Appendix C
International Comparison of Continuing Education and Continuing Professional Development

Examining international models and trends in continuing education (CE) and continuing professional development (CPD) for health professionals has been, and continues to be, an area of interest for the global community of health professionals and education theorists. A 1999 report prepared for the Organisation for Economic Co-operation and Development (OECD) emphasizes the importance of internationally comparable data for advancing the study of CE. Cross-fertilization of innovative education models provides comparative formative and summative evaluations to validate and improve best practices while leading the way toward international coherence on the training, registration, and continual assessment of health professionals (Merkur et al., 2008b).

This comparative synthesis, which primarily includes examples from Canada, Australia, the United Kingdom, and other European countries,1 reviews the development of and current practices in medical, nursing, dental, and pharmacy CE and CPD. The paucity of descriptive literature available made it necessary to limit this review to these selected professions.

This review aims to address three questions:

  1. Do definitions and mechanisms of CE and CPD differ, and to what extent are they tied to revalidation and licensure?

1

For the purposes of this review, the United Kingdom is examined separately from the rest of Europe.



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Appendix C International Comparison of Continuing Education and Continuing Professional Development E xamining international models and trends in continuing edu- cation (CE) and continuing professional development (CPD) for health professionals has been, and continues to be, an area of interest for the global community of health professionals and education theorists. A 1999 report prepared for the Organisation for Economic Co-operation and Development (OECD) emphasizes the importance of internationally comparable data for advancing the study of CE. Cross-fertilization of innovative education mod - els provides comparative formative and summative evaluations to validate and improve best practices while leading the way toward international coherence on the training, registration, and continual assessment of health professionals (Merkur et al., 2008b). This comparative synthesis, which primarily includes examples from Canada, Australia, the United Kingdom, and other European countries,1 reviews the development of and current practices in medical, nursing, dental, and pharmacy CE and CPD. The paucity of descriptive literature available made it necessary to limit this review to these selected professions. This review aims to address three questions: 1. Do definitions and mechanisms of CE and CPD differ, and to what extent are they tied to revalidation and licensure? 1 For the purposes of this review, the United Kingdom is examined separately from the rest of Europe. 233

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234 REDESIGNING CE IN THE HEALTH PROFESSIONS 2. Have countries changed or adapted their CE or CPD systems to improve content or learning methods, and how have they dealt with pharmaceutical support for CE? 3. What can the United States learn from the experiences of other countries? The literature search, performed in December 2008, included the EBSCO, OVID, Academic Search Premier, and Medline databases. Keywords included continuing professional development, European learning, international, continuing education, nursing, pharmacy, medicine/medical, dental/dentistry, accreditation, revalidation, and competence. This review indicates requirements for training, types of training, and the mechanisms by which the requirements are enforced. However, much about the effectiveness of many of these models remains unknown. The diverse definitions and terminologies associated with CE and CPD systems complicate comparative analyses. While CE credits or hours are the currency by which regulatory bodies often assess competence, these regulatory bodies have a myriad of purposes and synonyms, including licensure, certification, credentialing, and revali- dation. For example, Merkur and colleagues (2008a) define revalida- tion as aiming to “demonstrate that the competence of doctors is acceptable.” These regulatory processes may include periodic applica- tion forms, fees, and required participation in activities, such as CE, CPD, and peer assessment, to maintain and improve competence. Just as CE requirements within professions vary by state in the United States, Canadian licensing bodies, for example, which differ between jurisdictions of practice (i.e., provinces, territories), do not agree on requirements for CE and CPD as part of their processes for ensuring the competence of health professionals. The degree of inclusion of CE credits in revalidation and relicensure systems varies between and within countries. In the early 1990s, Australia, Canada, and the United Kingdom gradually shifted from CE to CPD. Whereas CE serves to update and reinforce knowledge (e.g., management of heart attacks, how to diagnose HIV), CPD deals with personal, communication, manage - rial, and team-building skills in addition to content (Merkur et al., 2008a; Peck et al., 2000). Limitations in the traditional methods of CE (e.g., educational courses, lectures) led to the development of the more self-directed and self-reflective approach, which is believed to encourage lifelong learning and better meet the educational needs of health professionals (Evans et al., 2002). For example, in 1997 the government of the United Kingdom stressed the role of CPD in

