Continuing medical education: a must for every medical oncologist
Authors: D. Schrijvers, J.B. Vermorken, C. Bokemeyer, H. Ludwig
Journal: Annals of Oncology (2003)

IntroductionMedical oncology is a rapidly changing subspeciality of internal medicine. Evidence-based medicine has led to continuous progress in knowledge, skills and attitudes of cancer care, and these improvements should be implemented in daily clinical practice. To ensure optimal treatment and care for cancer patients, medical oncologists must participate in continuing medical education (CME) programs. The main objectives of CME are to improve the quality of patient care, set standards of clinical competence for practice and encourage the continuing scholarship required for professional excellence over a lifetime of service.To guarantee the maintenance of levels of knowledge and skills, as well as the improvement in attitudes to cancer care, the European Society of Medical Oncology (ESMO) has taken several educational initiatives.ESMO examinationSince 1989, the ESMO Examination in Medical Oncology has given access to the ESMO Certificate in Medical Oncology. The main objective of this certificate was to create a basis for recognition of medical oncology as an officially defined medical speciality in the majority of European countries where this recognition was lacking. Other objectives were to generate incentives that would help improve the quality of training and education in medical oncology offered to medical students and doctors in European medical schools and hospitals, to create a basis for the standardization of medical oncology at a high level of excellence and to monitor the expected improvement in the quality of medical oncology [1.Alberto P. Mermillod B. Cocconi P.G. et al.Results of the first ESMO examination in medical oncology.London 1989. Ann Oncol. 1991; 2: 9-12Google Scholar].The examination is a written, multiple-choice paper and takes place annually during the ESMO congresses or European Conference of Clinical Oncology (ECCO) conferences. From 1989 to 2002, 1152 medical oncologists have taken the examination. The annual attendance has varied from 20 to 186, with a steady increase in participants from 1995; attendance has been higher at ESMO congresses than that at ECCO conferences (Figure 1). The main factor in the rising attendance was that for all German and Swiss medical oncologists the ESMO examination had become compulsory. The examinations level of difficulty has progressively increased over time, until the failure rate reached ∼20%, at which it has since stabilized. Encouragingly, the failure rate in recent years has decreased to ∼10%, while the level of difficulty was not felt to have decreased (Figure 2).Figure 2Failure rate in the European Society of Medical Oncology examination between 1989 and 2002.View Large Image Figure ViewerDownload (PPT)Certification is only available for full ESMO members, provided they have completed 6 years of training in internal medicine and medical oncology. Full ESMO members can take the examination more than once: either to become a certified member or for re-certification, if they previously failed, or simply to check their proficiency.ESMO medical oncology re-certification approval (MORA)ESMO certification expires 5 years after the examination was taken, and therefore to remain certified a re-certification is necessary. Re-certification may be achieved by passing another ESMO examination or by CME [2.Wagener D.J. Vermorken J.B. Hansen H.H. Hossfeld D.K. The ESMO programme of certification and training for medical oncology.Ann Oncol. 1998; 90: 585-587Abstract Full Text PDF Scopus (9) Google Scholar].ESMO-MORA was instigated in 1994 as a program of CME for medical oncologists. It consists of 250 h of CME over a 5-year period. Application forms are automatically mailed to medical oncologists who have passed an ESMO examination within the last 5 years so that they can continue to apply for credit points. Medical oncologists can apply for a certificate as soon as they have completed the required hours of CME. However, the CME reported must have been completed no more than 1 year prior to the date entered on the ESMO-MORA application form. Since 2000, only 37 ESMO members have applied for ESMO-MORA re-certification.ESMO educational toolsESMO Congress and ESMO Summer Education CongressSince 1980, ESMO has organized a biannual congress. This congress is aimed mainly at medical oncologists but is also attended by other specialists. ESMO congresses have both educational and scientific programs.The educational program was developed by the Educational Committee to give up-to-date and evidence-based information in the fields of basic science, epidemiology, tumor biology and treatment, psychosocial oncology, and palliative and