Physicians in the United Kingdom (RCPUK)

• UK CPD Certification Services

EACCME was founded in 2000 by the European Union of Medical Specialists (UEMS) to provide a mechanism for physicians to convert CME/CPD credit obtained in another country. The organisation now acts as a pan-European accreditor to accredit continuing education activities across Europe, as well as providing mutual recognition of CME credits with the American Medical Association and the Royal College of Physicians and Surgeons of Canada. Primary evaluation of educational activities reviewed by EACCME are evaluated in the UEMS office (home of EACCME), the national CME authority in the country where the programme will take place, the relevant UEMS section representing the speciality of the event, and/or the European Speciality Accreditation boards. The other accrediting bodies in Europe also accredit at the activity level but are much smaller in scope.

Review of the Literature on CME/CPD in Europe

A focused review of the literature on CME/CPD in Europe was conducted using electronic databases (MEDLINE, PubMed, and CINAHL), with inclusion criteria consisting of English language, full-text research studies published in a peer-reviewed journals within the past 10 years. A total of 12 articles were identified as meeting the inclusion criteria. Two studies reflected an evaluation of CME systems and physician requirements to engage in CME/CPD from across 27 European countries and the European Union, respectively. There was one study focused specifically on challenges physicians in the UK have in balancing engagement in education with patient care. One study addressed the lack of medical staff and CPD of physicians practicing in Ukraine. Seven studies assessed in-country CME/CPD: two in Georgia, three in Ireland; one study in Denmark, and one in Italy. One study compared national physician validation systems in Germany, Denmark, and the UK. A brief summary of these articles is provided below.

Pan-European CME/CPD System Characteristics

Saita and Dri [6], described a research study, the EU Tell Me Project, which included an evaluation of the CME systems across 27 European countries as part of a feasibility assessment of developing a common European e-learning tool that could be used to rapidly disseminate information in the event of a pandemic. The study was conducted using only information available on the internet at the time. Findings from the study demonstrated that a CME system was present in 96% of the countries included in the analysis; however, just over half of the countries required physicians to participate in CME as a condition to practice medicine. Multiple types of activities awarded credit, and most accepted or recognised e-learning as a valid type of CME activity. Credit requirements varied widely. Countries that participated in a common European framework had more CME system similarities that those countries that did not [6].

In an assessment of 10 European Union member states, researchers evaluated the procedures for ensuring that physicians meet criteria for registration and revalidation. The researchers also described the implications of these procedures on cross-border movement of health professionals. The assessment included three aspects: what body was responsible for ensuring adherence to the regulations, what processes of CME/CPD were involved, and what contextual factors impacted professional mobility. Results from the study demonstrated that CME/CPD systems were regulated by the profession of medicine, such as by a professional association, a royal college, an accreditation body, or a quality assurance body. Processes for registration and/or revalidation included an expectation or requirement that physicians engage in CME/CPD to maintain professional competence, however there were marked differences in the consequences of non-compliance and the degree to which physicians were free to choose their own educational activities. Contextual factors included an increasing need to permit cross-border movement of physicians and other health professionals while ensuring quality and safety in practice are maintained [7].

Interventions to Balance Education with Patient Care Delivery

A realist synthesis conducted by Sholl et al. explored the literature to evaluate key workplace interventions that helped to achieve a balance between health professions’ education and patient care delivery and assess how those interventions enabled or inhibited this balance. The focus of the synthesis was on the UK workplace. The study found that the most common interventions to balance education with care delivery included ward round teaching, protected learning time, and engagement in CPD. Enabling factors to achieve balance included organisational funding, workload management, and institutional and managerial support [8].

CPD as a Strategy to Address Shortage of Physicians

One study in this literature review described the role of CPD as critical to addressing the significant shortage of physicians and other HCPs in Ukraine [9]. The authors noted that in order to be successful, CME/CPD systems must be individualised and focused on specific practice needs of physicians, connected to the practice needs of health care organisations such as hospitals, and incorporate the feedback from stakeholder physicians. The authors also noted the need to involve medical associations and unions in the process of accreditation and licencing providers of CME [9].

