The Turkish Medical Association (TMA) has worked for many years on the idea of developing strategies that would contribute to raising professional standards for all Turkish medical doctors. Continuing medical education (CME) is essential in a country with an unequal geographic distribution of wealth and health resources, in which most of the doctors work in cities located in Western Turkey. Although medical education programs in Turkey are innovative and internationally acknowledged [1], it is very clear that basic and clinical medical sciences will expand exponentially and the technology and practice of medicine will change greatly with time. Therefore the body of knowlede in all medical scientific fields will accumulate, so that it will be impossible for any medical doctor to be aware of all of the new technology and knowledge in his field [2].

Another outstanding problem is that the doctor himself cannot appreciate his/her needs sufficiently to maintain a base of current medical knowledge. Therefore all doctors should be encouraged to improve their medical knowledge and skills by means of Continuing Medical Education (CME).

The medical profession has a duty to produce the best possible medical care for citizens. Clinicians should be up-to-date and provide the best possible care. In order to uphold higher standards, doctors should continue to learn throughout their working lives. Therefore the value of doctors participating in CME activities and receiving credits for them is universally accepted and non-controversial [7]. Although relative weak effect of formal planned CME on physician performance has been demonstrated [8], the ultimate effect of formal CME activities on physician performance must be understood in type of the delivered CME method. New evidence suggests activities with active learning opportunity, learning delivered in a longitudinal or sequenced manner, and the provision of enabling methods. It is also stated, that didactic CME modality has little or no role to play [9]. Therefore, new efforts are being made to integrate active learning sessions into their scientific activities by providers to enhance effectiveness of CME. Time will show their effect on medical care.

Although there is a wide variation across systems for CME in different countries, there are some similar features, including that one hour educational activity is awarded with one credit, and the types of educational activities. These educational activities can be divided into external activities (courses, seminars, meetings etc.), internal activities (case conferences, practice based activities, journal clubs etc.) and enduring materials (journals, CD ROM, web based materials) [10]. A survey of 18 European countries (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, United Kingdom, Luxembourg, the Netherlands, Norway, Portugal, Spain, Sweden, and Switzerland) revealed that CME is voluntary in 12 countries, and obligatory in 17 countries; that the responsible organisation is mostly the medical profession (n = 13); that 9 countries use credit based CME activities, that in no countries examinations are performed; that only in one country CME is used for re-certification purposes. No European country has followed the re-certification model of the United States of America (USA) [11]. The Canadian CME system encourages physicians to manage their own CME by attending a competence programme. They are required to report on their CME activities in a five-year cycle. Fellows are required to earn 400 credits during this period. Credit is mostly based on one hour's activity. Specialists who successfully complete the programme are awarded a certificate by their society [10, 12]. CME in USA is related to re-certification. Re-certification may be required especially by medical societies, insurers, health maintenance organisations and hospitals. CME activities are divided into two categories: Category 1 (formal programmes, journal based or enduring materials, international conferences etc.) and Category 2 (small group discussions, journal clubs, teaching, writing etc.). Credits are based on activity hours, and CME activities are provided by colleges, associations, academies, faculties and societies of different medical specialities [10, 13]. Programmes in Australia and New Zealand are directed by medical colleges and faculties and the programmes are based on self-reporting by physicians. Most of the programmes are mandatory and are organised in continuous 3–5 year cycles. Credits are allocated for CME activities using an hours-related credit system [14]. In New Zealand participation in a recognised programme is mandatory in order to retain specialist registration. In Australia, current legislation does not require physicians to participate in CME activities [10].

Limitations to participate in CME activities are that neither private nor state-employed doctors are supported by their employers. If the doctor does not have any pharmacological industry support, he must pay for the CME activity. Because CME providers often choose luxurious hotels and expensive convention centres, doctors often can not finance these activities. The TMA strives to change this approach by means of its ethics committee and other related working parties. Same problems with ethical issues exist in the USA. Rosner states, that ethical relationship between doctors and the drug industry require guidelines to maintain the integrity of the medical profession [15]. Acceptance of subsidies for the cost of CME conferences could be considered ethically acceptable, if the gifts are of minimal value and the control of content and the selection of presenters and moderators rest solely with the CME-sponsoring institutions [15, 16]. Another problem is that, doctors working for the state have problems in obtaining study leave. They have to use their vacation time to attend these activities. The Turkish Ministry of Health has to be convinced to change its policy.

