Doctors on the move: a European case study on the key characteristics of national recertification systems

A Changing Landscape for Lifelong Learning in Health Globally

On 25 July 2022, the Continuing Professional Development (CPD) Special Interest Group of the Association for Medical Education in Europe came together to open up discussions during a live webinar on 'Exploring the Evolution of CPD'. The objective was to bring together global medical educators to consider perspectives of CPD from the role of global lifelong learners, the role of educators and the role of education providers and health regulators. The landscape of CPD is evolving, and the roles of each key player must include specific actions for facilitated change. Delivering competency outcomes-based learning, fit for purpose, to lifelong learners in health will require (1) learner agency, (2) leadership from educators and (3) providers of lifelong learning to come together to improve delivery of CPD that leads to meaningful change in practice care delivery.

Design, delivery and effectiveness of health practitioner regulation systems: an integrative review

BACKGROUND

Health practitioner regulation (HPR) systems are increasingly recognized as playing an important role in supporting health workforce availability, accessibility, quality, and sustainability, while promoting patient safety. This review aimed to identify evidence on the design, delivery and effectiveness of HPR to inform policy decisions.

METHODS

We conducted an integrative analysis of literature published between 2010 and 2021. Fourteen databases were systematically searched, with data extracted and synthesized based on a modified Donabedian framework.

FINDINGS

This large-scale review synthesized evidence from a range of academic (n = 410) and grey literature (n = 426) relevant to HPR. We identified key themes and findings for a series of HPR topics organized according to our structures-processes-outcomes conceptual framework. Governance reforms in HPR are shifting towards multi-profession regulators, enhanced accountability, and risk-based approaches; however, comparisons between HPR models were complicated by a lack of a standardized HPR typology. HPR can support government workforce strategies, despite persisting challenges in cross-border recognition of qualifications and portability of registration. Scope of practice reform adapted to modern health systems can improve access and quality. Alternatives to statutory registration for lower-risk health occupations can improve services and protect the public, while standardized evaluation frameworks can aid regulatory strengthening. Knowledge gaps remain around the outcomes and effectiveness of HPR processes, including continuing professional development models, national licensing examinations, accreditation of health practitioner education programs, mandatory reporting obligations, remediation programs, and statutory registration of traditional and complementary medicine practitioners.

CONCLUSION

We identified key themes, issues, and evidence gaps valuable for governments, regulators, and health system leaders. We also identified evidence base limitations that warrant caution when interpreting and generalizing the results across jurisdictions and professions. Themes and findings reflect interests and concerns in high-income Anglophone countries where most literature originated. Most studies were descriptive, resulting in a low certainty of evidence. To inform regulatory design and reform, research funders and governments should prioritize evidence on regulatory outcomes, including innovative approaches we identified in our review. Additionally, a systematic approach is needed to track and evaluate the impact of regulatory interventions and innovations on achieving health workforce and health systems goals.

Doctors' attitudes to maintenance of professional competence: A scoping review

CONTEXT

Recent decades have seen the international implementation of programmes aimed at assuring the continuing competence of doctors. Maintenance of Professional Competence (MPC) programmes aim to encourage doctors' lifelong learning and ensure high-quality, safe patient care; however, programme requirements can be perceived as bureaucratic and irrelevant to practice, leading to disengagement. Doctors' attitudes and beliefs about MPC are critical to translating regulatory requirements into committed and effective lifelong learning. We aimed to summarise knowledge about doctors' attitudes to MPC to inform the development of MPC programmes and identify under-researched areas.

METHODS

We undertook a scoping review following Arksey and O'Malley, including sources of evidence about doctors' attitudes to MPC in the United States, the United Kingdom, Canada, Australia, New Zealand and Ireland, and using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) as a guide.

RESULTS

One hundred and twenty-five sources of evidence were included in the review. One hundred and two were peer-reviewed publications, and 23 were reports. Most were from the United Kingdom or the United States and used quantitative or mixed methods. There was agreement across jurisdictions that MPC is a good idea in theory but doubt that it achieves its objectives in practice. Attitudes to the processes of MPC, and their impact on learning and practice were mixed. The lack of connection between MPC and practice was a recurrent theme. Barriers to participation were lack of time and resources, complexity of the requirements and a lack of flexibility in addressing doctors' personal and professional circumstances.

CONCLUSIONS

Overall, the picture that emerged is that doctors are supportive of the concept of MPC but have mixed views on its processes. We highlight implications for research and practice arising from these findings.