Creating a Formal and Contemporary CME/CPD System in One Country

Two research studies from Georgia described steps taken by the country to incorporate a formal, rigorous, and contemporary CME/CPD system that focused on innovative teaching methods, and evaluating outcomes of learning to assess change in competence, performance, and patient outcomes [10,11]. The authors described how educational needs and physicians’ preferences in educational formats were assessed, and identified the biggest obstacles that prevented them from engaging in CME/CPD. Results from the study were used by the responsible authorities to develop an educational strategy that better met the needs of physicians in country [10,11].

Physicians’ Perceptions of National Physician Validation and CPD Systems

In a qualitative study of perceived benefits, barriers and potential improvements to the CPD system in Ireland, researchers analysed responses to an open-ended survey related to physicians’ participation in the Royal College of Physicians of Ireland’s Professional Competence Scheme (PCS). Thematic analysis revealed five themes in the qualitative data: evidence of participation (difficulties obtaining evidence and recording evidence of participation); how PCS was structured (content not relevant, system is inflexible and unrealistic); participation valuable but formal, credit-based system is not necessary; lack of time to engage; challenges accessing [12]. The researchers noted that the findings were similar to other published studies exploring barriers.

Using a constructivist, grounded theory approach, researchers explored the perceptions of practicing respiratory physicians from Germany, Denmark, and the UK to evaluate perceptions and self-reported acceptance of validation across three different country-level systems in Europe [13]. Outcomes of the study demonstrated that all physicians, regardless of country, were intrinsically motivated to engage in personal development and engagement in CPD. Physicians in this study reported that they exceeded any mandatory requirement to engage in CPD and noted that the mandatory requirements were primarily designed to ensure that they captured those smaller groups of physicians who chose not to participate. Physicians in this study reported that the CPD systems were disconnected from true work-related learning and that they were incapable of actually identifying physicians with practice-based deficits. Findings from the study included perceived misalignment of physician validation systems with daily practice and a concern that the systems encouraged a “tick box” behaviour to meet requirements [13].

Utilizing National Needs Assessment Surveys to Identify Educational Gaps

Using a cross-sectional survey administered to 547 Irish physicians practicing in hospitals, researchers found an increased demand for non-clinical topics that included resilience training and time management, a desire for more interactive, participatory learning methods, and a need to consider the diverse educational needs of physicians across different clinical specialities [14]. Barriers to participation included lack of time and funding [14]. Using a national educational needs assessment in Ireland that focused on general practitioners (GPs), researchers documented the challenges facing practicing GPs and described how data from such studies could be used to develop relevant and effective CPD that could positively impact practice and patient outcomes [15].

A study in Denmark that used a national needs assessment demonstrated prioritised, country-level educational themes for GPs based on a collaborative, consensus-oriented process [16]. The authors noted the value of the rigorous process to develop educational themes. They also acknowledged that a successful CME/CPD system should incorporate a combination of a consensus-built curriculum as well as educational activities based on individual learning needs [16].

In Italy, researchers assessed the educational needs of occupational medicine (OM) physicians by administering a national survey. Researchers identified a number of clinical topics that were needed to meet the needs of practicing OM physicians, as well as non-clinical topics focused on communication and teamwork skills that were needed to work effectively with interprofessional teams [17].

Summary

The included studies explored different aspects of CME/CPD systems, processes, and approaches in several European countries and revealed that nearly all the countries evaluated have formal CME/CPD systems but participation may be mandatory or voluntary that physicians overall were engaged and wanted to participate in CME/CPD, and that there were significant opportunities to better individualise education and eliminate barriers that can impede physician participation in CME/CPD.

Mixed-Methods Assessment Strategy

To evaluate each country in greater depth, a mixed-methods assessment strategy was employed in a three-pronged approach that included 1:1 interviews with in-country subject matter experts (SMEs) and an electronic survey to capture both quantitative and qualitative data from in-country physicians. The survey employed to capture data from in-country physicians was used in two previous assessments conducted in Japan and the Asia-Pacific region and in the regional assessments conducted in China, Latin America, and the Middle East/North Africa; therefore, the results of this assessment provide an opportunity to compare results globally [1,2]. The electronic survey captured demographic data as well as self-report data from in-country physicians that reflected characteristics of the CME/CPD system in country, perceptions of industry-supported CME/CPD, and perceptions of how well the current CME/CPD system was meeting physicians’ educational needs (Appendix B).

Institutional Review Board (IRB) Approval

This assessment was conducted in accordance with the principles embodied in the Declaration of Helsinki and in accordance with local statutory requirements.