There are plans for making participation in CME activities obligatory, to make the CME credits useful. The Co-ordination Council of Medical Speciality Societies in Turkey is now forcing its member societies to prepare their boards. By making CME credits an obligatory part of the board examination, this will be the first step to use these credits in the certification and re-certification of the doctors in Turkey.

Recognition of disparity in doctors' skills and the need to maintain common core standards have been the main reason for re-certification by the American Board of Medical Specialities in USA. Although re-certification is a voluntary process, doctors have to get re-certified every seven to ten years, because the board certification has become essential to admit patients to hospitals and to receive top salaries as a specialist. Most of the boards use a written examination to assess knowledge, skills and performance. Half of the American Boards (n = 11) require 50 hours a year participating in CME activities for three years before re-certification [17]. Re-certification in the USA has a drawback. It is not cheap. Site visits, examinations using standardised patients, and case recall interviews have been found to be too expensive or impossible to implement with the huge number of doctors in the USA. Outside the USA most countries do not incorporate formal "snapshot" examinations into their re-certification procedures. The initial certification is based on in-training evaluation over many years [18]. The same approaches are now found in some Societies of Medical Specialities (General Surgery, Neurosurgery, Respiratory Medicine, Family Medicine) in Turkey.

The colleges in some countries offer mostly formal education programmes after postgraduate training in a medical speciality. Usually, 50 hours attendance in CME activities at recognised courses per year are required for re-certification. In Canada weighted credit systems have been established where traditional didactic sessions are rated 1 credit per hour and interactive workshops receive 2 credits per hour [12, 18]. In Australia, re-certification criteria are related more closely to physician's performance than attendance at traditional CME activities. Participation in quality improvement activities like audit of practices and formal CME activities are required. The Royal Australasian College of Physicians has also a peer- and patient rated assessment programme, where the doctors' clinical management and personal skills are assessed [19].

On the other hand, Holm [20] claims that maintaining clinical competence might not be effected by strict legislative and regulatory measures. Reliable and valid identification of incompetent doctors may require well-planned and rather expensive programmes. And he further adds, that CME is hardly a solution for these persons.

As can be seen there is no wide consensus, concerning programmes and re-certification. A portfolio-based learning system has been proposed, where doctors could meet the speciality board requirements by setting up their own learning plans [21]. The Canadian Maintenance of Competence Programme (MOCOMP) and a programme appointed by the Royal College of General Practitioners in Britain are the first portfolio-based learning approaches [20]. In the USA four member boards of the American Board of Medical Specialities (family practice, plastic surgery, obstetrics and gynaecology and orthopaedic surgery) began a programme based on a combination of audit of practice data and documented evidence of continuous learning in practice. Doctors are required to submit summary reports on patients to be evaluated. A continuous re-certification could be built on this assessment method [18].

Fox and Bennett [13] suggest the following implications for the future of CME: (a.) Self-directed curricula designed by each doctor to incorporate new knowledge might be useful; (b.) Learning in groups serves as a source of interaction and will help to shape the practice of medicine; (c.) Learning within learning organisations is necessary, because these organisations create standards that govern practice and fit local problems and needs.

As can be seen there are still doubts concerning the ideal model of CME. Turkey is still at the beginning of this process and has still a chance to make use of the experience of other countries, which are intensively involved in this process. But the primary goal of the TMA and The Co-ordination Council of Medical Speciality Societies are time-limited re-certification using the most contemporary and effective method. To fulfil this goal, legislation is necessary and the TMA is lobbying for it. At present the only authority for regulation and registration of doctors is the Turkish Ministry of Health, whose co-operation and support is vital [22]. Politicians must be persuaded of the importance of CME and the resulting benefits for health care.