Continuing Professional Development (CPD): Does it help improve the safety and quality of care provided for patients and the public?

Continuing Professional Development (CPD): Does it help improve the safety and quality of care provided for patients and the public? 

                                               Dr KS Dhillon

CPD and CME

How did the concept of continuing medical education (CME) come about? Through the 1960’s many believed that drug advertising was educational and many physicians relied on information provided by the pharmaceutical industry. Industry funders were choosing the subjects offered in the talks provided and the drug firms provided commercially biased prescribing information which led to inappropriate drug use. Policy makers decided to provide an alternative which saw the birth of the concept of CME in the USA [1]. In USA they started granting CME recognition awards to doctors in the 1960s.
The European Union of Medical Specialists (UEMS) first made the move from CME to CPD. UEMS defined the term CPD thus ‘(t)he term CPD acknowledges the wide-ranging competencies needed to practice high quality medicine, including medical, managerial, ethical, social and personal skills. CPD therefore incorporates the concept of CME, which generally is taken to refer only to expanding the knowledge and skill
base required by doctors’ [2].
The CPD subcommittee of Academy of Medical Royal Colleges (AoMRC) has put forth a succinct definition of CPD. They defined CPD as ‘a continuing process, outside formal undergraduate and postgraduate training, that enables individual doctors to maintain and improve standards of medical practice through the development of knowledge, skills, attitudes and behaviour, CPD should also support specific changes in practice’ [3].
This definition emphasizes two important aspects of CPD i.e gaining knowledge and improving patient care.
Although CPD and CME are frequently used interchangeably the current literature considers CME as an ingredient of CPD. Many countries are moving from skill and knowledge based CME system to a CPD system which promotes competencies in a wide range of areas resulting in high quality medical practice [4].

International perspective of CPD

Murgatroyd (4) in 2011 did a study to evaluate the international perspective of CPD programmes and requirements for doctors. The study involved 25 countries from around the world to form an overview of CPD. The countries studied were from Europe, North America, Africa, Australasia and Asia. Out of the 25 countries as of 2011, France had no CPD requirement, in 7 countries CPD was voluntary (including Malaysia) and in 17 countries (including Singapore) CPD requirements were compulsory. In Canada the yearly credit requirements were the highest at 80 credits and it was the lowest in Kenya at 5 points. In Singapore the requirement was 25 credits per year.
Regulatory bodies in countries where CPD is mandatory have developed standards and have guidelines on the use of CPD, although these standards and guidelines vary from country to country. Each country has its own minimum numbers of credit requirement per year to fulfill the regulatory body’s requirements. In majority of the countries it is between 40 to 50 points. There is no international, standardised system for obtaining CPD credits, though in most countries 1 credit point is given for 1 hour of CPD activity [4].
The CPD scheme is delivered by different bodies in different countries and these include accredited providers, universities, specialist societies, specialist boards, specialist colleges, professional societies and medical associations.
In countries with compulsory CPD requirement, failure to obtain the required credits would result in sanctions ranging from suspension from register, fine, reprimand, removal from register, removal of licence, retake examinations, licence loss /fees reduced and loss of status plus fees [4].

Effectiveness of continuing professional development

CPD is suppose to keep the doctor up to date in clinical knowledge and in practice so that he/she can provide high quality care to the patients. CPD is suppose to keep the doctor safe to practice and it is suppose to improve the quality of service provided. Hence CPD and high quality of care are supposed to be irretrievably intertwined. Having said that it is also known that new knowledge does not always translate into a change in behaviour [5].
Knowledge translation is an interesting concept. It ‘describes any activity or process that facilitates the transfer of high-quality evidence from research into effective changes in health policy, clinical practice, or products’ [5].
There is obviously a need to amalgamate elements of education, research and quality improvement in daily clinical practice to improve patient outcomes.
There are however obstacles to this knowledge translation. In orthopaedic surgery for example there is level I evidence that arthroscopic knee joint debridement and arthroscopic partial meniscectomy serves no purpose in the treatment of patients with knee OA and patients with partial tear of the meniscus respectively, yet these are the most common operations performed in clinical orthopaedic practice around the world. This is an example of an instance where validated evidence has failed to achieve widespread implementation. More research in knowledge translation is needed where the discrepancies between what is known and what is done can be determined.
Schostaka et al [3] studied the effectiveness of continuing professional development (CPD). They found that that the effectiveness of CPD is related to the impact it has on knowledge, skills, values, attitudes, behaviours and changes in practice it produces in the workplace. The quality of CPD will dictate the improvements which will occur in the quality of the professional practice which is required for delivery of service. Learning in the professional setting was found to be most useful. There is a definite need for an ‘in-dept identification of learning needs’ both within and external to the place of work [3].
There is some consensus that CPD is useful when it addresses the needs of the clinicians, the patients they serve and the organization where they work. However, the effectiveness of CPD programs which are very diverse and not uniform, remains uncertain. The assessment of outcome of CPD activities remains difficult.