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235 APPENDIX C ensuring quality and encouraged professional bodies to strengthen systems for self-regulation and lifelong learning (UK Department of Health, 1997). This process of CPD, defined by Davis and colleagues as an “umbrella for all sorts of interventions,” including CE, ties learning more closely to practice (Davis et al., 2003, p. 11). Com - pared to CE, which is frequently based on acquiring credits, CPD relies on processes of self-accreditation and reflection via personal portfolios. COMPARATIVE EXAMPLES OF CONTINUING MEDICAL EDUCATION In a series of articles in the British Medical Journal exploring how the United States can improve its health care system, Quam and Smith (2005) argue the United States could improve its continuing medical education (CME) system by more closely mirroring the United Kingdom’s guidelines for CPD. A brief historical survey provides the background in which CE systems can adapt and change based on international models presented in Table C-1. Although methods of CE are continually evolving around the world, CE models may be classified into two distinct categories: the learning model, seeking to improve clinical competence, and the assessment model that emphasizes both performance and com - petence (Merkur et al., 2008a). These CE models are presented in Table C-2. The majority of countries use the learning model only. While some countries (e.g., Austria, France, the Netherlands, United Kingdom) screen all physicians for competence, no coun- tries included in the 2008 comparative survey used more selected, targeted screenings to ensure competence. Maintenance of Certification in Canada Through the latter half of the twentieth century, Canadian con- cepts of CME developed alongside those in the United States until patient advocacy, government regulation, and an increase in medi- cal knowledge led the Royal College of Physicians and Surgeons of Canada (RCPSC) to explore new frameworks for continued compe- tency. The framework, known as CanMEDS, was adopted in 1996 and outlines essential physician competencies with the aim of improving patient care. A program of mandatory professional development, called the Maintenance of Certification (MOC) program was man- dated by the RCPSC beginning in 2000 (Royal College of Physicians and Surgeons of Canada, 2008). At this time, fellows of the college

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236 REDESIGNING CE IN THE HEALTH PROFESSIONS TABLE C-1 Continuing Medical Education—An International Comparison Ways of Ensuring Competence Country CME or CPD Peer Review Compulsory Australia CPD No No Austria CME Yes Yes Belgium CME & CPD Yes No Canada CPD Yes No France CME Yes Yes Germany CME No Yes for government employees

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237 APPENDIX C Incentives Regulating + – Authority Requirements Financial Respective Cycle varies disincentives for medical colleges between 3 and 5 noncompliance and faculties years. Mandatory (professional components vary by bodies) college Legal Austrian Medical 150 1-hour credits requirement Chamber over 3 years (professional body) Financial Minister of 20 hours every year incentive Public Health OR accreditation (4% salary (government (requires 200 credit increase) body) hours over 3 years and participation in two peer reviews per year) Participation Royal College 400 credits over 5 awards of Physicians years (some activities and Surgeons worth more credits (professional based on content) body) Lawsuits by National Councils regional councils for Continuing Medical Education (professional bodies) Reduced Regional 250 45-minute credits reimbursement; chambers of over 5 years accreditation physicians withdrawn (professional bodies) continued

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238 REDESIGNING CE IN THE HEALTH PROFESSIONS TABLE C-1 Continued Ways of Ensuring Competence Country CME or CPD Peer Review Compulsory Italy CPD No Yes The Netherlands CME & CPD Yes for specialists Yes New Zealand CPD No Yes Spain CME (9 of 17 No No regions) United Kingdom CPD Yes: 360° Pending feedbacka United States CME No Yes NOTE: CME = continuing medical education; CPD = continuing professional development. a 360° feedback is a process whereby colleagues (including nursing and administra- tive staff) evaluate a physician’s performance. The process was initially developed in the commercial sector as a means of highlighting an employee’s strengths as well as areas in need of improvement. SOURCES: Merkur et al., 2008a,b; Peck et al., 2000. .