In this assessment, CME and CPD were defined as:

• CME: educational activities which serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession (ACCME, 2022).

• CPD: educational activities to enhance medical competence in medical knowledge and skills, as well as management, team building, professionalism, interpersonal communication, technology, teaching, and accountability (Filipe, Silva, Stulting, & Golnik, 2014).

In this assessment, interprofessional continuing education (IPCE) was defined as:

• IPCE: when members from two or more professions learn with, from, and about each other to enable effective collaboration and improve health outcomes. IPCE relates to practicing HCP team-based education. In comparison, interprofessional education (IPE) relates to undergraduate health care students (Joint Accreditation, 2019).

In this assessment, independent CME/CPD was defined as:

• CME/CPD for which financial, or in-kind, contributions given by a commercial interest, which is used to pay all or part of the costs of an activity. The definition of roles and requirements when commercial support is received is outlined in the Accreditation Council for Continuing Medical Education (ACCME) Standards for Commercial Support and although this is a United States (US)-based organisation, it is accepted as the standard for defining roles and responsibilities. The commercial supporter cannot be involved in the planning, delivery, or evaluation of the educational activities and all decisions are made by the educational provider (Adapted from IACPD, 2019).

This assessment was led by an independent Health Professions Educator (HPE) with more than 27 years of experience in global CPD and IPCE, who also holds an international development role within the Association for Medical Education in Europe (AMEE). The HPE recruited the in-country SMEs with the assistance of an experienced European HPE. The European HPE identified and databased current European CPD experts through his role as the programme director of the European CME Forum, an annual Europe-focused CME/CPD meeting that is currently in its 17th year. Each of the experts was selected based on their professional experience in CPD, which included direct participation in the ministries of health or other governmental bodies responsible for oversight of CPD in their respective countries, research and publication in CPD, participation in the accreditation of activities or providers at a national or regional level, and history of presentations regarding national or regional CPD. One SME also participated on behalf of EACCME, sharing pan-European insights and information.

Each in-country SME participated in a 1:1 focused interview with the HPE to provide an overview of their CME/CPD system. In-country SMEs used PowerPoint presentations and open discussion to deliver the content. Interviews lasted between 30 and 60 min and were guided by the HPE using a standard set of questions (Appendix C).

The English language electronic survey that was used to capture quantitative and qualitative data from in-country physicians across Europe was translated into native languages by the in-country SMEs in order to increase survey participation. Native languages included French, German, Italian, Polish, Spanish and Turkish. Once translation was complete, the survey was disseminated electronically using SurveyMonkey® by the in-country SMEs who also engaged partner organisations if needed. Purposive, heterogeneous sampling was used to access respondents as the aim of this assessment was to capture the perceptions of physicians who represented diversity across specialities, practice settings, age, gender and experience. Respondents self-selected to participate.

The survey in Europe was opened on 3 May 2022 for a total of 28 weeks and 3 days, and was closed on 18 November 2022. When necessary, reminders were sent to maximise participation. The survey remained open for an extended period to allow partner organisations to disseminate and to maximise the number of respondents.

Following the survey close, data were downloaded from SurveyMonkey® and the data file was then sent electronically to a doctorally prepared researcher for further analysis.

The original data file included 326 rows of respondent data, including quantitative data and original free text responses in native language. All personal identifiers including IP address were immediately removed from the data file and analysis was performed on the deidentified file. A case number was created for each respondent row to track and ensure accuracy during the analysis process. To ensure duplicates were not counted more than once, the researchers deduplicated the survey responses before conducting the analysis.

A review of countries reported by respondents was conducted to ensure that all respondents practiced in Europe. Eight cases were removed from the data set due to a respondent who practiced outside of Europe.

There were nine cases that were removed from the original data file because the respondent failed to answer the item “Are you responsible for educating medical students, postgraduates, residents, clinical specialists (consultants), other?” and failed to continue the survey after that item (e.g. no further data were entered by the respondent). There were 39 cases that were removed from the original data file because the respondent failed to answer the item “I am aware of the CME/CPD system in my country?” and failed to continue the survey after that item (e.g. no further data were entered by the respondent).

