The effect of continuing professional development on public complaints: a case-control study

The Likelihood That Remedial Continuing Medical Education (CME) Reduces Disciplinary Recidivism Among Physicians

PURPOSE

State medical boards are charged through their medical practice acts to regulate physician practice and, when necessary, discipline physicians for incompetent or inappropriate behavior. Boards often authorize remedial continuing medical education (CME) as part of a disciplinary action; however, it is unclear how effective remedial CME is in reducing the likelihood of physicians receiving additional discipline. This study examined the relationship between physicians who were required to complete remedial CME as part of their first discipline by state medical boards and the likelihood of additional discipline.

METHOD

The national-level sample included 4,061 MD-physicians whose first discipline included license restrictions, probation, or other conditions imposed by state medical boards between 2011 and 2015. A multivariate logistic regression model examined whether physicians required to complete remedial CME as part of their first discipline were less likely to receive additional discipline by boards within 5 years.

RESULTS

Of the 4,061 physicians, 36% (n = 1,449) were required to complete remedial CME as part of their first discipline, and 35% (n = 1,426) received additional discipline within 5 years. After accounting for other factors, physicians who were required to complete remedial CME as part of their first discipline by boards were less likely to receive additional discipline (odds ratio, 0.597; 95% confidence interval, 0.513-0.696; P < .001) within 5 years compared to physicians who were not required to complete remedial CME.

CONCLUSIONS

Findings support remedial CME as a means to help reduce physician disciplinary recidivism in certain circumstances. Physicians required to complete remedial CME as part of their first discipline were less likely to receive additional discipline by state medical boards within 5 years.

Patient characteristics of, and remedial interventions for, complaints and medico-legal claims against doctors: a rapid review of the literature

BACKGROUND

It is uncertain if patient's characteristics are associated with complaints and claims against doctors. Additionally, evidence for the effectiveness of remedial interventions on rates of complaints and claims against doctors has not been synthesised.

METHODS

We conducted a rapid review of recent literature to answer: Question 1 "What are the common characteristics and circumstances of patients who are most likely to complain or bring a claim about the care they have received from a doctor?" and Question 2 "What initiatives or interventions have been shown to be effective at reducing complaints and claims about the care patients have received from a doctor?". We used a systematic search (most recently in July 2023) of PubMed, Scopus, Web of Science and grey literature. Studies were screened against inclusion criteria and critically appraised in duplicate using standard tools. Results were summarised using narrative synthesis.

RESULTS

From 8079 search results, we reviewed the full text of 250 studies. We included 25 studies: seven for Question 1 (6 comparative studies with controls and one systematic review) and 18 studies for Question 2 (14 uncontrolled pre-post studies, 2 comparative studies with controls and 2 systematic reviews). Most studies were set in hospitals across a mix of medical specialties. Other than for patients with mental health conditions (two studies), no other patient characteristics demonstrated either a strong or consistent effect on the rate of complaints or claims against their treating doctors. Risk management programs (6 studies), and communication and resolution programs (5 studies) were the most studied of 6 intervention types. Evidence for reducing complaints and medico-legal claims, costs or premiums and more timely management was apparent for both types of programs. Only 1 to 3 studies were included for peer programs, medical remediation, shared decision-making, simulation training and continuing professional development, with few generalisable results.

CONCLUSION

Few patient characteristics can be reliably related to the likelihood of medico-legal complaints or claims. There is some evidence that interventions can reduce the number and costs of claims, the number of complaints, and the timeliness of claims. However, across both questions, the strength of the evidence is very weak and is based on only a few studies or study designs that are highly prone to bias.

Evidence for continuing professional development standards for regulated health practitioners in Australia: a systematic review

BACKGROUND

Health practitioner regulators throughout the world use continuing professional development (CPD) standards to ensure that registrants maintain, improve and broaden their knowledge, expertise and competence. As the CPD standard for most regulated health professions in Australia are currently under review, it is timely that an appraisal of the evidence be undertaken.

METHODS

A systematic review was conducted using major databases (including MEDLINE, EMBASE, PsycInfo, and CINAHL), search engines and grey literature for evidence published between 2015 and April 2022. Publications included in the review were assessed against the relevant CASP checklist for quantitative studies and the McMaster University checklist for qualitative studies.