Portfolios with Evidence of Reflective Practice Required by Regulatory Bodies: An Integrative Review

Purpose: Regulatory bodies impose continuing professional development (CPD) requirements on health care professionals (HCPs) as a condition for license revalidation. Many regulatory bodies require annual evidence of CPD activities that are informed by reflective practices, guided by learning plans, and compiled into a portfolio. The purpose of this integrative review is to summarize the literature discussing how regulatory bodies use portfolios with evidence of reflection for licensure renewal. Method: We reviewed English-language articles published until May 2020 discussing evidence of CPD and reflective practice in portfolios in the context of licensure renewal. Results: We located 17 articles for the review. None reported or measured outcomes beyond submission of reflective evidence. Sixteen articles (93%) included information about passive learning resources that regulatory bodies provided to help guide HCPs’ reflective learning activities. HCPs’ feedback about using reflective learning activities indicated mixed opinions about their utility. Conclusions: Few publications reported how jurisdictions expected HCPs to provide evidence of reflective practices for licensure renewal. None of the regulatory bodies required evidence regarding the impact of reflective practice on patient or organizational outcomes. HCPs reported both benefits and challenges of a mandated reflective process.

Doctors' maintenance of professional competence: a qualitative study informed by the theory of planned behaviour

BACKGROUND

Medical regulators worldwide have implemented programmes of maintenance of professional competence (MPC) to ensure that doctors, throughout their careers, are up to date and fit to practice. The introduction of MPC required doctors to adopt a range of new behaviours. Despite high enrolment rates on these programmes, it remains uncertain whether doctors engage in the process because they perceive benefits like improvements in their practice and professional development or if they solely meet the requirements to retain medical registration. In this study, we aimed to explore the relationship between doctors' beliefs, intention and behaviour regarding MPC through the lens of the Theory of Planned Behaviour (TPB) to make explicit the factors that drive meaningful engagement with the process.

METHODS

We conducted a qualitative study using semi-structured interviews. From a pool of 1258 potential participants, we purposively selected doctors from multiple specialities, age groups, and locations across Ireland. We used thematic analysis, and the TPB informed the analytic coding process.

RESULTS

Forty-one doctors participated in the study. The data analysis revealed doctors' intention and behaviour and the factors that shape their engagement with MPC. We found that attitudes and beliefs about the benefits and impact of MPC mediated the nature of doctors' engagement with the process. Some participants perceived positive changes in practice and other gains from participating in MPC, which facilitated committed engagement with the process. Others believed MPC was unfair, unnecessary, and lacking any benefit, which negatively influenced their intention and behaviour, and that was demonstrated by formalistic engagement with the process. Although participants with positive and negative attitudes shared perceptions about barriers to participation, such perceptions did not over-ride strongly positive beliefs about the benefits of MPC. While the requirements of the regulator strongly motivated doctors to participate in MPC, beliefs about patient expectations appear to have had less impact on intention and behaviour.

CONCLUSIONS

The findings of this study broaden our understanding of the determinants of doctors' intention and behaviour regarding MPC, which offers a basis for designing targeted interventions. While the barriers to engagement with MPC resonate with previous research findings, our findings challenge critical assumptions about enhancing doctors' engagement with the process. Overall, our results suggest that focused policy initiatives aimed at strengthening the factors that underpin the intention and behaviour related to committed engagement with MPC are warranted.

Later in Career Surgeon Performance Assessment: Why, When, What, and by Whom

BACKGROUND

The average age of practicing surgeons is increasing, consistent with the overall population; one third of Americans are over 55 years of age. Aging is clearly associated with varying loss of skills, yet there are no age-based state or federal requirements for professional skill assessment; or age-specific criteria for board certification, recertification, or retirement. Capability based policies are preferred to age based criteria (3) but very few organizations have such policies in place.

METHODS

A Delphi method study was utilized to answer: When should a surgeon's performance be assessed? If mandatory, then at what age? If adverse events triggered, then what events? What should be assessed? By whom? And, who determines the result-based actions? A systematic literature review indicated institutional stakeholders. On the basis of this a 20-member expert panel was created drawing from 13 US pediatric institutions: orthopaedic surgical department-division chiefs (14), children's hospital general counsel (3), surgical chief responsible for hospital bylaws-medical peer review (1), OR nursing managers (2). Three rounds of iterative questionnaires were utilized.

RESULTS

A 100% response rate was achieved. Consensus supported recommendations included: Mandatory assessments should start at the age of 65 years, after a medical disability, and or at the request of other health care professionals. Assessments should include criteria for behavioral health, mental capacity, physical health, surgical performance, 360 human resource reviews, and surgical adverse events. Assessments should be performed by an external group with validated tools and reviewed by the department and overall surgeon-in-chief. The final decisions for an action plan based on results should be made by departmental and overall surgeon-in-chief.

CONCLUSIONS

Our expert panel Delphi method study recognized aging is a risk factor in performance and recommended surgeon assessments should be automatically triggered by the age of 65 years, negative health events, or serious performance concerns. Assessments should be multifaceted, fair, reliable with minimal bias, and performed by an external professional group. Decisions should be managed by departmental and surgical chiefs.