Analysis was conducted on the final data set of 270 respondents, which represented 82.8% of all starters (Figure 1). A modest drop-off continued throughout the survey and which was noted as “missing data” on each table. Quantitative analyses were conducted using IBM SPSS Statistical software Version 28 and included descriptive statistics (mean, standard deviation, %). Analysis was conducted on the qualitative data collected via the survey (e.g. open response questions) by the researcher who aggregated and summarised comments by overall theme as they related to the survey item. The six-step process used for thematic analysis included familiarisation, coding, generating themes, reviewing themes, defining and naming themes, and writing up themes was followed [18]. Qualitative analysis was conducted on the interview responses and open-ended questions on the survey.

Figure 1.

Data cleaning for analysis, European cohort.

Respondent drop-off over survey noted in tables as missing data.

Results

Physicians from 27 countries across Europe responded to the electronic survey. The following is an aggregate summary of the quantitative and qualitative data captured through the survey. Qualitative data provided by in-country SMEs via focused interviews that reflect their perspectives are also presented in summary.

Quantitative Survey Data

Demographics (Table 1)

Table 1.

Demographic characteristics of respondents.

	Value
Number of respondents included in analysis (N)	270
Specialty area of practice (%)
General Practice	13.3%
Internal Medicine	7.4%
Internal Medicine Subspecialty	13.3%
Pediatrics	7.8%
Surgery	3.0%
Surgery Specialty	8.5%
Obstetrics/Gynecology	3.0%
Psychiatry	1.1%
Other	42.2%
Missing	0.4%
Place of employment (%)
University Hospitals	42.6%
Teaching Hospital	No data
Other Public Hospital	No data
Private Hospital	No data
Community Hospital	5.9%
Medical College (as Teaching Faculty)	10.4%
Other (non-specified)	25.2%
I do not do clinical work	6.7%
Years since graduation (%)
<6	9.6%
6–10	7.8%
11–15	8.1%
16–20	14.4%
21–25	13.0%
>25	40.0%
I do not treat patients	7.0%
Average number of patients seen per day (mean/standard deviation)	15.56 (SD 11.29)
Responsibility for educating others
Medical Students	27.8%
Postgraduate	15.9%
Resident Doctors	18.5%
Clinical Specialists (Consultants)	6.7%
Other	31.1%
Formal training in medical education
Yes	32.2%
No	31.1%
Other (with explanation)	36.7%

A total of 270 physicians were included in this analysis. The majority were from the UK (18%), Romania (15%), and the Netherlands (11%). Respondents from the other 24 countries ranged less than <10% of the total number.

Most respondents selected “other” for speciality area of practice and free text responses included 20 responses for anaesthesiology with or without critical care, 10 responses for neurology, 10 responses for ophthalmology, and 8 responses for public health. The remainder of the free text responses were scattered across a number of different specialities. General practice and internal medicine subspeciality was selected by 13% of respondents. Respondents were able to select multiple options therefore some selected internal medicine subspeciality and entered a free text speciality while others only selected “other” and entered the speciality in the free text line. The majority of respondents practiced in a hospital setting, while 25% of respondents selected “other” for place of employment. Free text responses for “other” included primarily private practice, clinic or office settings. Responses were not mutually exclusive, therefore some respondents selected both hospital and private practice or medical school and clinic for example. Most respondents practiced in large cities. Forty per cent of respondents graduated from medical school more than 25 years ago and 27% of respondents graduated from medical school between 16 and 26 years ago. Most respondents practice clinically and reported seeing patients, with the average number of patients for those in clinical practice being 15.56 (SD 11.29) per day.

Most respondents selected “other” in response to responsibility for education, and free text responses most often listed multiple types of learners across the education continuum (e.g. medical students and postgraduate and residents) and/or across professions (e.g. medical students, residents and nursing or dental students). Responses were mutually exclusive therefore other was the only item whereby a respondent could list more than one learner type.

Almost one-third of respondents either reported no formal training in medical education or reported having formal training in medical education. Respondents also reported “other” in response to this survey item and free text responses included a large number of respondents (N = 106) who reported holding educational certificates, who had completed a diploma, masters or doctoral programme in education, or who had completed courses such as the Essential Skills in Medical Education (ESME) or university-based education programmes. Combining those 89 responses with the 87 that reported receiving formal training in education resulted in 65% of respondents who had some level of formal training.

Perceptions of the Current In-Country CME/CPD System (Table 2)

Table 2.

Perspectives of in-country physicians: awareness and participation.

