Background

In recent years, general practice has experienced important changes and new developments in various European countries. This regards, for instance, the differentiation of competences of general practitioners (GPs), the cooperation within primary care and with different providers of secondary care, the delegation of tasks as well as the provision of patient information [1, 2]. Also, epidemiological developments such as population aging and the increase in the number of patients with chronic diseases and multimorbidity pose a challenge to general practice [3]. The latter, as well as the increasing demands of rapid changes in medical knowledge and the demands of authorities and patients for quality and safety of medical treatments, contribute to the current and future challenges of the GP’s daily work and are important drivers for continuing medical education (CME). Along with these developments, general practice has emancipated itself. Today, general practice is no longer understood as a conglomerate of different medical subjects, but as an independent speciality with a specific way of working. As GPs are concerned with health conditions in a low-prevalence setting, this includes, for instance, procedures that are different from specialised medicine [4].

As general practice has changed, so has CME of general practitioners: Today, based on the findings of research into learning styles, medical education is increasingly moving from the traditional teacher-centred approach towards a learner-centred approach. Whereas in the past the focus of academic and post-academic education was solely on the cognitive level of imparting knowledge, today the acquisition of competences, performance in real treatment situations and the development of a professional attitude are essential [5, 6]. This paradigm shift is increasingly reflected in the education, specialist training and CME of todays and future GPs. Nonetheless, the way CME for GPs has developed, varies considerably across countries and health systems.

In this narrative review we aim to identify the potential for future improvement of general practice specific CME by comparing CME development in an international perspective.

Methods

Study design and setting

General practice continuing medical education programs across different European countries are assessed, analysed, and compared. We thereby focus on the United Kingdom of Great Britain and Northern Ireland (the UK), Norway, the Netherlands, Belgium (Flanders), Germany, Switzerland, and France. The selection of countries considered in this international comparison aimed to analyse general practice continuing medical education in different health care systems in Europe and to show both different and similar developments. However, in order to derive insights from best practice examples, we have focused on countries that for the most part already have a more or less elaborated CME system. This resulted in a focus on north-western European countries.

Data selection

As a first step, for each country local experts in the field of primary care specific CME training for GPs we contacted (MD for the UK, HM for Norway, GJD for the Netherlands, ADS and BDV for Belgium, AA, SB and GE for Germany, TR for Switzerland and BD, FR, PB, and PTL for France). These experts were characterised by the fact that they had acquired specific knowledge about the respective country-specific GP training system over many years as academic general practitioners or as experts of corresponding specialist institutions. For each country, experts performed literature searches for regulations and formats for general practice continuing education. In addition to human medicine literature databases such as Pubmed, grey literature (writings of country-specific institutions and associations, congress reports, academic and non-academic writings, etc.) were critically assessed. Since structures, institutions, associations as well as the way information is published differ greatly from country to country, the experts involved took different approaches to obtaining information depending on the country-specific context. In some countries, for example, responsible representatives were also contacted personally.

Data analyses

Subsequently, to analyse CME programs we developed templates containing detailed items across seven dimensions of country-specific CME. Following the approach in qualitative studies, these dimensions were partly defined deductively in advance (top-down), partly derived inductively from the material studied (bottom-up) [7, 8]. These dimensions are: the role of primary care within the health system, legal regulations, published aims of CME, actual content of CME, operationalisation, funding and sponsorship, and evaluation. We also took developments over time into account. Also, in preparation of the country-specific reports we used qualitative semi-structured expert interviews with country experts to gain additional insight [9,10,11]. These were conducted with four of the country experts involved through video conferences. The interview guideline was based on the deductively established dimensions and was expanded during the process to include new dimensions [7, 8]. The interviews had a length of 120–230 minutes. Both the preparation of the country reports by experts and the conduct of the interviews were circular, with unresolved or emerging issues being clarified in an iterative process [12]. To analyse data a thematic approach was taken, and existing data was triangulated for each country. Based on this in-depth information on country-specific CME for GPs we synthesised the material and derived tables presenting information on a meta-level. The results reflect the outcome of the literature research and are based entirely on it. Personal assessments of the experts/authors are reflected in the discussion. Due to the design of the study, ethical approval was not required.