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239 APPENDIX C Incentives Regulating + – Authority Requirements None Continuing 150 1-hour credits Medical over 5 years Education Commission of the Ministry of Health (government body) Removal from Committees 200 hours of credits medical registry of specialists over 5 years; peer and primary visitation every care physicians 5 years (only for (professional specialists) body) Forced work Medical colleges Variable by region supervision; loss of and faculties and college registration (professional bodies) Spanish Medical Variable by region Variable by region Association (professional body) Forced work Department Parallel requirements: supervision of Health (1) relicensure (government) every 5 years and (2) recertification (variable by college) Variable by state Variable by state

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TABLE C-2 Synthesis of Models for Assessing Continuing Competence 240 Countries Using Models for Assessing Continuing Competence Pros Cons the Model Learning Model: CE seeks to improve clinical competence Seeks to improve Does not identify poorly Australia clinical competence performing professionals Austria Belgium Canada France Germany Italy The Netherlands New Zealand Spain United Kingdom United States Assessment Model: Responsie Assessment: assessment when a Potential to Cannot identify all poorly None emphasizes both complaint or problem occurs identify poor performing professionals performance and performers and requires centralized competence complaint system Periodic Assessment: full assessment of all Potential to Very ambitious and None domains of competence for all physicians identify poor potentially unfeasible performers

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Screening Assessment for All: identifies Potential to No single screening test Austria incompetence using peer review and identify poor has been developed that France patient questionnaires performers reliably and practically Hungary indicates poor performance Ireland The Netherlands Slovenia United Kingdom Screening Assessment for High-Risk Groups: Potential to May contravene privacy None assesses poorly performing professionals identify poor laws and requires a (e.g., based on patient outcomes or performers database of physician prescribing patterns) or targeting groups performance measures using other known qualities (i.e., older doctors) SOURCE: Merkur et al., 2008a. 241

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242 REDESIGNING CE IN THE HEALTH PROFESSIONS (approximately 90 percent of certified physicians in Canada are fellows of the RCPSC) were mandated to assess their professional needs and record participation in CPD, as well as learning outcomes achieved for their practice. The MOC program aims to make CPD an educational initiative to improve practice as opposed to an admin - istrative burden (Campbell, 2008). Box C-1 describes how technol- ogy is used to decrease the administrative burden placed on health professionals. Maintenance of Professional Standards in Australia and New Zealand In 1994, alongside Canada, the Royal Australasian College of Physicians (RACP)2 broke ground in CME by implementing a strat- egy to promote CPD. This CPD scheme, known as the Maintenance of Professional Standards (MOPS) program, included the accumu- lation of credit points and the recording of those points in a diary system. In consultation with the Royal College of Physicians and Surgeons of Canada, RACP is now phasing out MOPS and moving toward a fully electronic system. Between May 2008 and 2010, all RACP fellows will transition to an e-folio CPD system. This system will enhance opportunities for prospective learning by facilitating individual CPD plans tailored to individually identified needs and competencies (Royal Australasian College of Physicians, 2008). Continuing Professional Development in the United Kingdom While participation in CPD has long been a condition of employ- ment in the National Health Service (NHS), a string of unfortunate, and perhaps preventable, incidents spurred changes in the United Kingdom’s CPD system (Wall and Halligan, 2006). Most notably, a 2001 government inquiry into pediatric cardiac surgeries performed at Bristol Royal Infirmary focused attention on poor clinical team- work, a severe lack of performance data, and an absence of reflec- tive practice. The government and the public demanded competent health professionals; thus, the CME system in the United King- dom is composed of three interrelated yet separately monitored and administered parts, each of which requires CPD: (1) mandatory recertification, (2) annual appraisal (for doctors in England), and (3) mandatory revalidation. 2 In Australia, individual medical colleges, of which RACP is one, regulate CME requirements.

