Continuing Medical Education of Scientific Societies in Spain: Analysis of current situation and proposals for the future

Medicine is a highly changing scientific-technical discipline, with an exponential growth of knowledge, so that relevant clinical guidelines need to be updated in a short space of time.¹ The ultimate goal of biomedical research is to make health care more effective in order to achieve the best outcomes for patients and populations. The only way to maintain up-to-date knowledge, competence and professional skills throughout one's working life is through accredited quality Continuing Medical Education (CME) that is patient- and health system-oriented.^2,3

Individual CME is an ethical obligation and a right recognised in various legal and professional regulations, both national and international.^4,5 The Charter of the Medical Profession includes the commitment of physicians to professional competence, lifelong learning and individual responsibility for maintaining the medical knowledge and clinical and team skills necessary to provide quality care. In addition, the profession as a whole must strive to ensure that all its members are competent and have the appropriate mechanisms in place to achieve this goal.⁶

The Ley de Ordenación de las Profesiones Sanitarias (Law on the Regulation of the Health Professions) defines CME as “the process of active and permanent teaching and learning to which health professionals have the right and obligation, at the end of their undergraduate or specialisation studies, and which is aimed at updating and improving the knowledge, skills and attitudes of health professionals in the face of scientific and technological advances and the demands and needs of both society and the health system itself”.⁷ The General Law on Health requires the authorities to promote the adaptation of professional knowledge to the needs of Spanish society and its permanent updating.

The quality of a health system depends on the degree of qualification and updating of its professionals, and therefore, CME is a matter of strategic interest for a country.^8,9 New models of CME seek not only to impart knowledge, but also to influence the behaviour of clinicians and to facilitate change in healthcare organisations by redesigning systems to improve quality and care outcomes.^10,11

Scientific-medical societies (SMSs) play an essential role in postgraduate medical education, both in the training period of the specialty, and throughout the professional life of the specialist. An essential objective is to generate and disseminate up-to-date knowledge, as well as to promote clinical practice guidelines and consensus documents in their field of expertise, based on scientific evidence.

The COVID-19 pandemic has forced radical health, social, economic, and political changes, which have had a major impact on medical education and all CME's activities. For this reason, many SMSs have had to reorganise their services by reducing the number of face-to-face activities and increasing the number of virtual conferences and congresses.^12–14 In Spain, a radical modification of the current status has been proposed, with the inclusion of "the prohibition of the financing of CME activities, directly or indirectly, by the industry" in the plan for Social and Economic Reconstruction of the Parliament.¹⁵ At a time of radical changes and high uncertainty, it is essential to analyse the situation and put forward a strategic proposal to ensure a quality CME, in line with the current and future needs of our healthcare system, similar to that offered by the countries around us.

The objectives of our research were to evaluate the CME activity carried out by the SMSs belonging to the Federation of Spanish Scientific Medical Associations (FACME), to detail the types of training offered, to describe the investment required and the cost structure for financing these activities, to analyse the quality assessment model, to find out the situation of professional recertification and to offer FACME’s strategic positioning with some proposals on CME for the immediate future.

Materials and method

FACME is an umbrella organisation of 46 national SMSs, representing the medical specialties recognised in our country, which acts as a coordinating body between them and carries out shared activities. For this study, a letter was sent to all of them requesting their collaboration, with an explanation of the objectives of the study, and to collect information about the activities carried out.

To classify the activities carried out, we used the CME Provider Guide of the National Commission for Continuing Education of Health Professions: congress, course, internship, conference, round table, seminar, clinical sessions, symposiums, workshop and working group, and also included others such as master's degree or webinar.¹⁶

In addition to the members of the FACME Board, the panel of experts was made up of one member of each Scientific Society, usually the training manager, or a board member or chairperson of the participating SMSs. The survey, conducted between 01 September 2020 and 28 February 2021, contained questions on the following topics:

• 1

  If CME needs analysis in your Scientific Society, how is the identification of training needs carried out?

• 2

  Organisation of CME activities within the SMSs, who is/are responsible for the planning of CME activities within your organisation?

• 3

  Funding of CME activities in your Scientific Society. To what extent could you estimate the approximate annual budget expenditure for 2018 and 2019?

  • a

    For the development of CME activities.

  • b

    Can industry (pharmaceutical, biotechnology, technology, etc.) contribute to the funding of these training activities?