Results

In Tables 1, 2, 3, 4, 5, 6 and 7 we, first, present country-specific information for the above stated dimensions. Next, we compare dimensions across countries.

Table 1 CME for GPs in the UK
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Table 2 CME for GPs in the Netherlands
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Table 3 CME for GPs in Norway
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Table 4 CME for GPs in Belgium (Flanders)
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Table 5 CME for GPs in Germany
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Table 6 CME for GPs in Switzerland
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Table 7 CME for GPs in France
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The role of primary care within the health system

The UK, Norway and the Netherlands are characterised by a more or less pronounced gate-keeper system, in which patients always - except in an emergency - consult their general practitioner first when they have health problems. In these countries, patients are assigned to their GP or the corresponding practice via lists. GPs are expected to manage complex chronic conditions independently. Referrals to specialists, who work almost exclusively in hospitals, are exceptional and not the rule. GPs are usually supported in their practice by different kinds of health care professionals, such as nurses and pharmacists.

In Switzerland and France, patients are incentivised to enrol on a voluntary basis and to consult their GP first. A growing proportion of the population is opting for this type of insurance. The situation is similar in Belgium (Flanders). Although there is no compulsory registration with a GP, patients receive a higher reimbursement of their consultation costs if they are registered with a practice. Of the countries considered, Germany is the only country with a health system that grants patients largely “unhindered” access to specialists - despite regionally successful gate-keeper models. In most cases, patients with chronic illnesses are seen in parallel by their GP and by (several) specialists in private practice.

Legal regulations

The UK, the Netherlands and Norway have a recertification system. There, GPs must fulfil several requirements every 5 years to continue working as a GP. This includes participation in further training for GPs. The UK and the Netherlands have the stricter system of recertification. In case of failure to meet specified requirements, doctors are prohibited from continuing to practise medicine. In Norway, on the other hand, failure to fulfil requirements results in reduced remuneration. In Belgium, GPs have been able to obtain de facto recertification on a voluntary basis since 1994 – though officially the term “recertification” is not used. Linked to this is the provision of CME. A growing proportion of Belgian GPs use this system. In 2021, France introduced a recertification system with a long transition period. All recertification systems are seen as quality promotion instruments, in which continuing medical education is understood as an essential component.

Switzerland and Germany have a much less regulated system of GP training. In Switzerland, GP training has been mandatory by law since 2007 and is operationalised via the corresponding professional organisation. In Germany, the Model Continuing Education Regulation of the German Medical Association has regulated the formal criteria of CME since 2013.

Published aims of CME

In all countries considered, the objectives of general practice continuing medical education are broadly formulated. In the UK, GPs are expected to regularly review the latest scientific standards, to refresh and expand existing knowledge, to acquire new skills and to reflect on societal changes that affect their daily work. CME is largely understood as continuing professional development (CPD) centring on the learning process of the individual GP. The goals of CME are defined similarly in France. In addition, reference is made here to the concept of the reflective doctor, who reflects on her or his own actions to enter into a continuous learning process. In Germany, to maintaining and continuously develo** professional competence, special reference is made to ensuring high-quality patient care and safeguarding the quality of medical professional practice. Similarly, in Belgium, CME aims at the quality of care and the cost-effectiveness of the health care system. In the Netherlands, Norway and Switzerland, the objectives of general practice CME are not described at all or only implicitly.

Actual content of CME

In the countries considered, there are no comprehensive training curricula in the sense of longitudinal learning objectives aimed at different areas of competence, which would define the content of general practice CME. GPs in the UK, the Netherlands and Belgium have the greatest freedom in choosing topics for continuing education courses - although this freedom can also be viewed critically. While GPs in the UK independently determine the content of GP training in consultation with a GP peer (who in turn reports to a Responsible Officer) within the framework of a training portfolio, GPs in the Netherlands largely train in informal groups. They also determine the contents independently, but together. In Belgium, only a small part of the content of continuing education is determined (ethics and economics). The content specifications of general practice CME in Norway, Switzerland and Germany are rather vague. Nevertheless, there are differences. In Norway, at least one course (at least 15 hours) must deal with the topic of acute medicine. In Switzerland, a distinction is made in terms of content between subject-specific core continuing education and extended continuing education, which allows more leeway in terms of content. In each area, 25 credits (approx. 25 h) are to be earned annually. And in Germany, GPs are indirectly incentivised via the possible remuneration to attend CME courses with direct relevance for Disease Management Programs (DMP). In contrast to these different levels of content freedom of GP training, only France has a system in which, at least from 2021 onwards, the priority setting and learning objectives of general practice continuing education are to be defined and updated every 3 years. The role of the peer in continuing education is most pronounced in the UK and the Netherlands.