supportive care. The scientific program provides a forum for researchers in the fields of basic and clinical science to present the results of their research to their peers. Since 1994, the congress has been organized by the ESMO Office in Lugano. The number of participants, both ESMO members and non-members, is shown in Table 1.Table 1Year, place and number of participants of the biannual European Society of Medical Oncology (ESMO) congressYearPlaceNo. of participantsNon-membersESMO membersTotal1994Lisbon373758743241996Vienna482677756031998Athens452687053962000Hamburg4471103755082002Nice533712116548 Open table in a new tab In 2003, the ESMO Summer Educational Congress (ESEC) was organized for the first time. This high-profile program was designed to provide an interactive and comprehensive educational program, with special focus on certain tumor types, psycho-oncology, communication, palliative and supportive care, and quality-of-life aspects. It was an intensive 4-day meeting that featured key-note lectures and ‘take home’ messages, case study discussions and direct interaction with patients.ESMO coursesESMO organizes courses to improve standards in medical oncology and this has been done by giving teaching sessions on specifictopics, e.g. basic medical oncology, advanced courses in medical oncology, good clinical practice and palliative care.From 1994 to 2002, 27 courses (one to five courses per year) were organized. Topics and number of participants are given in Table 2. Ten courses were organized together with the European Oncology Nursing Society (EONS) and three with the European School of Oncology (ESO). Thirteen courses were given in Eastern European countries.Table 2European Society of Medical Oncology coursesYearCountryTopicNo. of participants1994SwitzerlandMolecular biology–1996SwitzerlandMalignant lymphoma and leukemiaaIn collaboration with European School of Oncology.–1997SwitzerlandClinical pharmacology–1997DenmarkGood clinical practice–1997SwitzerlandMolecular genetics in solid tumorsaIn collaboration with European School of Oncology.–1998RomaniaCytostatic agents: delivery and toxicitybIn collaboration with European Oncology Nursing Society.–1998EstoniaPalliative cancer carebIn collaboration with European Oncology Nursing Society.–1998RussiaGood clinical practicebIn collaboration with European Oncology Nursing Society.–1999SloveniaCytostatic agents: delivery and toxicitybIn collaboration with European Oncology Nursing Society.–1999SwitzerlandMalignant lymphoma and leukemiaaIn collaboration with European School of Oncology.–1999PolandGood clinical practicebIn collaboration with European Oncology Nursing Society.–1999HungaryReading, writing and randomized trials–2000PolandCentral Eastern European Educational SymposiumbIn collaboration with European Oncology Nursing Society.–2000TurkeyBasic course in Medical Oncology–2000HungaryPalliative cancer carebIn collaboration with European Oncology Nursing Society.642000ArgentinaGood clinical practice402000DenmarkBasic course in medical oncology422001CyprusPalliative cancer carebIn collaboration with European Oncology Nursing Society.342001RomaniaReading, writing and randomized trials402001HungaryEducational symposiumbIn collaboration with European Oncology Nursing Society.1042001SwitzerlandClinical pharmacologyCanceled2001LatviaBasic course in medical oncology582002RussiaBasic course in medical oncology492002SwitzerlandMalignant lymphoma812002SloveniaGood clinical practicebIn collaboration with European Oncology Nursing Society.402002BelgiumPalliative careCanceled2002ItalyCancer geneticsCanceleda In collaboration with European School of Oncology.b In collaboration with European Oncology Nursing Society. Open table in a new tab ESMO faculty listFor all its educational activities, the Educational Committee has put together a faculty list for all the different topics. For each topic, four to 12 persons have been selected on the basis of their expertise and upon the recommendation of National Representatives and/or the Educational Committee members. These faculty members have agreed to help ESMO with its educational duties. They are willing to participate in ESMO courses and other educational initiatives. Moreover, help and support can be requested forup to four faculty members in national courses, which are being organized in conjunction with ESMO.Annals of Oncology and educational booksAnnals of Oncology is the official journal of ESMO. It is a multidisciplinary journal that publishes articles addressing medical oncology, surgery, radiotherapy, pediatric oncology, basic research and the comprehensive management of patients with malignant diseases. Since the 1992 ESMO meeting in Lyon, educational books have been published at each ESMO meeting and, from 2000, these books have been edited