CPD in Malaysia

In Malaysia CPD is and has been voluntary. However, on 1st July 2017, the
Medical (Amendment) Act  2012, which is the amendment to the Medical Act 1971, and the Medical Regulations 2017 which replaces the Medical Regulation 1974, came into force.
Section 28(2)(b) of the Medical Regulations 2017 makes it mandatory for  registered medical practitioners to obtain a stipulated number of CPD points to make them eligible for the Annual Practising Certificate (APC).
This requirement will take effect for submissions received on or after 1 January 2019. The present requirement for the APC is 20 CPD points which are accumulated in a year. The collection of CPD points for the application of APC for a CPD year will be from 1st July to 30th June.
The medical practitioner is expected to take responsibility for his/her own  learning and professional development. The medical practitioner is expected to identify his/her educational needs and plan the CPD activities to be undertaken.
The practitioner is ‘encouraged’ to undertake CPD activities that are relevant to his/her field of practice and which will support his/her professional development. There is however no compulsion to undertake CPD activities in one’s own medical field or speciality. The doctor is advised to attend CPD activities that have been approved by the CPD review committees [6].
The Malaysian Medical Council – Continuing Professional Development  (MMC-CPD) grading system scoring schedule 2018,  is divided into 9 categories from A1 to A9.

A1- Medical congress (Local/International) - Attendance for 3 full days allows participant to earn a maximum of 20 points. A full day is 5 to 8 hours. Points for 1 day is 8, two days is 16 and three or more days is 20 points. The speakers at the congress must be of international standing. The guidelines however does not state what is speaker of international standing. The congress should contain plenary lectures /symposia. Presentation of free communication /poster (sic), etc should be allowed at the congress.

A2--Scientific Meetings of Academy / Universities /Colleges / Association / Institutions. Maximum points per meeting is 20 points.
a. 1- 2 hours 2 points
b. 2-4 hours (½ day) 4 points
c. 5-8 hours (full day) 8 points
d. 2 Full days 16 points
e. 3 or more full days 20 points

A3--Workshops/Course/ study tour which includes hands-on & skills
courses.
a. Half day (2-4 hours) 4 points
b. Full day (5-8 hours) 6 points
c. Two full days 10 points
d. Three or more full days 15 points
e. Skills accredited courses by specific disciplines (e.g. ALS, PALS, NRP, MTLS) 20 points.
f. Study tour 5 points

A4--CME session/ other professional activities. This include topic seminar, forum, lectures, formal ward rounds (teaching rounds), clinic attendance, hospital clinical meeting, video presentation, medical video conferencing, morbidity and mortality reviews, epidemiological reviews.
         a.Organising chairman for a scientific meeting gets 5 pts/ meeting
         b. Topic seminar 1 point/hr
         c. Forum 1 point/hr
         d.Lectures 1 point/hr (postgraduate lectures are not eligible for points)     
         e. Ward rounds 1 point/hr
         f. Clinic attendance 1 point/hr
         g. Hospital clinical meeting 1 point/hr
         h. Video presentation 1 point/hr
         i. Medical video conferencing 1 point/hr
         j. Morbidity and mortality  reviews 1 point/hr
         k. Epidemiological reviews 1 point/hr