Operationalisation

The organisation of general practice continuing education is carried out by numerous bodies or institutions in the majority of the countries considered. This is particularly the case in Germany, the Netherlands, Belgium, the UK and Switzerland. In France, where the contents of the training are determined, there is also a large number of providers. Only in Norway most of the training is provided by the Norwegian Medical Association (Norske Legeforening) itself.

Apart from the UK, general practice CME is accredited in all the countries considered. In Switzerland, for example, CME points are awarded via the society of General Practitioners. In Norway, this is done by the Norwegian Medical Association or its subject-specific committees. In France, the “Agence Nationale du Développement Professionnel Continu” (ANDPC) is responsible, in Germany the federal state-specific “Landesärztekammern” and in Belgium the “Rijksinstituut voor Ziekte en Invaliditeitsverzekering”. In all countries included here, the individual or institutional accreditation of CME is rather formal and mainly based on various key data, such as topic, speaker and content.

Funding and sponsorship

While in the UK the sponsoring of general practice CME by the pharmaceutical industry is generally regarded uncritically or as unproblematic, this is fundamentally different in the other countries considered. In the Netherlands and France, the sponsoring of medical training is prohibited and strictly controlled. In Norway, sponsorship by the pharmaceutical industry fundamentally precludes CME accreditation. In Switzerland, where financial support from industry is possible, at least two companies must participate. In Switzerland, sponsors officially have no influence on the content and course of the event or on the selection of speakers. Furthermore, participants must bear a reasonable share of the costs despite sponsorship. In Belgium, pharmaceutical sponsorship is only possible within a very restrictive framework. In Germany, directly and indirectly pharmaceutical-sponsored training courses for GPs are increasingly viewed critically, but they are still frequently offered and attended.

Independent of these developments, structures exist in the UK, Norway, Belgium and France that compensate financial expenses for general practice continuing medical education. In the UK, GPs receive lump sums depending on the region, which compensate for the costs of self-organised training. In Norway, most of the costs for GP training, including travel costs, are financed by the Norwegian Medical Association’s training fund. In Belgium, accredited GPs receive an annual lump-sum allowance for training costs. And in France, in addition to the costs paid for training events, doctors also receive a compensation payment for the loss of earnings incurred during the period of training. This is financed, among other things, by a compulsory levy on pharmaceutical companies based in France. GPs in the Netherlands and, in the case of non-sponsored events, in Switzerland and Germany largely finance their own CME.

Evaluation

Except for the UK where unstructured feedback will usually suffice, CME courses for GPs are systematically evaluated in all the countries studied. In most cases, this is done by means of standardised questionnaires provided by the accrediting institutions or the organisers, which are filled out by the participants after the respective training event. In the vast majority of cases, the event is evaluated subjectively by the participants in terms of learning atmosphere, relevance and learning success. There is no objective assessment of learning and competence gains. In Switzerland and Norway, “success checks” at the end of training events are common. In Belgium, only the evaluation of e-learning is obligatory.

Discussion

Main findings

The comparison shows that none of the analysed countries has established a system of general practice specific CME that addresses all our predefined criteria - so there are no “magic bullets”. In all systems, the resources available for GP training are limited - be it in terms of time or economy. The way in which general practice continuing education takes place seems to be determined by medico-cultural traditions and the status of general practice in the prevailing health system.

Strengths and limitations

The results of this narrative review are limited by the focus on north-western European countries. Also, we are aware that a narrative review can have gaps. To address this drawback, we have taken as structured an approach as possible and collected information along a matrix with the help of country experts. The project benefited greatly from this cooperation.

Interpretation of findings

Regarding future developments, depending on the system, there are several fields of action that seem to be particularly worthy of discussion. Apart from France, there are no curriculum objectives for GPs in any of the countries studied. The development of a catalogue of learning objectives seems to make sense, which focuses on the maintenance and expansion of competences as well as the process of moving from CME to CPD.