as a supplement to the journal. The supplement contains an evidence-based review of topics included in the educational program.ESMO Minimum Clinical RecommendationsThe use of clinical practice guidelines to make informed medical decisions in oncology is important for the quality of care of cancer patients. Therefore, ESMO developed minimum clinical recommendations as guidelines for medical oncology in Europe. These guidelines should assist medical oncologists in their daily clinical decisions and promote medical oncology in countries where there is no official recognition.ESMO newsletterThe ESMO newsletter provides information about the organization and functioning of ESMO. It also gives information about CME for its members.ESMO technology transfer grantThe ESMO technology transfer grants are available to medical oncologists in training who wish to learn a specific technique that is relevant to medical oncology within a European laboratory/clinic.The grant is also available to non-medical staff (e.g. pharmacists, nurses, laboratory technicians) who are involved in the clinical/laboratory program of a full ESMO member. The applicant may apply for up to 3 months of financial support.ESMO fellowshipThe ESMO Fellowship and Award Committee fosters a fellowship program. This program provides scholarship to young medical oncologists for 1 or 2 years of preclinical and/or clinical training to take place in a European laboratory and/or clinical facility with excellence in that field.ESMO websiteThe website provides information about ESMO and the different educational programs that are being developed within the organization, as well as guidance on where ESMO-MORA credits can be obtained. Furthermore, it gives access to several educational tools, such as lectures, books and abstracts from the ESMO congresses, minimum clinical recommendations, and access to the journal Annals of Oncology and the ESMO newsletter. There are links to the journal Cancer News, the American Society of Clinical Oncology (ASCO), Physician Data Query–National Cancer Institute (PDQ–NCI) and the PubMed site.Difficulties and challengesDespite the importance of CME to medical oncology, the different educational initiatives have encountered several difficulties and challenges.ESMO examinationAttendance at the ESMO examination has increased in recent years, but the majority of participants are limited to only two European countries: Germany and Switzerland. The participation of members from other European countries is either scarce or non-existent. Actions to increase participation may be to oblige those specialists in internal medicine who want to become members of the National Society of Medical Oncology to pass the ESMO examination.Moreover, the failure rate of participants from Eastern Europe is 30–35%, whereas in Western European (10–15%) and non-European countries (10–15%) it is lower. This may be due to the lower educational standards required of medical oncologists in these countries. This problem will be addressed by the ESMO5 × 5 × 5 program—a program that will provide organ-specific teaching courses over 5 years in five Eastern European regions.ESMO-MORAThe ESMO-MORA re-certification system has not been successful. Many medical oncologists who need re-certification do this by repeating the ESMO examination instead of gaining ESMO-MORA points.There are several possible reasons for this lack of interest in ESMO-MORA. First, it may be too difficult to collect ESMO-MORA points, since only a limited number of educational activities are accredited them. Secondly, the procedure to reapply may be too cumbersome. The need for adequate accounting and the collection of certificates of ESMO-MORA points may be difficult. A problem that may be overcome if the procedure was web-based and easier to complete. Thirdly, the ESMO-MORA point system is not a recognized method of accreditation. Since accreditation by CME is mandatory in some countries (Italy, Croatia, Czech Republic, Hungary and Slovenia), and is mainly a national issue, some medical oncologists are not interested in ESMO-MORA.To ensure European accreditation, the European Union of Medical Specialists (UEMS) initiated the European Accreditation Council for Continuing Medical Education (EACCME). EACCME can award European accreditation to CME activities if there is a favorable quality assessment by a professional body other than the organizer and if the national body responsible for accreditation gives its approval to the event.The Federation of European Cancer Societies (FECS) organized the Accreditation Council of Oncology in Europe (ACOE) that can evaluate ESMO-initiated courses, congresses and conferences. In receiving European accreditation, the ESMO-MORA system may gain in importance for medical oncologists in need of