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Covid-19 is accelerating changes to the delivery of continuing medical education, which is the focus of a broader review at the Medical Council. Catherine Reilly reports on what it could mean for registered doctors
Continuing medical education has undergone seismic change due to Covid-19 and physical distancing guidelines.
In large numbers, doctors have dialled in to webinars providing rapidly-emerging clinical updates on the novel coronavirus, as well as on many other topics. This journey into the virtual world has pros and cons — greater access and flexibility, but reduced human connection and screen fatigue. In some specialties, such as anesthesiology, there are considerable limitations as to what can be maneuvered online (see panel).
This all presents new pieces in the puzzle of evolving the professional competence model, which the Medical Council has been working towards for a number of years.
In recent months, the Council has stepped back from monitoring compliance with continuing professional development (CPD) due to the Covid-19 crisis. With many specialties under intense service pressures and the cancellation of conferences and other CPD-approved events, the Council decided not to monitor for the 2019/2020 year and it has reduced requirements for 2020/2021. An offshoot is that Council staff have had more time to advance work on a new professional competence scheme model.
In 2016, the Council identified that a significant cohort of registered doctors were not enrolled on a scheme, despite a legal requirement to do so.
About one-quarter were not fully compliant with CPD requirements, according to the Council’s report Maintenance of Professional Competence: Report of Progress 2011-2018. The Council has been working with the postgraduate training bodies to significantly reduce non-enrolment and non-compliance to a proportionally small number of the total registered doctors to whom CPD requirements apply.
The Medical Independent (MI) recently reported that around 1,000 registered doctors were being “monitored” for compliance as of late 2019 (out of over 14,000 registered doctors to whom the requirements apply). Also, approximately 400 doctors were found to be not enrolled (see top panel on page 5). Current enrolment stands at 99 per cent, which is the highest possible figure in light of the transient nature of the medical register, according to the regulator.
Nevertheless, the Council’s 2018 report on professional competence found that monitoring of doctors’ compliance needed to be strengthened, with a greater role indicated for postgraduate colleges and employers. The report also drew attention to the importance of protected time for ongoing medical education. Overall, postgraduate training bodies reported positive engagement in CPD activity through the schemes. According to the Council report, it was “always envisaged ” that the model would evolve to ensure it remained relevant to a doctor’s current work practice and environment.
A new model may involve a three-year rather than annual cycle, according to Ms Jantze Cotter, the Council’s Director of Professional Development and Research. It will place greater focus on reflective practice, thereby building on the audit component of the current requirements.
“So it is more about the quality improvement processes and they can be related to an individual, a team, a practice, a hospital,” Ms Cotter told MI.
“We are working on that at the moment. And in that, we will have to build some sort of appraisal system and I wouldn’t want it to be noted that we were looking necessarily at revalidation, like the GMC [General Medical Council, UK]. We are looking internationally to see what models have been implemented there, and we will be pulling those into a thought process which a working group will look at; what might be best suited and applicable to Ireland.
“In doing that, the model will possibly become more of a tri-cycle [three-year] rather than an annual cycle, and the credits will be required over a period of time with an appraisal. Ideally, it would be great if we could implement a licensing model down the track instead of a single registration model.” Engagement with stakeholders is ongoing, “so it is not something that will ‘land’ on people.”
“Mixed with that, we have also been working on the quality of the continuing professional development activities,” added Ms Cotter. “At the moment, the postgraduate training bodies, or other organisations, offer CPD, and we just want to make sure we have got agreement on standardised quality, [ie] quality standards that apply to continuing medical education.
“We will be undertaking some work with an organisation to look at how we implement a CPD accreditation model, which again would complement that work…
“We know doctors are engaging in activities, we know most of them do it really well, we know most of it is ‘sort of relevant’; however, we don’t really have a measure of the quality of what is being engaged in, and the impact that has on the delivery of patient care and professional development.”
Would postgraduate training bodies have to undergo an accreditation process?
“The model that is around at the moment is that the training bodies and equivalent organisations will be the accreditor. The Medical Council won’t in any way take on any functions around accrediting CPD; but they will have standards in place where accrediting bodies will apply them and there will be a monitoring process. That is what is being discussed.”
On the assessors in an appraisal model, Ms Cotter said they could be from training bodies or employment organisations, for example, but this required further examination. Ms Cotter acknowledged that some of the terminology may give rise to certain perceptions or unease about what a new model may entail.
“How we communicate it is really important,” she said, emphasising that various models are being examined.
To date, healthcare employers have had a limited role in the area of CPD. Service demands have also led to lack of protected time for medical education, an issue that has escalated for many doctors during Covid-19 and which raises further concerns around burnout. The Medical Practitioners Act 2007 “clearly” states that employers have a role in facilitating maintenance of professional competence, underlined Ms Cotter. She said the Council needs to engage further with employers about how “they can satisfy themselves that doctors are getting access to CPD”.