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243 APPENDIX C BOX C-1 An Integrated System for CE The College of Family Physicians of Canada (CFPC), which accredits activities in which family physicians participate, has an integrated system for CME, called Maintenance of Proficiency (known as Mainpro). Mainpro is based on the principle that physicians should plan and manage their own programs of self-directed, practice-based, lifelong learning (College of Family Physicians of Canada, 2003). Both the MOC program and Mainpro utilize online tools to aid physicians in tracking their learning objectives and participation in learning events. Individual learning portfolios can be a useful tool for planning and recording learning and incorporating personal development plans. The portfolio can then form the basis for peer or exter- nal review, providing documentation necessary for revalidation while also encouraging the individual professional to identify his own learning goals (du Boulay, 2000). The General Medical Council (GMC) has defined the competen- cies needed by all doctors, while professional organizations, including for example the Royal College of General Practitioners, have defined the extra competencies needed for their specialties (Quam and Smith, 2005). Like most of the CE systems discussed in this report, the royal college systems depend on the accrual of hours related to credits. To be recertified, a doctor must meet the CPD standards set by his royal college before being said to be “in good standing.” In 2001, the NHS made annual appraisal compulsory for all doc- tors in England. This process requires the formation of a personal development plan with identified learning needs relevant to the competencies developed by their respective specialist associations. An appraisal process evaluates how the doctor has worked toward meeting those learning needs (Quam and Smith, 2005). This system hinges on the training and competence of its appraisers, all of whom are employed and trained by the NHS. In 2004, the NHS introduced standards for moving the health care system toward patient-centered care, preventive medicine, and local decision making. Of 37 standards, 3 specifically relate to updat- ing skills and training and participating in peer review and appraisal (UK Department of Health, 2004). The Commission of Healthcare Audit and Inspection has responsibility for the implementation of these standards at an organizational level. In 2008, the Department of Health gave the royal colleges a key role by making the Acad- emy of the Royal Medical Colleges a clearinghouse for funding of

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244 REDESIGNING CE IN THE HEALTH PROFESSIONS CE development (see Box C-2 for the role of industry funding). For example, “e-Learning for Healthcare” provides cash to individual royal colleges for the development of online learning programs. In sum, the royal colleges develop content, set standards, provide examinations, and accredit the content of events and online courses provided by commercial competitors (Hawkes, 2008). Disparate Continuing Education Systems in Select European Countries European countries face a mosaic of CE and CPD stakeholders and incentives for and mechanisms of revalidation (Table C-2). In Belgium, participation in CME yields higher salaries; in the Neth - erlands, CME is mandatory and failing to participate can result in a physician’s removal from the medical registry; and in Italy, mandatory interprofessional training with other professionals such as nurses and medical technicians is the norm (Braido et al., 2005). Professional medical bodies tend to regulate CME in most Western European countries, sometimes within legal frameworks established by national governments; in other countries, however, insurers may require physicians with whom they contract to fulfill specific CME requirements (Merkur et al., 2008a). A patchwork system of fund- ing, including physician self-payment, professional associations or governments subsidizing costs, and pharmaceutical companies con- tributing to CME, further entangles the CME process. The European Union, predicated on principles of free move- ment across borders, has a vested stake in ensuring the mobility of health care professionals. This requires mutual recognition of profes- sional qualifications, but this principle is difficult to uphold because the legal framework in certain countries does not require training beyond initial education whereas other countries make this manda - tory. Until 2005, France, for example, did not require any training beyond receipt of a medical diploma. Despite efforts to encourage CE through the use of incentives, physicians did not embrace it; thus, the French government passed a law making CME mandatory. A parallel law made the evaluation of professional practice manda - tory for all doctors. While control of these processes was placed under the responsibility of an independent organization, compliance with the requirements is yet unknown (Segouin et al., 2007). The European Commission [sic] recognized in 2006 the need for minimal standards for CPD for physicians and nurses (European Commission High Level Group on Health Services and Medical Care, 2006). Despite this acknowledgment, a directive was never placed on