Regarding the teaching formats used, the international comparison has shown that the classic formats - formal lectures - have a certain status in every system. Nevertheless, the importance of innovative teaching and learning formats, and here especially peer exchange, is increasing [6, 54]. In the shadow of the Corona pandemic, teaching formats have inevitably had to evolve and have experienced a push towards more digitalisation in all the countries considered. E-leaning and peer-led webinars have become more important. We know from implementation research that both peer exchange and feedback are important instruments for reflecting on one’s own professional activities and have measurable effects on performance [55]. Therefore, when evaluating GP training, the teaching format should also be considered more in the future and CME points should be awarded in a differentiated manner [56, 57].

Although already implemented in some countries, many countries hardly offer joint events for doctors in specialist training and practicing general practitioners. Yet this could be profitable for both groups. While the doctors in specialist training are still closer to their studies and approach topics relevant to general practice care with a critical curiosity, the GPs in private practice could contribute their professional expertise and ability for realistic reflection. At the same time, the networking of “young” and “old” colleagues could be promoted [56, 57].

In some countries we found a varied mix of GP training in terms of quantity and quality which does not lend itself to robust evaluation. In addition to innovative approaches, which in some cases meets curriculum requirements, there is still some content guided by different interests (e.g. from the pharmaceutical industry, or health policy prioritisations) that are, in the worst cases, inappropriate. A comprehensive learning platform which lists general practice CME courses and communicates their contents and learning objectives based on defined criteria, appears urgently advisable.

Regarding the sponsoring of CME events by the pharmaceutical industry, there is a corresponding awareness of the problem in all the countries considered [58]. However, most countries have developed and implemented different strategies to deal with possible influence. While pharma financed events in the Netherlands and Norway do not receive CME accreditation, in Germany, for example, the discussion about the influence of sponsorship on medical continuing education is somewhat stuck. Although efforts could be made to ensure that sponsorship is no longer allowed at all, at least for accredited CME events, obviously the current CME program in several countries only works because companies often finance or at least top up large parts of the speakers’ fees and room rents. To change this, separate funding is necessary.

Good teaching requires sufficient financial resources. Internationally, most of the countries examined here have implemented some ways to fund GP training. The discussion of which “pots” the necessary funds have to be taken from is outside the scope of this paper, although the international comparison suggests joint financing is valuable, by health insurance funds (and thus the insured), state institutions and the physicians themselves. From the insurers’ point of view, in turn, financial gains can be expected from greater rational use of diagnostics and therapy. Further, the recognition of GP training within working time also seems important. This is already being implemented in several countries.

The evaluation of CME for GPs has so far usually only been carried out on the basis of descriptive criteria, primarily aimed at subjective participant satisfaction. None of the countries compared used elaborate evaluation methodology. In future, scientifically based evaluations should focus on whether previously formulated learning objectives were achieved, competencies were imparted, further developed, or expanded and whether the performance of the participating physicians has improved further through participation in individual events or a longitudinal, curricular-based continuing education programme. To gain deeper insights, GPs could take a test after completing their CME training. The corresponding results could then form the basis for the further development of the system of continuing professional development. 

Implications

Future CME programs for GPs face a variety of challenges. They should develop curriculum objectives, promote innovative teaching and learning formats, use synergies with specialist GP training, create comprehensive learning platforms, establish clear rules for sponsorship, develop new financing models, and scientifically evaluate CME training. Especially in view of European cooperation (for instance in border areas) and EU-wide freedom of movement, cross-EU CME programs should be promoted in the future. Also, in view of the limited financial resources, it will be important in future to orient CME in such a way that questions about the efficiency and quality of primary medical care are given greater attention. The current pandemic will further strengthen this process. Moreover, the experience of the Corona pandemic shows us that cooperation between primary care providers and health authorities can be incredibly important. Forecasts of an increase in pandemics underpin the importance of appropriate training content in CME.

Conclusions

Although the analysed models can be considered as precursors in different dimensions, there is no model that fully meets the current requirements of GP specific CME. The country-specific approaches described therefore offer selective stimulus for future developments, but each leaves more or less room for further development.