(Introduction by Croakey)
Towards the end of last year, the Medical Board of Australia released a new Professional Performance Framework for patient safety.
The framework has five “pillars,” which can be viewed in more detail via links on the board’s website. They are:
- Strengthened continuing professional development (CPD) requirements.
- Active assurance of safe practice.
- Strengthened assessment and management of medical practitioners with multiple substantiated complaints.
- Guidance to support practitioners.
- Collaborations to foster a culture of medicine that is focused on patient safety, based on respect and encourages doctors to take care of their own health and well-being.
The post below, from Drs Kerry Breen, Greg Whelan and Katrina Watson, relates to proposed changes that will make the manner in which doctors undertake continuing professional development (CPD) less flexible than the current arrangements.
While the authors would welcome well-designed, high quality, equitably accessible CPD programs, they raise concerns about the unintended consequences of a one-size-fits all approach, and provide suggestions for a way forward.
In a recent Newsletter, the Board indicated that there are ongoing consultations with stakeholders (including specialist colleges, the Australian Medical Council, Australian Medical Association, government representatives and medical insurers) about the new Framework, so concerns such as those outlined below will hopefully get a hearing.
Dr Kerry Breen, Dr Greg Whelan and Dr Katrina Watson write:
The new requirements for “strengthened” continuing professional development (CPD) proposed by the Medical Board of Australia (MBA) include the formal accreditation of all providers of CPD, a minimum of 50 hours per year of CPD under the umbrella of a nominated provider with whom the doctor must be enrolled, an annual personal professional development plan for every doctor, and documented participation in measurement of patient outcomes.
For doctors who are primarily hospital- based and supported by departmental structures, these requirements will be only marginally more onerous and time-consuming than the current ones. However, for many other competent and conscientious doctors, the new scheme may be too rigid, or too impractical, or too burdensome, or unacceptable for other reasons that are understandable and justifiable.
While every doctor in clinical practice should be obliged to seek to keep their knowledge and skills up-to-date, a rigidly-structured compulsory CPD scheme aiming to achieve this has drawbacks and a doubtful evidence base. It greatly favours doctors working in certain environments (e.g. teaching hospitals) while disadvantaging other doctors (e.g. those in rural or remote areas). It assumes that every doctor learns by exactly the same processes, which is clearly not the case.
Rigid requirements ignore reality
In addition, its rigidity does not allow for ongoing changes in the nature of medical practice. These changes include many doctors working fewer hours with increased time for family and other activities, more part-time employment, and more doctors with specialist qualifications working in regional areas.
Many general practitioners now work part-time as independent external contractors in corporately-owned clinics. Many of these doctors rely almost exclusively on “online” material to keep up to date as they have fewer opportunities for informal education with peers and face-to-face group education sessions. While this trend is not desirable, it is unclear if the owners of such clinics have any interest in assisting their staff to maintain their knowledge and skills. Whether or not changes are made to CPD requirements however, corporate clinic owners should, perhaps, be obliged to take an interest, and obliged to contribute to funding this activity.
An open door to industry interests
It also needs to be acknowledged that a points-based CPD system plays into the hands of pharmaceutical companies only too willing to sponsor or provide “education”. This has already happened in the USA where pharmaceutical companies and medical device companies have partnered with accredited providers of continuing medical education, and is happening in the UK.
In Australia, the pharmaceutical industry subsidises almost all medical college conferences and educational programs as well as many educational events in hospitals and in general practice. As outlined in an interesting commentary by health journalist Ray Moynihan last year, industry support for medical education predictably influences the behaviour of doctors, generally to the advantage of industry. For this and other reasons, some doctors avoid educational events that are so sponsored and are thus placed at a disadvantage in terms of earning points for attendance.
Quality at issue
An additional problem with the current model of CPD is that it usually has no structure, no curriculum and no clear planned outcomes. Instead, most often, doctors are presented material of interest (sometimes vested) to the speaker, a drug company or a hosting private hospital. Imagine what a medical school curriculum would be composed of if it were funded mostly by drug companies.
A points-based CPD system can also be “gamed” by doctors, no matter how much post hoc auditing takes place. Indeed one college in 2016 encouraged “gaming” by offering double CPD points without any educational justification and apparently as a means of attracting more fellows to its annual congress.
In addition a rigid CPD system does not acknowledge the learning that takes place in the workplace via other mechanisms including referring difficult cases for second opinions, discussing cases informally with colleagues, and self-directed learning that occurs when researching current cases.
Keeping up-to-date is more an attitude than a process. The system fails to acknowledge that there are many doctors who remain competent and up-to-date without meeting official CPD requirements.