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245 APPENDIX C BOX C-2 The Role of Industry Funding Despite the differences in CPD and CE, the UK, Canadian, and U.S. systems of CME face similar challenges, one of which is the role of industry- subsidized learning opportunities. A 2008 editorial in the Canadian Medical Association Journal called the pharmaceutical industry’s role in funding CME in Canada “unacceptable” (Hebert, 2008, p. 179). Although there are no reliable data on the percentage of accredited CME activities in Canada funded by pharmaceutical and medical device manufacturers, there are widely held beliefs that the situation is similar to that in the United States, where $1.21 billion (48 percent of all money spent on accredited CME) in 2007 came from commercial support (ACCME, 2008; Spurgeon, 2008). For example, while online CME is an important approach to CPD in Canada, much online CME is currently funded directly or indirectly by industry. As a result, in January 2008, the Canadian Medical Association convened a meeting of national specialty societies and related medical organizations to discuss issues related to online CME, particularly how the sources of funding might be identified. A study published in 2003 by a team of Scottish researchers found that the pharmaceutical industry funded approximately half of CME in the United Kingdom. Since that time, the Association of the British Pharmaceutical Industry has introduced a code of conduct, including a ban on gifts worth more than 6 pounds sterling and a guideline that companies do not pay for “key opinion leaders” to attend conferences abroad (Hawkes, 2008). Because pharmaceutical companies, in particular, generally target prescribers as their clients, conflicted funding sources are not nearly as prominent an issue in CE for nurses, dentists, and pharmacists as they are for physicians. the agenda to develop these standards. Harmonized systems of CME still need to be developed, potentially by the European Accreditation Council for Continuing Medical Education (Braido et al., 2005). COMPARATIVE EXAMPLES OF CONTINUING NURSING EDUCATION A systematic review of nursing education and regulation stresses the importance of Europe’s harmonizing nursing education sys- tems to minimize problems with nursing retention and recruitment (Robinson and Griffiths, 2007). The review of 18 countries including the United States acknowledges difficulties in obtaining accurate information on CE requirements for nurses and documents dispa- rate examples of nursing CE systems.

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246 REDESIGNING CE IN THE HEALTH PROFESSIONS The United Kingdom, which has acknowledged the need for a functioning system of CE for nurses since the mid-1990s (Nolan et al., 1995), has a system in which nurses must register with the Nursing and Midwifery Council. This registration requires triannual renewal dependent on evidence that CPD was performed. Simi- larly, advanced degree nurses in Japan (as categorized by their level of education) must apply for certificate renewal every 5 years, a process requiring participation in designated CPD events and the development of a practice report. Nurses with advanced degrees (postbaccalaurate) do not, however, need to renew their certifica- tions or engage in CE (Harayama, 1994). To further illustrate the vast differences that exist in nursing regulation, licensure, and CE, Swedish nurses must register with the National Board of Health and Welfare but are not regulated once licensed (Josefsson et al., 2008). In Denmark, to deal with specific local education needs, the Branch Boards of the Denmark Nursing Organi- sation offers study days and seminars on topical issues (Vejlgaard, 2003). Similarly, Italian universities, health care institutions, and CE agencies offer courses for speciality nurses, allowing them to choose among relevant training (Robinson and Griffiths, 2007). COMPARATIVE EXAMPLES OF CONTINUING DENTAL EDUCATION In order to build a culture of professional competency, the Asso- ciation for Dental Education in Europe (ADEE), an organization that promotes high standards of dental education to its membership of European dental schools, specialist societies, and national dental bodies, has emphasized that undergraduate education should “act as a springboard which engenders the concept of continuing pro- fessional development and life long learning” (Cowpe et al., 2008, p. 20). In its Profile and Competencies for the European Dentist (2008), the ADEE states that upon graduation, a dentist must seek CE on an annual basis and demonstrate this through the use of a logbook or e-folio. Additionally, graduating dentists must prove competency in using information technology for documentation of participation in CE. The Commonwealth Dental Association, a trade association comprised of 53 countries currently or formerly associated with the British crown, conducted a review of its dental workforce in 2007. Mandatory CE for dentists was limited to eight of the surveyed nations, including Canada, New Zealand, the United Kingdom, and the Victoria region of Australia (Table C-3). Of these, only New