A5 --  Presentation at meetings.
Plenary lecture/long paper/free paper/short paper/poster/other lectures, hospital clinical meeting, CME sessions, public medical talks
a. Free paper/ short paper/poster 10 points
b. Plenary lecture / long paper 10 points
c. Lecture presentation 5 points
d. Hospital clinical meeting 5 points
e. CME session 5 points
f. Public medical talk 5 points

A6 ---Publications of original articles in journal/ chapters in book / reports & important role in journal.
Publication of original articles in journal /chapters in books/reports
a. Indexed/peer reviewed journal (authors) 20 points
b. Non-indexed journal (authors) 10 points
c. Chapters in book (authors) 10 points per chapter
d. Reports e.g. Technical reports, working papers etc. 10 points
e. Editor 10 points,
         F. Member of Editorial Board 5 points
         G. Referee/reviewer (per article) 5 points

A7-- Self-study/group study/distance learning.
Reading scientific papers from indexed journals, organised
group discussion under accredited co-coordinator 1point per
paper or session. There needs to be documented evidence of the activity in the form of self administered MCQ  or documented evidence in the form of synopsis / evidence table.

A8-- CME Online. One point  per article or session. It requires accreditation of the providers by the CPD board.

A9--Special interest training courses (Short training courses/ Fellowship / Attachment).
These should be conducted by relevant recognised authorities - local or international which have been verified by the CPD committee.
Points are given only once, on completion of studies.
a. >3 - 6 months 20 points
b. >6 months - 1 year 30 points

The introduction to the guidelines for CPD, for medical practitioners in Malaysia by the Malaysian medical Council states that ‘the medical profession has not only a legal but a moral duty to promote high standards of patient care. Medical practitioners must be updated and competent throughout their working life by regularly participating in continuing professional development activities. The amendments to Medical Act and the Regulations were made to ensure that this objective is realised.

Does obtaining 20 CPD points ensure that the medical practitioner is uptodate and competent?The answer would probably be no.
The guideline encourage the medical practitioners to undertake CPD activities that are relevant to their field of practice and will support their professional development but there is no compulsion to undertake CPD activities relevant to their field of practice. Hence a medical practitioner may accumulate 20 points from an activity which is unrelated to his practice and still be eligible for renewal of his APC.

Lets analyse the MMC-CPD grading system.

Let's take category ‘A1- Medical congress (Local/International)’. A medical practitioner may register for the congress and not attend any of the session during the 3 days and still obtain 20 points. Most of the so called speakers of ‘international standing’ invited for these congresses are sponsored by pharmaceutical and or medical devices companies. How can they impart information which is not biased? Surely they cannot be expected to keep us updated and competent!

Category A 2 --Scientific Meetings of Academy / Universities /Colleges / Association / Institutions. Here too a practitioner may register and not attend any of the sessions and still receive the 20 points. Many of the conferences organised by medical associations and  academies cater for many medical disciplines and are not focused on a particular medical discipline and hence cannot update doctor from several disciplines. The needs of a general practitioner, a neurosurgeon, cardiac and orthopaedic surgeon are very different and cannot be fulfilled by meetings organised by medical associations and academies. Here too many of the speakers are sponsored by pharmaceutical and medical devices companies, who are biased and will not impart knowledge which is necessary to keep us updated and competent.

Category A3--Workshops/Course/ study tour which includes hands-on & skills courses. Points from such courses can be obtained once only and cannot be a source of points every year. These courses will not keep a person uptodate on the latest developments in one's speciality. These courses are basically meant for horning skills which the practitioner already possess.

Category A4--CME session/ other professional activities. Opportunities to participate in these activities are grossly limited. However, the organizing chairman of a scientific meeting gets 5 points. How organising a meeting makes a person uptodate and competent in his/her field of expertise is difficult to fathom. Why giving undergraduate lectures makes one eligible for points and giving postgraduate lecture does not make one eligible for points remains a mystery. One would believe that more in depth knowledge is needed to give postgraduate lecture as compared to an undergraduate lecture.

Category A5--  Presentation at meetings.
Points allocated for plenary lecture/long paper/free paper/short paper/poster/other lectures, hospital clinical meeting, CME sessions and public medical talks are well deserved. Such activities do help the practitioner remain uptodate.

Category A6 ---Publications of original articles in journal/ chapters in book / reports & important role in journal.