RESULTS

The search yielded 87 abstracts of which 37 full-text articles met the inclusion criteria. The evidence showed that mandatory CPD requirements are a strong motivational factor for their completion and improves practitioners' knowledge and behaviour. CPD that is more interactive is most effective and e-learning is as effective as face-to-face CPD. There is no direct evidence to suggest the optimal quantity of CPD, although there was some evidence that complex or infrequently used skills deteriorate between 4 months to a year after training, depending on the task.

CONCLUSIONS

CPD is most effective when it is interactive, uses a variety of methods and is delivered in a sequence involving multiple exposures over a period of time that is focused on outcomes considered important by practitioners. Although there is no optimal quantity of CPD, there is evidence that complex skills may require more frequent CPD.

Evaluation of clinical versus non-clinical continuing education in terms of preferences and value for oral healthcare workers

BACKGROUND

Continuing professional development (clinical) and continuing education (non-clinical) is fundamental to education and self-improvement of all categories of staff within a large healthcare facility.

AIM

This study sought to examine the attendance preferences and perceived value of clinical and non-clinical oral healthcare workers towards clinical continuing professional development (CPD) and non-clinical, continuing education (CE) activities.

METHODS

A retrospective cross-sectional survey design was used capturing 8640 self-reported evaluations collected across 8 successive years and 160 CPD and CE activities in a large dental hospital. Analysis was performed using descriptive statistics including mean scores, independent t-test and cross tabulations using chi-square.

RESULTS

A strongly significant association (p < 0.001) was found between attendee position type (clinical or non-clinical) and attendance preference to either clinical or non-clinical education. Dental assistants, compared to Dentist/Specialist (p < 0.001) found the programs more accurate, relevant, improved their knowledge, would use what was learned and rated the sessions higher overall. Clinical CPD was deemed more relevant (p = 0.025) and improved knowledge (p = 0.01) while non-clinical CE had higher presenter quality (p < 0.001) and overall mean scores (p = 0.015).

CONCLUSION

There was a preference towards attending clinical CPD over non-clinical CE, by not only clinical, but also non-clinical oral healthcare workers. Non-clinical CE was scored higher by both clinical and non-clinical participants and should therefore be considered for inclusion in CPD education programs with similar settings.

Multisource feedback: an overview of its use and application as a formative assessment

Multisource feedback (MSF), often termed 360-degree feedback, is a formative performance assessment in which data about an individual's observable workplace behaviors are collected through questionnaires from those interacting with the individual; data are aggregated for anonymity and confidentiality; the aggregated data, along with self-assessment if available, are provided to the individual; and the recipient meets with a trusted individual to review the data and develop an action plan. It is used along the continuum of medical education. This article provides an overview of MSF's utility, its evidence base and cautions.

Family Physician Quality Improvement Plans: A Realist Inquiry Into What Works, for Whom, Under What Circumstances

INTRODUCTION

Evaluation of quality improvement programs shows variable impact on physician performance often neglecting to examine how implementation varies across contexts and mechanisms that affect uptake. Realist evaluation enables the generation, refinement, and testing theories of change by unpacking what works for whom under what circumstances and why. This study used realist methods to explore relationships between outcomes, mechanisms (resources and reasoning), and context factors of a national multisource feedback (MSF) program.

METHODS

Linked data for 50 physicians were examined to determine relationships between action plan completion status (outcomes), MSF ratings, MSF comments and prescribing data (resource mechanisms), a report summarizing the conversation between a facilitator and physician (reasoning mechanism), and practice risk factors (context). Working backward from outcomes enabled exploration of similarities and differences in mechanisms and context.

RESULTS

The derived model showed that the completion status of plans was influenced by interaction of resource and reasoning mechanisms with context mediating the relationships. Two patterns were emerged. Physicians who implemented all their plans within six months received feedback with consistent messaging, reviewed data ahead of facilitation, coconstructed plan(s) with the facilitator, and had fewer risks to competence (dyscompetence). Physicians who were unable to implement any plans had data with fewer repeated messages and did not incorporate these into plans, had difficult plans, or needed to involve others and were physician-led, and were at higher risk for dyscompetence.

DISCUSSION

Evaluation of quality improvement initiatives should examine program outcomes taking into consideration the interplay of resources, reasoning, and risk factors for dyscompetence.

College complaints against resident physicians in Canada: a retrospective analysis of Canadian Medical Protective Association data from 2013 to 2017

BACKGROUND

An understanding of regulatory complaints against resident physicians is important for practice improvement. We describe regulatory college complaints against resident physicians using data from the Canadian Medical Protective Association (CMPA).