	Value
Number of respondents included in analysis (N)	270
Aware of CME/CPD system in country (%)
Yes	78.5%
No	4.8%
Not sure	9.3%
There is no formal CME/CPD system in my country	7.4%
Hours of CME/CPD in past year
0	8.9%
1–10	20.7%
11–20	13.3%
21–30	9.6%
31–40	10.7%
41–50	16.7%
>50	20.0%
CME/CPD available meets my needs
Strongly agree	23.3%
Agree	53.7%
Disagree	18.9%
Strongly disagree	4.1%
Participation in CME/CPD should be compulsory
Strongly agree	39.3%
Agree	48.1%
Disagree	11.5%
Strongly disagree	1.1%
Interprofessional CE is needed
Yes	71.9%
No	5.2%
Not sure	11.9%
Missing	11.1%

Almost four-fifths of respondents were aware of the CME/CPD system in their country, while 7% of respondents reported that there was no formal CME/CPD system in their country. When responding to the number of hours of participation in CME/CPD in the past 12 months, 43% reported 0–20 h while the remainder reported over 20 h. Most respondents strongly agreed or agreed that the CME/CPD available to them met their needs. Most respondents strongly agreed or agreed that participating in CME/CPD ensures they have current knowledge to care for their patients, increases competence and skills, and should be compulsory. Most respondents believe that IPCE is needed in their countries and most have participated in IPCE.

Preference in Educational Format

When asked to rank educational format based on their preference and using a scale from 1 (low) to 5 (high), respondents selected 4 or 5 most often for the following formats: hands-on learning (N = 158), attending live regional educational activities (N = 157), attending national and international conferences/symposia (N = 139), and serving as a supervisory physician N = 136). Online patient case-based learning programmes (N = 115), reading journal-based or other printed materials (N = 108), answering questions at the end of e-learning activities (N = 99), authoring medical papers and books (N = 107), online video lectures (N = 96), and listening to podcasts (N = 46) were also selected but less frequently.

Perceptions of Industry-Supported CME/CPD (Table 3)

Table 3.

Perspectives of In-country physicians: independence and commercial influence/bias.

	Value
Number of respondents included in analysis (N)	270
CME/CPD in my country is free from control by pharmaceutical or other commercial interests
Strongly agree	14.4%
Agree	35.6%
Disagree	29.3%
Strongly disagree	5.6%
Missing	15.2%
I have participated in CME/CPD that has been developed by independent CME/CPD providers with financial support from pharmaceutical or other commercial interest organizations
Yes	58.5%
No	26.3%
Missing	15.2%
CME/CPD funded by pharmaceutical or other commercial interest organizations can be free from bias:
Strongly agree	6.3%
Agree	35.2%
Disagree	30.4%
Strongly disagree	11.1%
Missing	17.0%

More respondents strongly agreed or agreed that the CME/CPD in their country was free from any control by pharmaceutical or other commercial interest organisations as compared to those who disagreed or strongly disagreed. More than half of respondents had participated in independent, commercially supported CME/CPD. Approximately the same number strongly agreed or agreed that independent CME/CPD can be free from bias as compared to those who strongly disagreed or disagreed.

Participation in Pharma or Commercially Supported CME/CPD (Table 4)

Table 4.

Participation in pharma or commercially supported CME/CPD.

	Value
Number of respondents included in analysis (N)	270
Independent CME/CPD should be used towards my requirements	8.1%
Strongly agree	51.1%
Agree	18.5%
Disagree	7.0%
Strongly disagree	15.2%
Missing	8.1%
If CME/CPD funded by Pharma or a Commercial Interest was available to you, how would you choose to participate:
Based on my clinical specialty	46.0%
Based on the presenting faculty	22.2%
Only when at least one presenting faculty member is from my country	1.1%
The relevance of the education to my practice	56.0%
Curiosity for the topic (but not necessarily related to my practice)	20.0%
The city where the meeting is located	13.3%
I could not participate in independent CME/CPD funded by a pharmaceutical or other commercial interest organization	10.7%

Most respondents strongly agreed or agreed that content developed independently by a CME/CPD education company could be used towards their required educational hours (credits). A large number of respondents would choose to participate in independent CME/CPD if the content was based on their clinical speciality and/or the education was relevant to their practice.

Perceptions of Independence in CME/CPD (Table 5)

Table 5.

Perspectives of in-country physicians: what independence in CME/CPD means.