LEVEL OF EVIDENCE

Level V.

Maintenance of certification for radiologists: an overview of European countries

Background

It is currently unclear whether the continuing medical education (CME) requirements for radiologists to keep up their certification are equal across Europe, which would be desirable for uniform cross-border quality of radiology and because of the fundamental principle of free movement of workers in the European Union. This study aimed to determine the maintenance of certification requirements for radiologists in different European countries.

Methods

National radiological societies of European countries and/or their delegates as listed on the European Society of Radiology website were contacted to inquire about the maintenance of licensure requirements for radiologists in their country. Data were analysed using descriptive statistics.

Results

Forty-six European countries were contacted. Response rate was 80%. Twenty-two of 36 responding countries (59%) reported mandatory requirements to maintain a radiologist’s license to practise. The median license period was 5 years (range 1–7). The median required number of CME points per year was 40 (range 8–58, interquartile range 30). Eight countries reported additional requirements, including practising clinical radiology, attending quality meeting/clinical audit, and attending additional courses (such as radiation safety training and advanced medical training course). Fifteen of 37 responding countries (41%) did not report mandatory requirements.

Conclusions

There is considerable heterogeneity across European countries regarding the maintenance of certification requirements for radiologists. More homogeneity is desired for uniform quality assurance and professional mobility of radiologists across Europe. The data from our overview may be used to establish a benchmark for national societies who issue maintenance of licensure requirements for radiologists.

Reforming regulatory relationships: The impact of medical revalidation on doctors, employers, and the General Medical Council in the United Kingdom

In 2012, medical regulation in the United Kingdom was fundamentally changed by the introduction of revalidation - a process by which all licensed doctors are required to regularly demonstrate that they are up to date and fit to practice in their chosen field and are able to provide a good level of care. This paper examines the implications of revalidation on the structure, governance, and performance management of the medical profession, as well as how it has changed the relationships between the regulator, employer organizations, and the profession. We conducted semi-structured interviews with clinical and non-clinical staff from a range of healthcare organizations. Our research suggests that organizations have become intermediaries in the relationship between the General Medical Council and doctors, enacting regulatory processes on its behalf and extending regulatory surveillance and oversight at local level. Doctors' autonomy has been reduced as they have become more accountable to and reliant on the organizations that employ them.

Meeting challenges in delivery of patient care: a reflection on the involvement of ERS in CPD of respiratory physicians

At the end of his mandate, Gernot Rohde (European Respiratory Society (ERS) Education Council Chair 2014–2017) and the ERS Education Council had the opportunity to reflect on the goals achieved over 3 years and the challenges in implementing continuing professional development (CPD) programmes for our respiratory specialists. The third ERS Education Research Seminar took place in Frankfurt, Germany, in June 2017 with >30 international experts in medical education and respiratory medicine. >1 year later, we can now reflect on the ERS Education Seminar, the achievements of the Education Council over 3 years, and the continuing path to better understand the education needs of practicing respiratory medicine specialists. This article reflects on the core principles of medical education and offers a reflection on CPD for respiratory professionals within ERS Education.

A reflection on @EuroRespSoc education, a learning pathway for the future: better practice, better physicians, better patientshttp://bit.ly/2XHmr3J

Perceptions of people with respiratory problems on physician performance evaluation-A qualitative study

BACKGROUND

Despite increasing calls for patient and public involvement in health-care quality improvement, the question of how patient evaluations can contribute to physician learning and performance assessment has received scant attention.

OBJECTIVE

The objective of this study was to explore, amid calls for patient involvement in quality assurance, patients' perspectives on their role in the evaluation of physician performance and to support physicians' learning and decision making on professional competence.

DESIGN

A qualitative study based on semi-structured interviews.

SETTING AND PARTICIPANTS

The study took place in a secondary care setting in the Netherlands. The authors selected 25 patients from two Dutch hospitals and through the Dutch Lung Foundation, using purposive sampling.

METHODS

Data were analysed according to the principles of template analysis, based on an a priori coding framework developed from the literature about patient empowerment, feedback and performance assessment.

RESULTS

The analysis unearthed three predominant patient perspectives: the proactive perspective, the restrained perspective and the outsider perspective. These perspectives differed in terms of perceived power dynamics within the doctor-patient relationship, patients' perceived ability, and willingness to provide feedback and evaluate their physician's performance. Patients' perspectives thus affected the role patients envisaged for themselves in evaluating physician performance.

DISCUSSION AND CONCLUSION

Although not all patients are equally suitable or willing to be involved, patients can play a role in evaluating physician performance and continuing training through formative approaches. To involve patients successfully, it is imperative to distinguish between different patient perspectives and empower patients by ensuring a safe environment for feedback.