METHODS

We conducted a retrospective analysis of college complaint cases involving resident doctors closed by the CMPA, a mutual medicolegal defence organization for more than 100 000 physicians, representing an estimated 95% of Canadian physicians. Eligible cases were those closed between 2008 and 2017 (for time trends) or between 2013 and 2017 (for descriptive analyses). To explore the characteristics of college cases, we extracted the reason for complaint, the case outcome, whether the complaint involved a procedure, and whether the complaint stemmed from a single episode or multiple episodes of care. We also conducted a 10-year trend analysis of cases closed from 2008 to 2017, comparing cases involving resident doctors with cases involving only nonresident physicians.

RESULTS

Our analysis included 142 cases that involved 145 patients. Over the 10-year period, college complaints involving residents increased significantly (p = 0.003) from 5.4 per 1000 residents in 2008 to 7.9 per 1000 in 2017. While college complaints increased for both resident and nonresident physicians over the study period, the increase in complaints involving residents was significantly lower than the increase across all nonresident CMPA members (p < 0.001). For cases from the descriptive analysis (2013-2017), the top complaint was deficient patient assessment (69/142, 48.6%). Some patients (22/145, 15.2%) experienced severe outcomes. Most cases (135/142, 97.9%) did not result in severe physician sanctions. Our classification of complaints found 106 of 163 (65.0%) involved clinical problems, 95 of 163 (58.3%) relationship problems (e.g., communication) and 67 of 163 (41.1%) professionalism problems. In college decisions, 36 of 163 (22.1%) had a classification of clinical problem, 66 of 163 (40.5%) a patient-physician relationship problem and 63 of 163 (38.7%) a professionalism problem. In 63 of 163 (38.7%) college decisions, the college had no criticism.

INTERPRETATION

Problems with communication and professionalism feature prominently in resident college complaints, and we note the potential for mismatch between patient and health care provider perceptions of care. These results may direct medical education to areas of potential practice improvement.

Evaluation of a High Stakes Physician Competency Assessment: Lessons for Assessor Training, Program Accountability, and Continuous Improvement

INTRODUCTION

There is a dearth of evidence evaluating postlicensure high-stakes physician competency assessment programs. Our purpose was to contribute to this evidence by evaluating a high-stakes assessment for assessor inter-rater reliability and the relationship between performance on individual assessment components and overall performance. We did so to determine if the assessment tools identify specific competency needs of the assessed physicians and contribute to our understanding of physician dyscompetence more broadly.

METHOD

Four assessors independently reviewed 102 video-recorded assessments and scored physicians on seven assessment components and overall performance. Inter-rater reliability was measured using intraclass correlation coefficients using a multiple rater, consistency, two-way random effect model. Analysis of variance with least-significant difference post-hoc analyses examined if the mean component scores differed significantly by quartile ranges of overall performance. Linear regression analysis determined the extent to which each component score was associated with overall performance.

RESULTS

Intraclass correlation coefficients ranged between 0.756 and 0.876 for all components scored and was highest for overall performance. Regression indicated that individual component scores were positively associated with overall performance. Levels of variation in component scores were significantly different across quartile ranges with higher variability in poorer performers.

DISCUSSION

High-stake assessments can be conducted reliably and identify performance gaps of potentially dyscompetent physicians. Physicians who performed well tended to do so in all aspects evaluated, whereas those who performed poorly demonstrated areas of strength and weakness. Understanding that dyscompetence rarely means a complete or catastrophic lapse competence is vital to understanding how educational needs change through a physician's career.

A qualitative study on factors influencing the situational and contextual motivation of medical specialists

OBJECTIVES

The aim was to investigate which factors influence the situational motivation of medical specialists and how situational and contextual motivation affect one another.

METHODS

A qualitative design was used, and a constructivist approach was adopted with the Self-Determination Theory of motivation as a framework. Twenty-two medical specialists from three medical centers in the Netherlands were recruited through convenience, snowball and purposive sampling and observed for two days each. At the end of the second observation day, a semi-structured interview was conducted. Data were transcribed and coded in an open manner. Themes were finalized through discussion and consensus.

RESULTS

Two-hundred and fifty hours of observation data together with the interview data identified that medical specialists experience six main themes influencing their situational motivation during a workday. Technical issues are influencing motivation negatively factors. Working with colleagues can be both a motivating factor and influence motivation negatively, e.g., filling in for each other through feelings of relatedness was motivating. Being in control of one's own planning through feelings of autonomy was motivating. Patient care, especially in combination with teaching, stimulated specialists' motivation.