• 4

  CME governance model. Who do you think ought to be the entities that:

  • a

    Should define the financing system for CME activities?

  • b

    Should define the CME activity programmes?

• 5

  Recertification model

  • a

    How do you think the recertification model should be in Spain and what role should SMSs have?

  • b

    Who do you think should be the entity(ies) that define the competence-based recertification system for health professionals?

  • c

    Has the Society initiated the development of the recertification model through a competence assessment? What is its state of development?

• 6

  To what extent are the education and training activities of your Scientific Society recognised under the European Credit Transfer and Accumulation System (ECTS), Continuing Education Credits (CFC) or another accreditation system? (%).

• 7

  What should be the role or contribution of FACME in the definition of the CME model in Spain?

• 8

  Indicate any examples of good practice or recommendations from your Scientific Society that are applicable to the rest of the SMSs.

• 9

  Further comments.

A SWOT analysis was also carried out where the experts were asked to identify Weaknesses, Threats, Strengths and Opportunities of their SMSs in relation to the CME within the current framework. Finally, the participants were asked to establish some strategic recommendations for the positioning of FACME regarding CME in our country. Confidentiality commitments were established regarding the information provided and the study was financed entirely with FACME's own resources.

Results

FACME represents 46 SMSs with 119,793 medical specialist members. Of the total, 37 societies (80.4%) participated in the survey, corresponding to 107,590 members (89.8%). These SMSs were: Spanish Academy of Dermatology and Venereology, Spanish Association of Medical Biopathology-Laboratory Medicine, Spanish Association of Surgeons, Spanish Association of Paediatrics, Spanish Association of Urology (AEU), and the Spanish Societies of Angiology and Vascular Surgery, Allergology and Clinical Immunology, Pathological Anatomy, Cardiology, Paediatric Surgery, Oral and Maxillofacial Surgery, Orthopaedic Surgery and Traumatology, Thoracic Surgery, Anaesthesiology, Resuscitation and Pain Therapy, Endocrinology and Nutrition, Clinical Pharmacology, Geriatrics and Gerontology, Haematology and Haemotherapy, Immunology, Geriatric Medicine, Primary Care Physicians, Family and Community Medicine, General and Family Physicians, Internal Medicine, Critical Intensive Care Medicine and Coronary Units, Nuclear Medicine and Molecular Imaging, Nephrology, Neurology, Medical Oncology, Radiation Oncology, Otolaryngology and Head and Neck Surgery, Pneumology and Thoracic Surgery, Digestive Pathology, Psychiatry, Laboratory Medicine, Medical Radiology, and Rehabilitation and Physical Medicine.

Data from 1607 activities carried out in two years were provided. Information from 2020 was excluded, given the atypical nature of the situation due to the pandemic. Of the registered activities, 93% correspond to CME, and 7% to exclusive training for residents. 14% of the activities were carried out through collaboration with other SMSs or with partner institutions. The most common activities were the Courses and Conferences, although there was a great variety within them, and 72% of the total were face-to-face (Table 1). 60% were annual activities, while 8% were carried out several times a year. The areas of expertise were clinical practice (81%), teaching (11%), public health (2%), management (1%), research (1%) and other (2%). Most of the activities lasted between 5 and 25 h, 4% between 50−100 hours and 6% over 100 h.

Table 1.

Types of continuing medical education activity.

Activity	2018		2019
	Nº of activities	%	Nº of activities	%
Course	360	49	346	45
Workgroup	15	2	14	2
Congress	59	8	67	9
Conference	83	11	85	11
Workshop	41	6	41	5
Other	174	24	221	29

Out of the total number of activities, 80% were accredited by an official certification system. In both years, 74% and 62%, respectively, were accredited with CECs from the National Health System and 15% had dual accreditation. The rest were accredited by the ECTS or Professional Spanish Credit for Continuing Professional Development CPD/CME (CEP-DPC, for its Spanish acronym) or others, with an average of 3.6 credits for all activities. 80% of the participating SMSs have the professional competence re-accreditation model under development or already completed.

The number of participants varied greatly depending on the CME activity, with the highest number at webinars (average 758) and national congresses, many of them between 650 and 800 participants, with an average of 733 (Table 2).

Table 2.

Number of participants in continuing medical education activities.