Additional problems with points-based CPD for some doctors are the associated costs. This may explain why “free” (i.e. drug company supported) educational events are very popular, particularly when the company also pays for an associated free meal. A hospital-based doctor can attend an educational meeting while being paid by the hospital, placing that doctor at considerable advantage when compared to a self-employed doctor.
The present system of CPD financially disadvantages those doctors working part time such as women doctors raising families. Whether one works one day a week or five days a week, the same CPD requirements apply. The part-time doctor is earning much less but has identical CPD costs, an issue of equity that to date has been ignored. When the cost of medical indemnity insurance and annual registration is added, the inequity for part-time doctors is exacerbated.
Alternate pathways – site visits and refreshers
Given the range of problems associated with a one size fits all compulsory CDP requirement, the Medical Board would be wise to provide one or more alternative pathways for a doctor to demonstrate that their professional performance in their chosen area of practice is at a safe and competent standard.
One such pathway could be a system of peer review using a site visit of the actual practice of the doctor. This approach has been employed in some Canadian provinces and was piloted by the Royal Australasian College of Physicians several years ago. This might be attractive to rural and regional doctors for whom participation in standard CPD activities is more costly and more time consuming.
A site visit by an accredited independent peer practitioner should include participation in the daily activities of the practice, sitting in on some consultations, and, if the doctor has a hospital appointment, joining a hospital round. The visit should include an audit of randomly selected patient records and could include feedback from providers of imaging, pathology and social and ancillary service services used by the doctor. A written report with any recommendations would assist the doctor to determine areas for improvement.
A site visit has several attractions. It is assessing the “real world”, not a theoretical knowledge base derived from CPD. Visits may lead to identification of readily remediable problems, including health issues. For isolated doctors, visits will provide close peer contact that may be lacking.
Site visits are not primarily educational and do not replace the need for some form of continuing education. Site visits should be seen as an alternate method of assuring the medical regulator that the doctor’s practice is safe, thereby excusing the doctor of the rigmarole of participating in compulsory CPD programs and giving the doctor flexibility in how, when, and where continuing education is sought.
Visits carry the additional advantage of the learning that takes place for the visitor. Most doctors have little appreciation of what clinical practice is like in geographic areas in which they have never worked. As an added benefit of this educational experience, the visiting doctor should be eligible to earn points as part of any CPD program in which the doctor is enrolled.
There would be some initial costs in training and accrediting site visitors. The recipient of the site visit assessment would be required to pay for the process, but as this cost would be tax-deductable and as the visited doctor may be able to reduce the amount of time and money spent in attending various educational events to earn CPD points, the net cost involved should be minimal.
Other important considerations will include how site visits are centrally coordinated, the frequency of visits (for example, every three, five or seven years) and how the report of any visit will be used.
As most doctors are fellows of a medical college, the most attractive coordination centres will probably be the colleges. It will need to be made clear that a report cannot be used as a form of summative assessment that might lead to notification to the Medical Board or AHPRA. On the other hand, situations may arise whereby a site visitor finds grounds to be ethically or legally bound to notify alleged impairment to the regulator. Clear guidelines will need to be developed to address such situations.
Are there any other alternatives to the present methods of pursuit of compulsory CDP as endorsed by the Medical Board? One educational option that has been suggested by Dr Christine Jorm from the University of Sydney (personal communication) is annual participation in an intensive, well-planned, and targeted “medical update” week. If this were to be combined with an assessment of gaps in learning at the end of the week, doctors could better target their on-going learning. Other doctors are likely to have more suggestions.
The time has come for all CPD providers to be required to develop and publish a curriculum, one with a purpose in mind. This should be more valuable than expecting every doctor to develop their own curriculum (“an annual personal professional development plan for every doctor”, as proposed by the Medical Board of Australia), a task that assumes considerable self-insight.
At present, most CPD is overseen by our medical colleges. If new providers of CPD (e.g. university faculties of medicine) were to come forward and be accredited, competition might produce a wider range of CPD programs, giving individual doctors the opportunity to choose a program that best suits their needs. Competition might also help to keep costs down.
In addition, CPD needs to be weaned off the support of drug company money. This will be difficult as most doctors are now accustomed to this support and no longer accept that, like other professionals, they should fully fund their own ongoing education.
If government recognises that weaning off drug company money will produce benefits (through more rational prescribing and reduced health care expenditure), taxpayer funds could be used in the short term, and on a gradually decreasing basis, to subsidise CPD until weaning is complete.
*Dr Kerry Breen is a retired physician who served as President of the Medical Practitioners Board of Victoria and of the Australian Medical Council.
*Professor Greg Whelan is a medical educator, a specialist in Addiction Medicine, and a senior advisor to AVANT Mutual.
*Dr Katrina Watson is a Melbourne physician with a long involvement in postgraduate medical education, especially in the subject of viral hepatitis.