CONCLUSIONS

The results indicate that factors influencing motivation negatively are mainly tasks and organizational processes that distract from patient care or that compromise the quality of care. When optimizing the work environment of medical specialists, autonomous motivation and continuing professional development are stimulated.  These, in turn, can improve the quality of patient care and wellbeing of specialists.

Learning With Patients, Students, and Peers: Continuing Professional Development in the Solo Practitioner Workplace

Conceptualizations of workplace learning have moved from knowledge acquisition to learning as participation in the practices and cultures of the workplace environment. Along with this has come an appreciation of applicability of sociocultural learning theories, which frame learning as occurring within "communities of practice" or learning being "situated" within a workplace environment where collaboration and social interaction are fundamental to the learning process. These conceptualizations of workplace learning are ideally suited to health professions where learners are supervised in clinical work environments and then continue to work in team-based environments as graduates. However, what happens to workplace learning for novice practitioners who have limited periods of clinical supervision and then graduate into solo or small group practices (which may also be in rural or remote locations) and embark on long working careers without supervision? This paper argues workplace learning needs to be scaffolded and supported to reach its full potential in these environments. Drawing on workplace-based learning theory, we highlight the ubiquitous nature of learning in the workplace, the importance of active engagement, reflection, and individual meaning making. Through this reframing of traditional notions of continuing professional development, we emphasize the importance of patients, students, and other practitioners as partners in workplace learning for solo practitioners. We also focus on the role of educators, professional associations, and regulators in helping solo practitioners recognize, access, and maximize the learning opportunities inherent in relatively isolated practice environments.

Where do Peer Review Groups fit in the international Continuing Professional Development literature?

OBJECTIVES

To describe what is reported in the Continuing Professional Development (CPD) literature on small group learning formats in medicine, including the Royal Australian and New Zealand College of Psychiatrists (RANZCP) CPD Peer Review Groups (PRGs).

METHOD

A literature review of international peer-reviewed publications in relation to the use of small group learning formats for CPD in medicine.

RESULTS

Small groups are commonly used as a learning format in medical CPD, primarily in general practice, but are little researched. Such groups take differing forms and they are valued by participants for a range of purposes, having effects on professionalism, clinical performance and doctors' wellbeing.

CONCLUSION

We believe that the contribution of these groups to medical CPD should be further explored. To this end, this review forms the first part of a research project focussing on the RANZCP PRG model used by Australian and New Zealand psychiatrists.

Medical specialists' basic psychological needs, and motivation for work and lifelong learning: a two-step factor score path analysis

BACKGROUND

Continuing professional development and lifelong learning are crucial to secure safe and good quality healthcare. Lack of motivation has been found to be among the most important barriers for participation in lifelong learning. This study was conducted to investigate the relationships between medical specialists' work motivation, lifelong learning motivation, autonomy, competence and relatedness satisfaction.

METHODS

Self-Determination Theory was used as a theoretical framework for this study. Data were collected through an online survey, that was sent to all (N = 1591) medical specialists in four Dutch hospitals. The survey measured background characteristics, autonomy, competence, and relatedness satisfaction, autonomous and controlled work motivation, and lifelong learning motivation. Two step factor path analysis with the method of Croon was used to analyze the data from 193 cases.

RESULTS

Autonomy need satisfaction was positively associated with autonomous work motivation which in turn was positively associated with lifelong learning motivation. Competence need satisfaction and age were negatively associated with controlled work motivation. Competence need satisfaction was also positively related with lifelong learning motivation. No significant nor any hypothesized associations were found for relatedness.

CONCLUSIONS

Our findings, in line with Self-determination Theory literature, show that autonomy and competence need satisfaction are the important factors as they were positively associated with medical specialists' motivation for work and for lifelong learning.

Continuing professional development and Irish hospital doctors: a survey of current use and future needs

Doctors rate clinical relevance and applicability as the most important determinants of continuing professional development (CPD) course selection. This study examined patterns of current CPD practice and perceived CPD needs among hospital doctors in Ireland across various clinical specialties. A cross-sectional survey was administered to doctors, focusing on the areas of training needs analysis, CPD course content and preferred course format. In total, 547 doctors identified doctor-patient communication as the skill ranked highest for importance and level of current performance. Workload/time organisation and stress management were areas where a skills deficiency was identified. Non-clinical CPD topics, including resilience training, management and communication skills, were preferred areas for future CPD offerings. All respondents favoured interactive, hands-on sessions. CPD course completion and preference patterns differed significantly across clinical specialties. These results highlight the importance of considering the individual needs and preferences of clinicians across clinical specialties to facilitate more effective CPD programmes.