	Europe
Number of respondents included in analysis (N)	270
CME/CPD that is developed by an independent CME provider with financial support from pharmaceutical or other commercial interest organizations means:
Pharma or Commercial Interest must review and approve all content	13.0%
Pharma or Commercial Interest can suggest speakers	25.2%
Pharma or Commercial Interest works with the educational provider to develop content	25.6%
Pharma or Commercial Interest has no influence on content and speaker selection	25.6%
Content is developed independently by the education company to address the needs of learners	28.9%
I don’t know	13.0%

Perceptions of CME/CPD developed by an independent provider with financial support from a pharmaceutical or other commercial interest organisation varied. One-quarter of respondents believed that the pharmaceutical or commercial interest organisation could suggest speakers, 26% believed that the pharmaceutical or commercial interest works with the educational provider to develop content, and 13% believed that the pharmaceutical or commercial interest must review and approve all content. In contrast, 29% of respondents reported that content is developed independently by the education company to address the needs of learners, and 26% reported that the pharmaceutical or commercial interest can have no influence over content or speaker selection in independent CME/CPD. Thirteen per cent of respondents did not know what independent CME/CPD means.

Missing from Current CME/CPD System and Barriers to Participation (Table 6)

Table 6.

Perceptions of in-country physicians: missing from CME/CPD system and barriers to participation.

	Value
Number of respondents included in analysis (N)	270
What is missing from the CME/CPD currently available to you?
Ability to choose education that suits my specific needs	20.0%
Ability to keep up to date with the most current research	14.0%
Ability to network with colleagues	20.0%
Content that is current/up to date	10.4%
Variety of educational formats (ie. Live, online, web-based, experiential, preceptorships)	23.7%
Innovative learning environments and new creative formats	29.3%
More frequent and more diverse programs	19.6%
Patient-focused programs	14.8%
Not applicable enough	10.4%
Nothing is missing	17.4%
What are your barriers to participating in CME/CPD (if any)?
Not covered in my budget	31.1%
Topics are not relevant/clinically important to me	14.4%
Quality is not high	14.8%
Learning objectives are not clear	14.1%
Not offered at convenient times	20.4%
Formats are not flexible enough	13.3%
Not enough skill building exercise	13.0%
I do not have any barriers	20.4%

Respondents reported that innovative learning environments and new creative formats, variety of educational formats, ability to choose education that suits my specific needs, ability to network with colleagues, and more frequent and diverse programs were most often missing from their current CME/CPD systems. Barriers to participation in the current CME/CPD systems were primarily related to funding/not covered in budget or not being offered at a convenient time. One-fifth of respondents reported having no barriers.

Preparation as a Lifelong Learner and Consultant

About 41.9% of respondents reported that their undergraduate training prepared them to be lifelong learners and 57.4% of respondents reported that their postgraduate training prepared them to practice as a consultant.

Annual Requirements to Practice Medicine (Table 7)

Table 7.

Annual requirements to practice medicine.

	Value
Number of respondents included in analysis (N)	270
Yes, mandatory and participation required	54.8%
Yes, mandatory but no penalties	14.1%
No, but I still participate	16.3%
No, and I typically don’t participate	4.1%
Missing	10.7%

When asked if an annual CME/CPD requirement exists in their country as a condition to practice medicine, more than half of respondents reported that it is mandatory and participation is required while 14.1% reported that it is mandatory but there are no penalties imposed for failing to participate. 16% of respondents in countries where participation is not mandatory reported still engaging in CME/CPD and only 4% of respondents in non-mandatory countries typically do not participate.

Collecting and Converting CME/CPD Credit (Table 8)

Table 8.

Collecting and converting CME/CPD credit.

	Value
Number of respondents included in analysis (N)	270
Where typically collect CME/CPD
Other	11.5%
Within own hospital or institution	11.5%
From my medical or specialty association	14.4%
Local training center or CME/CPD provider (in person)	3.3%
Local training center or CME/CPD provider (online)	4.1%
Local, national or international conferences	44.1%
Missing	11.1%
Convert credit or apply for reciprocity
Yes	15.2%
No	56.3%
Not aware possible	18.5%
Missing	10.0%

Most respondents in this survey received CME/CPD credits from attending local, national, or international conferences, and only 15% of respondents converted credit obtained outside of Europe to meet in-country requirements.

Bodies That Award and Accredit CME/CPD (Table 9)

Table 9.

When collecting CME/CPD credit and awareness of accrediting bodies.