It is important to find ways to ensure protected time and “employers have a key role in this”.
“And they have a key role in ensuring the people they engage and the people they employ are up-to-date and are maintaining professional competence. “They should be looking for that; they should be looking for evidence of that to satisfy themselves that the doctors are meeting the basic requirements from a legislative and registration point of view.” Meanwhile, Ms Cotter confirmed there had been no discussion of any increase in scheme fees and she did not envisage such a development. The Council is aiming to have a model ready for consultation “towards the end of this year”. A working group with representation from training bodies, the HSE, Department of Health and academia will also examine the proposals. A revised model will be put before Council and then go to public consultation.
Online medical education: Opportunities and limitations
In the current pandemic, there are “challenges” relating to provision of CPD “on many levels”, according to Prof Michael Griffin, Chair of the professional competence scheme (PCS) committee at the College of Anaesthesiologists of Ireland (CAI). “We are a hands-on clinical specialty, traditionally dependent on the tutorials and lectures on-site in our clinical working environment. It is suboptimal, although necessary, to change our method of delivery to a virtual platform,” he said.
“This comes with its own set of challenges, particularly the absence of the traditional interaction and questions and answers that are useful in the ‘live’ setting; clinical workshops (for example, our vascular, airway, echo workshops) for the moment are not possible to run in the traditional way; our simulation programme is requiring huge efforts by our clinical simulation department to continue in a modified way within social distancing guidelines. “The challenge of replacing meetings and conferences with virtual webinar events is that you lose the heart-to-heart you get from face-to-face and the social and networking aspect of academic meetings.
“Online conferences are proving to be much more tiring and intense than attending live lectures — I think we are only beginning to appreciate the limitations of learning in this way — again, something is missing in delivery of information without the animation and energy of the live presentation.”
More broadly, Prof Griffin noted that the “science of our specialties is constantly changing, which means that doctors require support in keeping up-to-date with new research, technologies and best practice guidelines, as well as the latest thinking in human factors and professionalism”.
“We have invested in an ambitious digital transformation in College to support new ways of working, including the recent launch of a new mobile e-portfolio for PCS participants to facilitate online and offline recording of CPD activities.”
A spokesperson for the RCPI said it had begun delivering more “blended learning” pre-Covid-19 and accelerated this process in recent months.
“Since March, we have delivered webinars and used virtual classroom tools to deliver courses to our trainees, members and fellows. The feedback has been very positive, with participants saying they enjoyed the virtual interaction and the greater convenience of not having to travel to attend.
“We also have created a digital library, where recordings of our webinars can be accessed at their convenience. The experience to date shows there is huge scope to develop and deliver more courses and events across our digital platforms. We will be guided by public health advice in terms of holding conferences and other live events in the months ahead.”
Prof Sean Tierney, Dean of Professional Practice and Development, RCSI, informed MI that the College had delivered “a comprehensive series of webinars” over the past four months. “In addition to a weekly President’s webinar dedicated to surgical practice, the Institute of Leadership organised a series of weekly webinars on medical topics that were of interest to many surgeons. The webinars are archived and available to watch back on our website.
“In addition, many specialties arranged weekly online teaching for trainees in our programmes and for other NCHDs working in specialist posts.”
In collaboration with the HSE National Healthcare Communications Programme, the RCSI developed several new free courses to help surgeons develop the skills of teleconsultations and video consultations.
The RCSI has also rolled-out a new programme of CPD courses for NCHDs in non-training posts for the 2020/2021 year.
“Classes will be delivered through a blended format, including online, in person and in our skills lab. While the capacity for classroom and skills-based training will be reduced, there will be opportunities for doctors pursuing a career in surgery to develop their skills in a simulated environment under the direct supervision of experienced surgeons while being Covid-19 compliant.” Dr Tony Cox, Medical Director of the ICGP, said the College had by necessity moved its delivery of medical education online in recent months.
Twice-weekly webinars commenced in April and these continue on a weekly basis. “They have been enormously popular with GPs, not only for their strong educational value and dissemination of up-to-date information, but also for the strong sense of collegiality and support that they have provided to GPs in these times.” Over 1,200 GPs consistently log in every week to the Zoom webinars; more than 1,700 joined for a webinar on chronic disease management on 15 July, and over 1,700 joined the half-day virtual conference ‘Learning from the Covid-19 pandemic’ on 9 May.
Dr Cox continued: “Our CME [continuing medical education] tutor groups have also risen to the challenge of remote meetings, and have delivered several small group teaching sessions via Zoom. Remote online meetings will never replace the traditional face-to-face small group learning sessions, but because of safety requirements and Covid-19 restrictions, they are a practical and very satisfactory solution at this time. GPs have continued to engage with the CME small group sessions throughout the pandemic.”
Meanwhile, an IMO spokesperson said GPs with a GMS list receive 10 days’ study leave for ongoing medical education. They receive the locum rate of €197.24 per day.