Activity	Average	Standard deviation
Congress	733	1030
Course	143	255
Internship	16	30
Forum	32	28
Workgroup	133	123
Conference	143	127
Training day	58	11
Master	107	83
Other	574	890
Meeting	238	60
Seminar	112	73
Symposium	261	431
Workshop	78	78
Webinar	758	613

The funding needs were variable according to the number of attendees, organisational, support and infrastructure requirements, and much higher for National Congresses (average euro288,312), Masters (average euro125,109), Meetings (average euro59,500) and Working Groups (average euro56,178) (Table 3). SMSs estimate that, approximately, 75% of the costs of CME activities developed by them are financed directly or indirectly by the pharmaceutical and/or health technology industry, 20% by membership fees and participant registration fees, and less than 5% with other funds such as donations or the contributions of public administrations.

Table 3.

Cost in euros (euro) of continuing education activities.

Activity	2018			2019
	Average	Maximum	Minimum	Average	Maximum	Minimum
Congress	288,312	1,372,973	4100	298,350	1,340,011	400
Course	25,073	414,598	48	21,468	348,686	45
Workgroup	56,178	140,000	813	48,523	140,000	5070
Conference	37,676	380,000	285	30,761	150,000	300
Master	125,109	273,969	3100	156,194	305,354	12,880
Meeting	59,500	74,000	45,000	84,710	154,839	28,000
Seminar	13,400	15,000	7000	8333	15,000	1000
Webinar	37,593	97,695	9297	32,741	106,824	1495
Other	15,709	30,794	500	26,185	150,000	500

In terms of qualitative analysis, the following were identified using FACME’s SWOT technique with regard to CME:

Weaknesses

• 1

  Lack of visibility and representativeness in decision-making bodies as a key independent actor for the definition of CME.

• 2

  Need for greater coordination and standardisation among SMSs to reach a consensus on common aspects of the CME model.

• 3

  Shortage of time and «burn out» of medical professionals to be able to combine the high burden of care with training and/or teaching.

• 4

  Insufficient economic resources for the development of CME, which leads to the search for funding from external agents, whether private or public.

• 5

  Excessive dependence on industry funding for the development of education and training activities.

• 6

  Lack of development and implementation by the Health Administration of recertification models with the collaboration of the SMSs on the basis of specific agreements.

• 7

  Excessive increase in e-learning activities to the detriment of the quality of training, overloading teaching and training.

Threats

• 1

  Lack of recognition by the Public Administration of the role of the SMSs as agents involved in the organization, development and planning of CME.

• 2

  A decrease in the development of training activities and their quality if the ban on industry funding of these activities is enforced and no feasible alternative solutions and funding channels are put forward to meet the needs.

• 3

  Risk of inequity in the distribution of funding for CME activities, if it depends solely on the public administration and does not take into account SMSs as stakeholders in the decision-making process.

• 4

  Salaries of medical professionals, below the European average, which make self-financing of activities difficult, and the absence of tax benefits for resources invested in training for those who only work in public health.

• 5

  Emergence of other external agents with profit-making interests to offer CME that do not guarantee the scientific rigour and experience in healthcare practice necessary for the development of these activities.

• 6

  Decrease in the quality of care and health outcomes, and increase in health costs, if the continuity of a quality CME model is not guaranteed.

Strengths

• 1

  History and experience in organisational development and structure of education and training activities.

• 2

  Stability and organisational independence for the planning and development of training activities.

• 3

  Analytical capacity to identify the training needs of medical professionals, through access to the most up-to-date scientific knowledge and the detection of good practices and areas for improvement, based on the experience of its members in clinical practice through professional experience.

• 4

  Organizational capacity to establish an adequate training plan adapted to the needs of the medical practice and the demands of its members.

• 5

  The ability of medical professionals to identify patients' needs through their healthcare practice, enabling the development of a patient-oriented CME, optimising the humanisation of healthcare and promoting better health outcomes.

• 6

  Boosting quality training by introducing and promoting numerous training activities recognised by the main national accreditation systems.

• 7

  Interest in the continuous improvement and evaluation of quality of care, through the development and implementation of recertification models for the reaccreditation of medical professionals' competencies.

• 8

  Collaboration and networking with reference medical professionals and SMSs, national and international, enabling synergies to be established in the search for the best scientific evidence and fostering cross-cutting and multidisciplinary collaboration.