	Europe
Number of respondents included in analysis (N)	270
When collecting CME/CPD credit for your own professional development, what type of organization awards the credit (select all that apply):
My own hospital/health system	17.0%
My specialty society or association	49.6%
A pan-European accreditation system (e.g. EACCME)	14.0%
Ministry of Health	10.0%
My own hospital/health system	17.0%
Which of the following European accreditation bodies are you aware of (select all that apply):
European Accreditation Council for Continuing Medical Education (EACCME)	38.2%
European Board for Accreditation in Cardiology (EBAC)	7.8%
Royal College of Physicians in the United Kingdom (RCPUK)	29.3%
UK CPD Certification Services	6.3%
None of the above	31.5%

Respondents in this assessment received most of their CME/CPD credits from their speciality societies or associations, while 14% received credit from a pan-European accreditation system and 10% received credit from their Ministry of Health. Respondents were most familiar with the EACCME and the RCPUK as accrediting bodies.

Qualitative Survey Data

Overall, qualitative data collected via the electronic survey substantiated the quantitative survey findings. Respondents reported a need for more creativity and flexibility in the modes of delivery and noted that the impact of COVID-19 may have positively influenced providers of CME/CPD to be more innovative. Respondents also reported a desire for more transparency and consistency of regulations related to CME/CPD, both within the profession of medicine and across professions, and a need for more funding to cover true costs of participating as a physician learner.

Qualitative Data from the In-Country SME 1:1 Interviews

Discussions from the in-country SME interviews added an additional dimension to the findings of this assessment. Overall, in-country SMEs reported the quality of their CME/CPD systems to be high, with education focused primarily on knowledge gain and practice improvement. Several noted that evaluating the relationship between participation in CME/CPD and patient-level outcome changes was challenging. The in-country SMEs noted that there continues to be a need for increased funding to support physician participation, decreasing the administrative regulatory burden, increasing consistency within and across the professions, and incorporating more innovative, active-learner engagement strategies. There was limited acceptance of industry-provided CME/CPD in these countries and most have implemented strategies to limit any industry influence or control over content.

Discussion

Results from our assessment of CME/CPD systems in 15 countries through in-country SME input demonstrate a high degree of congruence in many areas. These consistencies may be expected given the country collaboration that occurs across Europe. There were a few differences noted, some of which may be expected based on political and economic differences.

Regional Overview

There is a high degree of congruence across countries in the early stages of the education continuum. In all countries, entry into medical school occurs after secondary school and concludes with successfully passing all required examinations. In the majority of countries, physicians must pass a national licencing exam to practice medicine after which graduates are then eligible to practice medicine as a general practitioner. In all countries, completion of a residency and/or fellowship programme is required to practice as a speciality physician. Residency and/or fellowship programmes can be competitive but are widely available.

When comparing CME/CPD systems, the primary differences relate to whether the system is mandatory or not, the extent to which interprofessional education is available, and to what extent commercial interest organisations (e.g. industries such as pharmaceutical or device companies) can provide and/or influence educational content.

In countries where participation in CME/CPD is mandatory, the regulatory body responsible for physician and CME/CPD provider requirements is most often the same as the regulatory body for the practice of medicine. The regulatory bodies are all governed by the professions that they are regulating. France has the broadest regulatory system across the professions with its National Agency on CPD, while the other countries are regulated by the profession of medicine. In these systems, credit for engaging in CME/CPD is most often awarded based on one credit per hour of participation. Several countries in this assessment use multiple methods to ensure their CME/CPD systems incentivise physicians to engage in self-assessment and lifelong learning, in contrast to systems that focus primarily on participation that is recorded solely on “time in seat”. For example, France, the Netherlands, and the UK incorporate such requirements as self-reflection, portfolio-based practice review, and educator auditing as mechanisms to align CME/CPD, with professional practice gaps. In countries without mandatory participation, physicians are still strongly encouraged and supported to engage in CME/CPD. Several in-country SMEs suggested that there was value in implementing a mandatory system to ensure all physicians participated in CME/CPD though data suggest that most do regardless.

In most countries, physicians are expected to retain their own records of participation in CME/CPD and may be required to submit evidence to a regulatory body upon request. Sanctions for failure to participate were few.