Patient and public involvement in medical performance processes: A systematic review

Background

Patient and public involvement (PPI) continues to develop as a central policy agenda in health care. The patient voice is seen as relevant, informative and can drive service improvement. However, critical exploration of PPI's role within monitoring and informing medical performance processes remains limited.

Objective

To explore and evaluate the contribution of PPI in medical performance processes to understand its extent, purpose and process.

Search strategy

The electronic databases PubMed, PsycINFO and Google Scholar were systematically searched for studies published between 2004 and 2018.

Inclusion criteria

Studies involving doctors and patients and all forms of patient input (eg, patient feedback) associated with medical performance were included.

Data extraction and synthesis

Using an inductive approach to analysis and synthesis, a coding framework was developed which was structured around three key themes: issues that shape PPI in medical performance processes; mechanisms for PPI; and the potential impacts of PPI on medical performance processes.

Main results

From 4772 studies, 48 articles (from 10 countries) met the inclusion criteria. Findings suggest that the extent of PPI in medical performance processes globally is highly variable and is primarily achieved through providing patient feedback or complaints. The emerging evidence suggests that PPI can encourage improvements in the quality of patient care, enable professional development and promote professionalism.

Discussion and conclusions

Developing more innovative methods of PPI beyond patient feedback and complaints may help revolutionize the practice of PPI into a collaborative partnership, facilitating the development of proactive relationships between the medical profession, patients and the public.

Box-ticking and Olympic high jumping - Physicians' perceptions and acceptance of national physician validation systems

PURPOSE

National physician validation systems aim to ensure lifelong learning through periodic appraisals of physicians' competence. Their effectiveness is determined by physicians' acceptance of and commitment to the system. This study, therefore, sought to explore physicians' perceptions and self-reported acceptance of validation across three different physician validation systems in Europe.

MATERIALS AND METHODS

Using a constructivist grounded-theory approach, we conducted semi-structured interviews with 32 respiratory specialists from three countries with markedly different validation systems: Germany, which has a mandatory, credit-based system oriented to continuing professional development; Denmark, with mandatory annual dialogs and ensuing, non-compulsory activities; and the UK, with a mandatory, portfolio-based revalidation system. We analyzed interview data with a view to identifying factors influencing physicians' perceptions and acceptance.

RESULTS

Factors that influenced acceptance were the assessment's authenticity and alignment of its requirements with clinical practice, physicians' beliefs about learning, perceived autonomy, and organizational support.

CONCLUSIONS

Users' acceptance levels determine any system's effectiveness. To support lifelong learning effectively, national physician validation systems must be carefully designed and integrated into daily practice. Involving physicians in their design may render systems more authentic and improve alignment between individual ambitions and the systems' goals, thereby promoting acceptance.

ERS Congress highlight: educational forum on continuing professional development

Each year as part of its International Congress, the European Respiratory Society (ERS) dedicates a session to discuss the key themes in medical education affecting respiratory professionals working not only throughout Europe but worldwide. The forum is open to national societies, public health officials and patient representatives, as well as individual Congress delegates with an interest in medical education.

The ERS International Congress educational forum brings together experts to advance respiratory medicinehttp://ow.ly/hP9k30kz6ZM

Policing the profession? Regulatory reform, restratification and the emergence of Responsible Officers as a new locus of power in UK medicine

Doctors' work and the changing, contested meanings of medical professionalism have long been a focus for sociological research. Much recent attention has focused on those doctors working at the interface between healthcare management and medical practice, with such ‘hybrid’ doctor-managers providing valuable analytical material for exploring changes in how medical professionalism is understood. In the United Kingdom, significant structural changes to medical regulation, most notably the introduction of revalidation in 2012, have created a new hybrid group, Responsible Officers (ROs), responsible for making periodic recommendations about the on-going fitness to practise medicine of all other doctors in their organisation.

Using qualitative data collected in a 2015 survey with 374 respondents, 63% of ROs in the UK, this paper analyses the RO role. Our findings show ROs to be a distinct emergent group of hybrid professionals and as such demonstrate restructuring within UK medicine. Occupying a position where multiple agendas converge, ROs' work expands professional regulation into the organisational sphere in new ways, as well as creating new lines of continuous accountability between the wider profession and the General Medical Council as medical regulator. Our exploration of ROs' approaches to their work offers new insights into the on-going development of medical professionalism, pointing to the emergence of a distinctly regulatory hybrid professionalism shaped by co-existing professional, managerial and regulatory logics, in an era of strengthened governance and complex policy change.

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Responsible Officers are a new governance elite group in the UK medical profession.

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They work at the nexus of professional, managerial and regulatory spheres.

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Differ from other doctor-managers due to accountability for medical performance.

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Organisational context shapes experiences of this new role.

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Regulatory reform has engendered a new form of hybrid professionalism.