Opportunities

• 1

  Promote the visibility and recognition of the role of SMSs through FACME, as an agent representing all of them and mediator with the rest of the agents involved in the development of CME.

• 2

  Encourage collaboration between all the stakeholders involved in order to promote transparency, clear rules and relationships of trust, which will make it possible to define and guarantee a quality, equitable and sustainable CME model.

• 3

  Willingness to involve all social agents, private or public, who have an interest in promoting and contributing to improving the health of society through their economic collaboration for the development of quality CME.

• 4

  Increased accessibility and flexibility of training thanks to the development of new technologies and platforms for virtual training, overcoming geographical barriers and allowing the combination of healthcare activity with training and teaching.

• 5

  Potential reduction of resources in financial and organisational terms for CME due to an improved virtual format for the activities.

• 6

  Incorporation of a new generation of medical professionals more familiar with the use of technologies and training in virtual and dynamic environments.

• 7

  Possibility of benefiting from national public funds and European funds that can be used for the development of CME.

• 8

  The need to consolidate a strong and flexible CME model that can respond to the continuous updating of scientific knowledge required by subspecialisation and scientific innovation.

Finally, a consensus was reached on strategic recommendations for CME in Spain (Table 4). Complete information on the study is available on the FACME website.¹⁷

Table 4.

Strategic recommendations of the Federation of Spanish Medical Scientific Associations (FACME) on Continuing Medical Education.

1. The SMSs are the entities responsible for the development of CME in the fields of knowledge specific to their specialty.

2. They must continue to be the main agent in the governance model of CME, establishing channels of collaboration and consensus with the rest of the stakeholders involved: Professional medical associations, universities, public administration and others.

3. SMSs ask for institutional recognition by the Administration as a public law entity for the fundamental role and work they play in the organisation and development of the WBF, as well as in other representative and advisory activities.

4. They believe that barriers to funding should not be put in place without providing viable alternatives, as this may have a direct impact on the quality of CME and thus on the quality of care and health outcomes.

5. They are committed to ensuring collaboration between the different stakeholders involved in CME, in accordance with a framework of ethics and transparency.

6. They recognise FACME as the intermediary agent to enhance the visibility of their role in CME and as a representative to reinforce their position in decision-making bodies, exercising leadership, coordination and standardisation of the model, and dialogue with the Public Administration and other bodies involved.

7. Following the changes brought about by COVID-19, they welcome the incorporation of information and communication technologies in CME, although they consider that this modality should be complementary to, and not a substitute for, face-to-face training.

SMSs: Scientific-Medical Societies; CME: Continuing Medical Education; FACME: Federation of Spanish Scientific-Medical Associations.

Discussion

The study shows a high response rate in terms of the number of societies included in FACME and the percentage of doctors associated with a recognised medical specialty in Spain, so that the information provided is very representative of the CME under their responsibility. One limitation of our analysis, as it falls outside our scope, is that it does not include the training activities of regional medical societies, of others with fields of knowledge without an official specialty, of those dedicated to specific entities or diseases, nor those organised by other institutions, whether public or private, so that the number of actual activities, the number of participants and the associated costs are clearly underestimated. This in no way invalidates the data or the conclusions of the study, but rather confirms the wide range of activities and the essential role of SMSs in CME in our country.

SMSs are responsible for the development of CME in the fields of their specialty and have the experience to continue to be key agents in its organisation and development in Spain. Among their characteristics, it is worth highlighting their organisational independence in planning and carrying out training activities, based on scientific criteria, for the benefit of the patient and the quality of care, advocating transparency and good practices; furthermore, the continuity of their activity ensures their stability over time. The wide variety of training activities in terms of subjects, format, dedication time and modality, guarantees the accessibility and adaptability of the CME to all medical specialists in our country. Moreover, the survey shows that 80% of the CME activities undertaken by SMSs have a recognised accreditation, which demonstrates their commitment to quality and evaluation.

A quality-assured CME and professional recertification are two commitments of the SMSs with society as a whole, based on professionalism and transparency, in order to guarantee the level of qualification among medical specialists. Spanish doctors are aware of the importance of up-to-date training as a prerequisite for continuing to provide quality healthcare, improve the health of the population and develop professionally, which is why they request and demand accredited training programmes. On the other hand, it is important to highlight the capacity for collaboration and interconnection of the Spanish SMSs with other European and international societies, with other professionals and with patients' associations, which allows joining forces to update scientific knowledge and promote cross-cutting and multidisciplinary lines of work.