Black box towards glass box: 'Mapaloguing' a typology of public health CPD activities in UK in 2011/12

Background

The 1996 Faculty of Public Health study of specialists continuing professional development (CPD) diaries indicated forward-looking approaches. There has been little substantive research on public health CPD records since.

Methods

Mixed methods research assessed 795 CPD records/reflective notes from 2011/12. The quantitative methods aimed to analyse types of new learning; a qualitative sub-sample analysis of reflective standards will be reported elsewhere. Many current CPD categories were non-specific and situational, including conferences/workshops and learning as part of the job. These were later classified to a new CPD typology of 13 learning-orientated categories with sub-types.

Results

Most (572 = 71.9%) activities fell into current FPH CPD categories that did not identify the learning topic. The new categorization identified four most common CPD learning types: about health protection topics, key specialist knowledge/skills, experiences handling new public health systems and educator/trainer requirements.

Conclusions

This new typology illustrates wide-ranging CPD activities, including work-based opportunities from shifts in organizations and policies. A CPD 'Mapalogue' is proposed, with 'Mapaloguing' as an analytical research process, combining mapping of influences and direction of CPD alongside cataloguing actual CPD undertaken. This could inform individual professionals' choice menu for CPD and personal development and increase the profession's transparency and understanding of long-term trends.

Scholarly Conversations in Medical Education

This supplement includes the eight research papers accepted by the 2016 Research in Medical Education Program Planning Committee. In this Commentary, the authors use "conversations in medical education" as a guiding metaphor to explore what these papers contribute to the current scholarly discourse in medical education. They organize their discussion around two domains: the topic of study and the methodological approach. The authors map the eight research papers to six "hot topics" in medical education: (1) curriculum reform, (2) duty hours restriction, (3) learner well-being, (4) innovations in teaching and assessment, (5) self-regulated learning, and (6) learning environment, and to three purposes commonly served by medical education research: (1) description, (2) justification, and (3) clarification. They discuss the range of methods employed in the papers. The authors end by encouraging educators to engage in these ongoing scholarly conversations.

Oncology and medical education-past, present and future

Oncologists should contribute to the undergraduate curriculum whenever they can, and should teach communication skills, acute oncology, prescribing, and other transferable skills. Newly qualified doctors will care for many patients with cancer in their first years of work, and all doctors need to know when an urgent oncology referral is required and to be aware of the pace of change in oncology. Oncologists should involve their patients in teaching whenever it is appropriate. We should aim to inspire junior doctors to consider a career in oncology. The oncology education community should adopt new teaching methods, for example simulation, mock MDTs and student led clinics. CPD provided by honorable organisations, including online learning, is becoming more important for oncologists to keep up to date.

National programmes for validating physician competence and fitness for practice: a scoping review

OBJECTIVE

To explore and categorise the state of existing literature for national programmes designed to affirm or establish the continuing competence of physicians.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE, ERIC, Sociological Abstracts, web/grey literature (2000-2014).

SELECTION

Included when a record described a (1) national-level physician validation system, (2) recognised as a system for affirming competence and (3) reported relevant data.

DATA EXTRACTION

Using bibliographic software, title and abstracts were reviewed using an assessment matrix to ensure duplicate, paired screening. Dyads included both a methodologist and content expert on each assessment, reflective of evidence-informed best practices to decrease errors.

RESULTS

45 reports were included. Publication dates ranged from 2002 to 2014 with the majority of publications occurring in the previous six years (n=35). Country of origin--defined as that of the primary author--included the USA (N=32), the UK (N=8), Canada (N=3), Kuwait (N=1) and Australia (N=1). Three broad themes emerged from this heterogeneous data set: contemporary national programmes, contextual factors and terminological consistency. Four national physician validation systems emerged from the data: the American Board of Medical Specialties Maintenance of Certification Program, the Federation of State Medical Boards Maintenance of Licensure Program, the Canadian Revalidation Program and the UK Revalidation Program. Three contextual factors emerged as stimuli for the implementation of national validation systems: medical regulation, quality of care and professional competence. Finally, great variation among the definitions of key terms was identified.

CONCLUSIONS

There is an emerging literature focusing on national physician validation systems. Four major systems have been implemented in recent years and it is anticipated that more will follow. Much of this work is descriptive, and gaps exist for the extent to which systems build on current evidence or theory. Terminology is highly variable across programmes for validating physician competence and fitness for practice.