Points for publication of original articles in journal /chapters in books/ report are well deserved since such activity keeps the practitioner uptodate and competent.
There is however, some uncertainty as to whether being an editor, member of editorial board, referee/reviewer, helps one remain updated and competent. Whether CPD points should be allocated for such activity will depend on the quality of the journal,its impact factor and the number of issues published in a year. For example, there is a Malaysian journal which publishes 3 issues per year. More than half of the articles are case reports. It has a panel of 100 reviewers and its yearly Impact Factor‎ is ‎0.011 and 5-year Impact Factor is 0.009. Surely the reviewers of this journal do not deserve CPD points.
Points from categories A7 to A9 are unlikely to play a significant role in the CPD activities of medical practitioners.
Medical practitioners keen on keeping themselves updated and competent
will not need to participate in any of the activities prescribed by the MMC-CPD schedule. They will read and write to keep themselves updated. Medical practitioners who are forced to accumulate CPD points for the APC and are not keen to update themselves will find ways to get the points without getting updated. There are limits to professional self-regulation. So what can be done to make sure medical practitioners get updated?

What is the way forward? “Recertification”/Revalidation!

Recertification in USA

The unique strength of American medicine is a voluntary physician-led, nongovernmental process of setting standards. In 1936 the American Board of Internal Medicine (ABIM) was founded and the board set the standards for internal medicine practice and the practice of its subspecialties. It is physician-run organization which is independent of any
physician societies or membership organizations. The standards set by the board which are  measured by the “certification” process, lets the public know that the internist has met the ‘knowledge and practice requirements that ensure a high level of quality of care’ [7]. Though participation in this certification process is voluntary, about 98% of internists attempt certification and about 96% of them achieve certification [7].
In 1990 ABIM instituted a significant change to the program when they limited the validity of the certification to 10 years and after 10 years to maintain their certification the internist had to undergo a Maintenance of Certification (MOC) program. Those who did not do so would no longer be “board certified” [7]. About 85% of Diplomates continue to participate in the MOC program.
Studies show that  the board certified internist have better patient outcomes as compared to those who are not [8-12]. Studies also show that physician knowledge and the quality-of-care outcomes diminish with time, after graduation, with increasing years in practice [13].
The American Board of Medical Specialties (ABMS) is an umbrella organization for 26 specialty board. Most of the specialist boards require recertification every 10 years to maintain board certified status. The ABMS 
require every MOC program to have 4 components i.e ‘evidence of professional standing (license to practice); participation in lifelong learning and self-assessment; evidence of cognitive expertise (examination); and assessment of practice performance’ [7].

Revalidation in UK

The General Medical Council (GMC) in UK introduced revalidation for doctors in December 2012, after several years of discussion and debate.  The doctors in UK need revalidation to show to the GMC that they are uptodate and fit to practice and thereby maintain their licence to practice.
The doctors have to take part in a robust appraisal process and collect evidence to show they meet the necessary standards set by GMC. The revalidation cycle runs for 5 years and they need to revalidate once every 5 years. The first cycle was from 2012 to 2016.

For revalidation the doctor has to fulfill the following requirements:

Take part in an annual appraisal process
Complete at least one appraisal per year based on good medical practice
Collect and reflect on six types of supporting information.
The six types of supporting information include
           1. continuing professional development (CPD)
           2. quality improvement activity
           3. significant events
           4. feedback from colleagues
           5. feedback from patients
           6. review of complaints and compliments.
The above information has to be provided and discussed at their appraisal at least once in each five–year cycle.

Recertification & continual professional development

New Zealand has very comprehensive guidelines on recertification and continual professional development. Doctors in New Zealand must meet recertification and continual professional development (CPD) requirements if they want to maintain the right to be issued with a practising certificate. The Medical Council of New Zealand, requires doctors to undertake 50 hours of professional activity each year, which is directed to the maintenance of professional competence. This includes participation in audit of medical practice, peer review and continuing medical education. There has to be at least one audit per year, which entails ‘a systematic, critical analysis of the quality of a doctor’s own practice and is used to improve clinical and/or health outcomes, or to confirm that current management is consistent with
current available evidence or accepted consensus guidelines’ [14].
 There has to be a minimum of 10 hours of peer review per year. The peer review could involve joint review of cases, review of charts, practice visits to review a doctor’s performance, 360° appraisals and feedback, critique of a video review of consultation and discussion group, inter-departmental meetings that may review cases and interpretations of finding and mortality and morbidity meetings.
Doctors would need a minimum of 20 hours per year of Continuing medical education (CME) which would include attendance at relevant educational conferences, courses and workshops, self-directed learning programmes and learning diaries, assessments designed to identify learning needs in areas such as procedural skills, diagnostic skills or knowledge and journal reading [14]. CME may also include:

• examining candidates for college examinations
• supervising or mentoring others
• Teaching
• publication in medical journals and texts
• Research
• committee meetings with an educational content, such as guideline development
• giving expert advice on clinical matters
• presentations to scientific meetings
• working as an assessor or reviewer for the Council. 

Doctors are subjected to an audit by the Medical Council to ensure that doctors are complying with their recertification. Failure to satisfy requirements can result in the Council proposing to place conditions on the scope of practice or limitations on the practice and in serious cases, the Council can propose to suspend the doctors registration.

References

1. Rodwin MA, ‘Drug Advertising, Continuing Medical Education, and Physician Prescribing: A Historical Review and Reform Proposal’, Conundrums and Controversies in Mental Health and Illnesses. 2010 807-815 (p.809).
2. Charter on continuing medical education/continuing professional development approved by the UEMS Specialist Section and European Board of Anaesthesiology. European Journal of Anaesthesiology 2007; 24: 483–485.
3. Schostak J, Davis M, Hanson J, Schostak J, Brown T, Driscoll P,  Starke I, Jenkins N. The Effectiveness of Continuing Professional Development. A report prepared on behalf of College of Emergency Medicine, Federation of Royal Colleges of Physicians and Manchester Metropolitan University. 2010 College of Emergency Medicine at http://www.aomrc.org.uk/wp-content/uploads/2016/04/Effectiveness_of_CPD_0610.pdf accessed on 20/6/2018.
4. Murgatroyd GB. Continuing professional development -- The international perspective. Intelligence Unit, General Medical Council, July 2011 at https://www.gmc-uk.org/static/documents/content/CPD___The_International_Perspective_Jul_11.pdf_44810902.pdf accessed on 19/6/2018.
5. Lang ES, Wyer PC & Haynes RB. Knowledge translation: closing the evidence to practice gap. Ann Emerg Med 2007; 49 (3): 353-366.
6. Guidelines on Continuing Professional Development (CPD) For Medical Practitioners In Malaysia. Malaysian Medical Council 17 April 2018 at http://www.mmc.gov.my/images/contents/CPD/MMC-CPD%20Guidelines%20(updated).pdf accessed on 26/6/2018.
7. Levison W, Holmboe E. Maintenance of certification: 20 years later. Am J Med 2011; 124: 180-185.
8.  Norcini JJ, Lipner RS, Kimball HR. Certifying examination performance and patient outcomes following acute myocardial infarction. Med Educ. 2002;36(9):853-859.
9. Norcini JJ, Kimball HR, Lipner RS. Certification and specialization: do they matter in the outcome of acute myocardial infarction? Acad Med. 2000;75(12):1193-1198.
10. Chen J, Rathore SS, Wang Y, Radford MJ, Krumholz HM. Physician board certification and the care and outcomes of elderly patients with acute myocardial infarction. J Gen Intern Med. 2006;21(3):238-244.
11. Pham HH, Schrag D, Hargraves JL, Bach PB. Delivery of preventive services to older adults by primary care physicians. JAMA. 2005;294(4):473-481.
12. Ramsey PG, Carline JD, Inui TS, Larson EB, LoGerfo JP, Wenrich MD. Predictive validity of certification by the American Board of Internal Medicine. Ann Intern Med. 1989;110(9):719-726.
13. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142(4):260-273.
14. Recertification and continuing professional development. Medical Council of New Zealand, April 2018 at https://www.mcnz.org.nz/assets/News-and-Publications/Recertification-and-continuing-professional-development-30-4-2018-v7.pdf accessed on 4/7/18.