The European Professional Qualifications Directive,¹⁸ which almost exclusively affects health professions, establishes that each state must ensure and conform to its own procedures, as well as encourage continuing professional development, so that they can update their knowledge, skills and competences for the safe and effective practice of their profession. Its application in Spain is pending regulatory development, yet the majority of SMSs, 80%, have advanced or completed their technical proposal of knowledge and skills for the re-accreditation of their corresponding specialty. With the economic data provided and estimating the annual expenditure per professional, with a total of 276,191 practising doctors in Spain,¹⁹ it can be inferred that the total budget for the organisation of the CME would be between 340 and 876 million euro, not including related indirect costs. A high proportion, around 75%, of CME funding in our country comes from the pharmaceutical or medical technology industry, which is similar in other European countries. The funding of CME in all countries is costly, and the participation of employers, both public and private, is a rarity.²⁰ The approach to CME set out in the Opinion of the Commission for Social and Economic Reconstruction of the Spanish Parliament, with the prohibition of direct or indirect funding of CME activities by the industry, may have a negative impact on the quality of CME and on the safeguard of professional qualifications. Therefore, if viable financing alternatives are not proposed in consensus with the SMSs, care quality and the achievement of health outcomes may be compromised. In this regard, it is important to bear in mind that the average salary of Spanish doctors is much lower than in many other European countries,²¹ even taking into account purchasing power parity levels,²² as they often fully or partially finance the costs of their CME activities.

The risk of a conflict of interest of CME funding by the medical industry has been pointed out, as it could induce a bias in the therapeutic decision or lead to lower medical prescription quality.²³ For this reason, it is strongly recommended that the relationship between industry and physicians, both in research and training, be subject to regulatory standards and transparency.²⁴ When external funding is received from for-profit organisations for scientific and training activities, the nature and extent of the sponsorship must be clearly and openly stated, and the organisers of the activity must guarantee the independence of the content and the freedom of the speakers.¹¹ In this regard, many SMSs and FACME itself have developed Codes of Good Practice based on the public performance principles of transparency, cooperation, honesty and integrity towards all stakeholders: members, patient associations, public administrations, the pharmaceutical and technology industry and the media.²⁵ In addition, other organisations have established standards for collaboration with the pharmaceutical industry such as the Consejo General de Colegios Oficiales de Médicos,²⁶ Farmaindustria²⁷ and the Federación Española de Empresas de Tecnología Sanitaria (FENIN).²⁸ In this complex relationship, radical or simplistic measures of dubious applicability must be avoided.²⁹ In conclusion, the responsibility for CME is shared by professionals, scientific societies, employers, especially the health administration, and the pharmaceutical or technology industry, always under a transparency perspective and with a specific regulation.³⁰ SMSs consider that FACME, as a representative body, should exercise a leadership role, promote coordination and standardisation among them and establish channels for dialogue and collaboration with public administrations and other bodies involved, with the aim of ensuring the continuity and independence of a quality CME in Spain.

FACME Board of Directors:

Pilar Garrido Lopez. Spanish Society of Medical Oncology. President.

Javier Garcia-Alegria. Spanish Society of Internal Medicine. Vice president.

Benjamin Abarca Buján. Spanish Society of General and Family Physicians. Secretary.

Andres Iniguez Romo. Spanish Society of Cardiology. Treasurer.

Vowels:

Cristina Avendaño Solá. Spanish Society of Clinical Pharmacology.

Paulino Cubero González. Spanish Society of Family and Community Medicine.

Juan Sergio Fernández Ruiz. Spanish Society of Primary Care Physicians.

Ángel Gayete Cara. Spanish Society of Medical Radiology.

José Ángel Hernández Rivas. Spanish Society of Haematology and Haemotherapy.

José María Jover Javalón. Spanish Association of Surgeons.

Cecilio Santander Vaquero. Spanish Society of Digestive Pathology

Funding

The project has been carried out with funds from the Federation of Spanish Scientific-Medical Associations (FACME).

Conflict of interests

The authors declare that they have no conflict of interest.

Acknowledgements

FACME would like to thank the Scientific Societies that participated in the survey for their enthusiasm and collaboration throughout the process.