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247 APPENDIX C TABLE C-3 Continuing Dental Education—An International Comparison Compulsory Requirements Australia No, except in one state Unknown (Victoria) Canada Yes Variable by province New Zealand Yes 160 hours over 4 years United Kingdom Yes 75 hours of formal courses and 250 hours of nonformal education over 5 years United States Yes (in 49 states) Variable by state SOURCE: Kravitz, 2007. Zealand and the United Kingdom have countrywide mandates for CE for dentists. The United Kingdom’s General Dental Council instituted its CE program in 2002, preceeding New Zealand’s countrywide CE program for dentists by 12 months. In addition to completing CE courses, all dentists contracted with the NHS must complete 15 hours of peer review every 3 years. A systematic survey of 2,082 dentists in three regions of England examined the effectiveness of the NHS mandate for CE for dentists based on the frequency and types of CE activities in which a dentist participated (Bullock et al., 2003). The review concluded that dentists have little personal incentive to engage in activities other than CE courses and discus - sion with colleagues because the mandate permits dentists to choose the methods of CE activities in which they engage and does not, for example, require peer review. Mandated professional development plans are one means of reflection and thus may be an appropriate vehicles of CE for dentists. COMPARATIVE EXAMPLES OF CONTINUING PHARMACEUTICAL EDUCATION A report prepared for the International Pharmaceutical Founda- tion (FIP) acknowledges a breadth of new knowledge relevant to the field of pharmacy and the important role CE plays in maintaining and updating pharmaceutical skills and knowledge (International Pharmaceutical Federation, 2006). The FIP initially stressed the link between the development of pharmacy skills and quality improve- ment when, in 2001, it established the International Forum for Qual - ity Assurance of Pharmacy Education to develop a set of principles

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248 REDESIGNING CE IN THE HEALTH PROFESSIONS for CE programs (Rouse, 2008). Furthermore, the FIP’s Statement of Professional Standards on Continuing Professional Deelopment includes a provision about a pharmacist’s individual responsibility to ensure his own competency through “systematic maintenance, develop- ment, and broadening of knowledge, skills, and attitudes” (Inter- national Pharmaceutical Federation, 2002). The FIP differentiates CPD from CE by stressing that CPD requires pharmacists to take personal responsibility for planning for their own development, meeting these needs, and subsequently evaluating their success in doing so. The Pharmacy Workforce Survey, administered in 2005, surveyed 37 countries representing each of the six World Health Organization regions: 9 of the 37 countries had mandatory CE for individual pharmacists (International Pharmaceutical Federation, 2006). Infor- mation on the regulatory boards and the CE systems is presented in Table C-4. CE courses for pharmacists, provided by professional associations, pharmacy boards, universities, teaching hospitals, and pharmaceutical companies, vary widely in their scope and breadth of content, and only a few countries (e.g. France, Iraq, Japan, Kenya, Singapore, Zambia) have mandatory accreditation of providers of CE for pharmacists. APPLICABLE LESSONS FOR THE UNITED STATES CE, which serves a variety of purposes, may improve quality of care and patient safety while minimizing risks and containing costs. The notion that the acquisition of a qualification is an adequate measure of lifelong competence (Merkur et al., 2008b) has been challenged in recent decades. As a result, many countries are in the process of reforming their CE systems (Braido et al., 2005). Overall, this literature review suggests that the definitions and mechanisms of ensuring competence vary significantly across countries. While divergence exists in monitoring and enforcement, similarities exist as well: most systems rely on professional self-regulation (Peck et al., 2000); a principal barrier for improving and implementing CE systems at the organizational level is lack of financial resources (Merkur et al., 2008a); and the most demanding systems incorporate peer review or practice audit. Although no CE system is obviously superior, considerable scope exists to learn from experiences in other countries. Increasingly, professional associations and regulatory bodies encourage health professionals to learn together with other profes- sional groups. As an example, health professionals in Italy engage