accreditation by CME.ESMO coursesESMO courses have been less successful than expected. This has been particularly true in recent years, where some courses have been canceled due to lack of interest (see Table 2).Several different reasons have been postulated for these cancellations. First, the topics may not be of interest to medical oncologists. However, the topics that were chosen have important clinical implications in daily practice, and therefore this reason may only be of minor importance. Secondly, many other bodies (e.g. organ-based specialities, pharmaceutical companies) are initiating their own courses and activities, leading to a plethora of educational opportunities. Thirdly, medical oncologists have the opportunity to participate in educational activities outside their region. In the past, many Eastern European oncologists were limited in their opportunities to travel due to political and financial restraints. This has recently changed, leading to the more global participation of medical oncologists from Eastern European countries.Therefore, ESMO has decided to change its strategy. Courses will not be organized by the ESMO office. Instead ESMO will help local organizers by financing the travel costs and honorarium of up to four faculty members, provide a limited number of travel grants for participants and promote these courses through ESMO publications. The local organizer is responsible for the practical organization of the course and course evaluation.The recent course on palliative care in Mumbai, India, was organized according to these new guidelines. It proved feasible and was a success for the participants, the local organizer, the ESMO faculty and ESMO.Future strategySince the number of medical oncologists is small relative to the total number of cancer patients, and as the latter will inevitably increase over time, there is likely to be more work to do with less resources [3.Working Group of the Royal College of Physicians. Joint Speciality Committee for Medical Oncology in collaboration of Cancer Physicians of the UK. The Cancer Patient's Physician 2001. [on-line] http://www.rcplondon.ac.uk/pubs/books/cpp/index.htm (26 February 2001, date last acessed).Google Scholar]. The availability of the worldwide web makes it an attractive tool for use in educational activities for people with limited time and less opportunity to travel. Therefore, the need to develop different web-based learning tools will become increasingly important.ESMO has already made available the educational program of the last two ESMO congresses on its website. People who were not able to attend the meeting can listen to the lectures by different experts. However, this relatively passive method of learning is not the most interesting as it lacks interactivity.Interactive case reports produced with the cooperation of the ESMO Educational Committee will be tested within the framework of the FECS. These cases are more interactive, a concept that has been discussed over the last 2 years within the Education Committee of ESMO. The initiative of FECS has given further impetus to the exploration of such possibilities within ESMO itself.The Clinical Discussion Forum is a method of learning by contact with peers or experts. Individual medical oncologists can put questions to experts and peers about specific problems and cases. These cases and discussions will become available to other medical oncologists via the website.Furthermore, the development of a global curriculum for medical oncologists will set a minimal educational standard to be acquired by specialists in internal medicine in order to be entitled ‘medical oncologist’. ESMO and ASCO are working together to develop such a curriculum.CME is a must for all medical oncologists. The accreditation of new methods of CME remains a challenge that needs to be tackled.D. Schrijvers*, J. B. Vermorken, C. Bokemeyer & H. LudwigEuropean Society of Medical Oncology(*E-mail: [email protected]) IntroductionMedical oncology is a rapidly changing subspeciality of internal medicine. Evidence-based medicine has led to continuous progress in knowledge, skills and attitudes of cancer care, and these improvements should be implemented in daily clinical practice. To ensure optimal treatment and care for cancer patients, medical oncologists must participate in continuing medical education (CME) programs. The main objectives of CME are to improve the quality of patient care, set standards of clinical competence for practice and encourage the continuing scholarship required for professional excellence over a lifetime of service.To guarantee the maintenance of levels of knowledge and skills, as well as the improvement in attitudes to cancer care, the European Society of Medical Oncology (ESMO) has taken several educational initiatives.