Perhaps nowhere in the world more than in Europe has medical practice benefited from cross-border exchange and the sharing of discoveries, research and healthcare practices. This proximity has made it possible to define a common standard for the provision of continuing education courses.

CME, an international practice

The medical profession, and health care in general, is a profession that requires constant passion and curiosity about the subject. The complexity of this scientific knowledge, the mission of patient care, and the social value of these professions make continuing education a personal choice made at the beginning of one's studies even before it is a requirement for carrying out this work.

Nationally, continuing education in the health sector has been regulated for just over twenty years. Thanks to the implementation of Legislative Decree 502/1992 and Legislative Decree 229/1999, the National Continuing Medical Education (CME) Programme was established. Responsible for this programme is AGENAS, the Health Agency for Regional Services, which is responsible for the administrative management of the CME programme and the support of the National Commission for Continuing Education.

This practice is also widespread and organised internationally, where the provision of training credits is delegated to super partes agencies such as the International Association for Continuing Education and Training (IACET), and the European Accreditation Council of Continuing Medical Education (EACCME).

Different approaches to CME

Internationally, there are different approaches to continuing medical education. Broadly speaking, four distinct approaches can be distinguished with regard to the validity of courses taken in the context of CME:

• Mandatory validity
• Valence on an incentive basis
• Valence on a professional basis
• Valence on a voluntary basis

Countries such as Mexico, Saudi Arabia, South Africa, Singapore, Iran, South Korea, the United Arab Emirates and Peru stipulate mandatory accreditation for professional certification. In Europe, these include the Netherlands and Austria. Belgium and Norway have adopted an incentive-based approach for this purpose, while Germany, Ireland, Spain and the United Kingdom are on an incentive basis. Finally, countries such as Chile, Costa Rica, Kuwait, Australia and New Zealand are exclusively on a voluntary basis. In Europe, Finland, Portugal Sweden, Greece, Denmark, Iceland and Luxembourg belong to this group.

IACET and the US Standard

Created in 1968 as a task force of the US Department of Education, IACET took its final form in 2006, when it was granted Standard Developer status by the American Institute of Standards. With ANSI/IACET Standard 2018-1, IACET sets standards for providers of training materials, defining all aspects of continuing education and training along nine categories:

• Organisation, Accountability and Control
• Learning Environment and Support Systems
• Planning and Instructional Personnel
• Need for analysis
• Learning outcomes
• Learning content and requirements
• Assessment of learning outcomes
• CEU IACET assignment and maintenance of student records
• Evaluation of Learning Events

This standard, which has also been adopted internationally, serves as a guideline for training content providers. Thanks to this standard, providers have an easier task in establishing an appropriate accountability and control system; they can adopt an analytical approach to identify learning needs; they can design, plan and execute a learning event; they can establish appropriate evaluation criteria based on learning outcomes; and, finally, they can monitor and improve the learning process.

The EACCME, a European standard

Perhaps nowhere in the world more than in Europe has medical practice benefited so much from cross-border exchange and the sharing of discoveries, research and healthcare practices. Geographical proximity, the ability to speak several languages, and the opportunity to spend periods of study, exchange and further education in foreign research and treatment centres has helped create a widespread culture that promotes comparison and the adoption of common standards. It is no coincidence that from the 4th century B.C. to the present day, physicians take the Hippocratic Oath before starting their profession. This oath is not just an artefact but embodies the spirit that, from ancient Greece through European civilisations, has endured throughout the world.

In Europe, the management of EMC training credits is handled by the European Accreditation Council of Continuing Medical Education (EACCME). This institution is part of the European Union of Medical Specialists (UEMS), an organisation representing national associations of medical specialists in the European Union and associated countries. Founded in 1958, the UEMS has 41 member states, according to three different types of association:

• Full membership association
• Association as associate member
• Association as observer

The status of full associate member includes all member states of the European Union, as well as states that are part of the European Economic Area, such as Norway, Switzerland or Iceland. These states participate in the UEMS through their national associations. For Italy, participation is through the National Federation of the Orders of Surgeons and Dentists (FNOMCeO). States participating as associate or observer members have consultative capacity.

The UEMS represents more than 50 medical disciplines, including 43 recognised specialist sections worldwide. Each of these sections is organised in a European Council whose purpose is to define the standards of education and training valid in Europe. The work of the individual councils is complemented by that of the Multidisciplinary Joint Committees, which aim to harmonise topics that span more than one specialist discipline. These include topics such as adolescent medicine, breast care, intensive care medicine and oncology, sexual medicine and rare and undiagnosed diseases. These standards are defined through the creation of the European Training Requirements, which require the practitioner to hold a portfolio of training in which details are specified among others:

• Details of previous training and trainers
• The list of publications, together with abstracts
• The list of research presentations
• The list of courses attended 

In addition to the portfolio, the training requirements specify the number and procedures that students must have performed or attended in order to complete postgraduate training.

CME credits are evaluated by the EACCME by weighing one credit for each hour of training attended, with a limit of eight credits per day. This institution, part of the UEMS, was established in October 1999, when the EMC programme transitioned from a voluntary to a compulsory basis in Europe. The Criteria for International Accreditation of EMC Credits, formulated in the same year, empower the EACCME to grant EMC credits in agreement with the UEMS section responsible for evaluating training events. This is relevant to the application for international certification by a training content provider, who must comply with the criteria and submit proof of quality of the content produced to the EACCME. In this regard, the provider is required to provide the EACCME with the following information:

• Information on the learning objectives of the activity valid for CME credits
• The detailed programme of content provided in the course / event
• Information about the provider itself, with specification of the programme director
• The qualifications of the other lecturers / presenters of the event
• The organisational structure of the provider
• Information on previous experience such as conferences organised
• Details of any conflicts of interest, such as investments or funds received

The UEMS website provides, for those who qualify, the possibility to apply as a provider for the following activities:

• Live training events
• e-Learning training material
• Credit recognition of CME-CPD activities

The application criteria for the three activities were renewed in 2017. In particular, the criteria for the provision of e-Learning courses distinguish between essential and desirable requirements. Among the essential requirements are, firstly, those concerning the educational objectives and the satisfaction of learning needs: the provider must communicate that the e-Learning course material has been prepared taking into account the educational needs, the results it is expected to produce and the target audience it is intended for. Secondly, the descriptive material provided by the provider must clearly define the content of the courses as well as the duration and date of the last update. Regarding the nature of the material presented, the requirements demand that the content of the courses is based on scientific evidence and that the learner is encouraged to employ the most advanced learning methods such as, problem solving and task oriented thinking, reflection on what has been learned and case-based learning. The courses must be able to estimate the commitment of the learners and be free from commercial influences or other biases. The criteria specify the details of the provider that must be provided, such as the organisational structure, the names and qualifications of the individuals involved in the preparation of the course content, the name of the physician taking responsibility for the course content, as well as the declaration of possible conflicts of interest and the sources of funding obtained. Finally, the provider is required to provide an assurance of the quality of the courses provided, as well as a way for trainees to provide feedback on the course. As desired qualities, the provider is required to ensure that the courses are user-friendly, that hyperlinks to further relevant information are presented and that trainees are provided with the necessary technical support for easy use of the courses.

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