In Croatia, most CME/CPD is provided by commercial interest organisations and while there have been some efforts to implement regulations restricting influence, they have not been widely adopted. In the other countries in this focused assessment with in-country SMEs, there have been regulations and oversight implemented to restrict commercial interest organisations from influencing or controlling the content of CME/CPD.

Physicians across Europe have a wide range of activity formats to choose from for their CME/CPD activities, and many different types of organisations can be providers of CME/CPD.

Although IPCE is philosophically supported and endorsed by in-country SMEs and survey respondents, there was wide variation in whether it is actually available for physician learners. In some countries, IPCE was widely available and strongly supported, while in other countries it was essentially non-existent.

Survey Data Analysis

Survey respondents in this assessment were predominantly from the UK, Romania, and the Netherlands; therefore, results are more heavily influenced by physicians in these CME/CPD systems.

Best Practices in CME/CPD Systems

The CME/CPD systems that support physicians and other HCPs to engage in lifelong learning vary widely across different countries yet are critical to improving health care practice, and patient and population health outcomes. Best practices for CME/CPD systems should demonstrate that they are based on adult learning principles, are aligned with contemporary learning science frameworks, include mechanisms to ensure quality and independence, provide educational opportunities in multiple formats and via multiple modes of delivery, and are easily accessible and affordable. Regulatory mechanisms should be driven by the profession, include methods to validate learner participation, and should be clearly understood by all stakeholders. Systems should incorporate strategies for self-assessment, be based on identified practice gaps for individuals and health care teams, and include evaluation of change (learner, practice, health outcomes). There should be an investment in developing HCPs as lifelong learners, interprofessional team members, and teachers.

Comparison of European CME/CPD Systems to Best Practices

This assessment in Europe reflects countries with CME/CPD systems that are quite mature when compared to other areas of the world. Almost all the European countries included in this review, regardless of whether participation in CME/CPD is mandatory to practice medicine, have CME/CPD systems that are professionally self-regulated. Austria has implemented the most structured and regulated mechanism to track physician participation, while other countries rely on an attestation with audit mechanism to validate participation. Physicians in these countries generally participate in 20 or more hours of CME/CPD annually regardless of whether participation is required, and sanctions are generally not applied for failure to meet regulations. Almost all countries have implemented policies or laws to limit the influence of commercial interest organisations (pharmaceutical or device) over content in CME/CPD.

Several countries in this assessment have incorporated a learning sciences framework into their CME/CPD systems, including requirements for physicians to engage in self-assessment/self-reflection and evaluation of professional practice gaps. In-country SMEs describe the overall quality of CME/CPD in their countries as high, with education focused on knowledge and practice change. There was limited discussion of CME/CPD tied to patient/population health gaps; however, one SME noted the challenges of aligning CME/CPD and evaluating at that level.

Overall, respondents in this assessment reported that CME/CPD is readily available to them in a variety of different formats; however, they are hampered by costs to attend/participate and by time constraints. Travel across Europe is relatively easy as compared to other geographic regions in the world and this may have an impact on ease of access.

When questioned about opportunities for improvement, in-country SMEs and free text survey responses focused primarily on increasing innovation, improving transparency and consistency, and decreasing administrative burdens. As compared to regions of the world where CME/CPD systems are not well established, these responses reflect continuing to grow and advance mature systems to improve quality and not about the infrastructure of building systems that do not exist.

About half the countries in this review have and support IPCE, which is likely also a marker of a more mature CME/CPD system. This is an area for expansion to other European countries.

Limitations

There are several significant limitations to this assessment. As the survey was disseminated using a purposive sampling method to capture a broad heterogeneous audience, it was not possible to calculate an accurate response rate. Using the number of physicians in each country as the maximum number of respondents, the response rate was very low, and the results may not accurately reflect the perspectives of the broader physician community. The SMEs participating in the assessment may have a limited or biased perspective of their CME/CPD system and therefore may not reflect the broader physician community perspectives.

Conclusion

This mixed-method assessment demonstrates that the CME/CPD systems in the 15 European countries reflect elements of mature systems globally. Physician participation is mandated or strongly encouraged and supported. Physicians have access to a wide variety of opportunities to participate in CME/CPD and they do participate even if not required by regulation. Mechanisms have been implemented mechanisms to ensure the quality of CME/CPD provided within countries even if they permit pharmaceutical or device companies to provide and/or support education. Suggestions for improvement focus on quality and not basic elements of structure.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Supplementary Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/28338073.2024.2435731