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TABLE C-4 Continuing Pharmaceutical Education—An International Comparison Incentives + – Compulsory Regulating Authority Requirements Canada Yes (in most Potential Provincial pharmacy Variable by province provinces) for refusal boards to renew license France Yes Certificate for Ordre National des Currently being considered completion Pharmaciens and the Social Affairs Ministry Germany No (ethical Certificate for N/A 150 45-minute credits over 3 obligation stated in completion years law) United Kingdom Yes Potential Pharmacy profession CPD not measured (guidelines for removal (subnational advise one CPD entry per from pharmaceutical month) pharmacy associations) register United States Yes Potential State boards of Most common (varies by state) for license pharmacy is 30 hours over 2 years revocation 249 NOTE: N/A = not applicable. SOURCE: International Pharmaceutical Federation, 2006.

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250 REDESIGNING CE IN THE HEALTH PROFESSIONS in interprofessional CE in a system that aims to ensure the impact of education on practice quality (Braido et al., 2005). The Learn- ing Opportunities for Teams (LOTUS) program, facilitated by the European Commission, furthered the advancement of Italy’s team- based CE by linking 214 primary care professionals at four sites across Europe. This pilot program, which began in 1997 and has now ended, highlighted the relevance of multidisciplinary facili- tation and technology for organizational and individual growth (Mathers et al., 2007). Furthermore, Canada’s well-established sys - tem of interprofessional education serves as a model for the further development of interprofessional education (Ho et al., 2008) and has recently been adopted by the Royal Dutch Medical Association (Wigersma et al., 2009). The 2005 examination of CE by the British Medical Journal acknowledges widespread acceptance that systems to ensure com - petence should be nonpunitive, with efforts focused on professional development (Kmietowicz, 2005). Professional organizations could take the lead in this by introducing a system rewarding physicians who participate in CE and CPD. The United States has the oppor- tunity to understand the current challenges in CE both nationally and internationally and to use the platform of CPD as a means to address deficiencies in the current CE system. International CE and CPD systems are vehicles from which the United States can learn, gleaning best practices and offering solutions and leadership. REFERENCES ACCME (Accreditation Council for Continuing Medical Education). 2008. ACCME an- nual report data 2007. http://www.accme.org/dir_docs/doc_upload/207fa8e2- bdbe-47f8-9b65-52477f9faade_uploaddocument.pdf (accessed January 16, 2009). Braido, F., T. Popov, I. J. Ansotegui, J. Gayraud, K. L. Nekam, J. L. Delgado, H. J. Mailing, S. Olson, M. Larche, A. Negri, and G. W. Canonica. 2005. Continuing medical education: An international reality. Allergy: European Journal of Allergy and Clinical Immunology 60(6):739-742. Bullock, A., V. Firmstone, A. Fielding, J. Frame, D. Thomas, and C. Belfield. 2003. Participation of UK dentists in continuing professional development. British Dental Journal 194(1):47-51. Campbell, C. 2008. Maintenance of certification: Back to the future. http://rcpsc.medical. org/news/documents/MOCCraig_e.pdf (accessed December 15, 2008). College of Family Physicians of Canada. 2003. Mainpro background information. http:// www.cfpc.ca/English/cfpc/cme/mainpro/ (accessed January 23, 2009). Cowpe, J., A. Plasschaert, W. Harzer, H. Vinkka-Puhakka, and A. D. Walmsley. 2008. Profile and competencies for the European dentist, update 2008. Dublin, Ireland: As- sociation for Dental Education in Europe.

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