“This payment only covers a portion of the cost of getting cover and of undertaking the activities, and GPs fund the vast majority of this continuing education themselves. “Despite this and in spite of the inability to attend small group learning, conferences and other physical meetings, GPs have adapted and given up significant amounts of their personal time to attend the webinars run by the IMO and the ICGP in order to keep up-to-date with both the developing response to Covid and with other areas of practice.”
Ms Jantze Cotter, the Medical Council’s Director of Professional Development and Research, noted that training bodies had been “really successful” in delivering online education during Covid-19. “I think going forward, the online activities are really important,” she added.
However, she acknowledged that online activity could not replace networking and face-to-face support and advice from colleagues at physical meetings.
Managing doctors who fail to comply with CPD requirements
Managing doctors who fail to comply with CPD requirements
Around 1,000 registered doctors were being “monitored” for compliance with continuing professional development (CPD) requirements in late 2019, according to a report from the Medical Council CEO to members of the Council. Currently, CPD requirements apply to over 14,000 registered doctors. The monitoring exercise was commenced through a “proportionate risk management approach”, stated the CEO’s report, which was presented at a Council meeting in November.
In December, the CEO’s report referred to monitoring of “non-enrolment compliance” involving approximately 400 registered doctors.
Ms Jantze Cotter, the Medical Council’s Director of Professional Development and Research, told MI: “In the retention for registration documentation, we ask doctors to declare they are enrolled on a scheme and what scheme they are enrolled in.
“We then do cross-checks and get in contact with those who have not enrolled on a scheme… Every year we end up with a certain number that have not enrolled on a scheme and we contact those and we always manage to get that down to about 99 per cent being enrolled…
“Last year, we piloted a risk assessment framework, which was looking at CPD compliance of doctors and we asked training bodies to report to us doctors who were compliant with the full complement of requirements, so the 50 credits across the appropriate categories and also the clinical/practice audit.
“From that data, it was indicated that around 1,000 had not met the requirements. And really, not meeting the requirements can be not having one or two of the credits or not having an audit, versus some who record very little and we deal with those who record very little in a separate process as well… We then contacted that group of doctors to say, ‘you need to demonstrate that you are meeting the requirements and we will be looking at statements of participation’.”
Monitoring of compliance for the 2019/2020 year was cancelled amid Covid-19, but the Council understands there had been improvements.
Sometimes, the issue can be a failure to properly record the activity, outlined Ms Cotter. A “small” number of cases are still being referred to Council for consideration of making a complaint. This would follow consistent communications to the doctor “over a period of time”.
RCPI has the largest number of doctors enrolled in professional competence schemes. The number has increased from 2,848 in 2011/2012, to 4,564 in 2018/2019.
A RCPI spokesperson said the main “barriers” to CPD compliance identified through its research included time to engage in CPD activities, obtain evidence and record activities, along with finances. “This was particularly among junior hospital doctors not in training programmes.”
Protected time for CPD “should be included in all work practices”, the spokesperson added. The most common type of corrective actions identified during the annual verification process “are due to either issues with supporting evidence, incorrect dates being entered, or the minimum requirement not being recorded in one or more categories”.
The vast majority of RCPI fellows (generally consultants) have met requirements, while doctors on the general register (usually NCHDs not in training programmes) have “performed less well”.
“This vulnerable group requires greater support,” according to the RCPI.
Prof Sean Tierney, Dean of Professional Practice and Development, RCSI, commented: “Where doctors are not meeting their requirements, we have a system of supports in place to help them address the deficit and an ongoing monitoring process in place to identify their progress.”
RCSI has invested in a new operative logbook (RCSI elogbook), which was rolled-out to trainees in July. It will be made available to NCHDs in non-training posts later this year and to consultants subsequently. HSE National Doctors Training and Planning funds the continuous professional development support scheme (CPD-SS) programme directly. This has had “an enormous benefit in ensuring NCHDs in non-training posts have access to high-quality CPD”, noted Prof Tierney.
Enabling change: Colleges’ feedback on a new CPD model
Postgraduate training bodies provided feedback to the Medical Independent on the Medical Council-led project to reform the professional competence scheme model and changes they would like to see introduced.
Prof Michael Griffin, Chair of the professional competence scheme (PCS) committee at the College of Anaesthesiologists of Ireland (CAI), stated: “We support the changes proposed by the Irish Medical Council to the statutory professional competence scheme. The Irish Medical Council have recognised the meaningful reflective practice opportunities and professional development gains that exist during Covid-19 and have been pragmatic and flexible, promising to keep the situation under review.
“In terms of changes to the PCS model, we are in favour of it being less rigid in its categories and more supportive of doctors selecting relevant educational activities proportionate to their stage of career.
“We incentivise reflective practice and support personal development plans and would like to see the introduction of specialty-specific mandatory components to be undertaken in specific time periods — for example, every three-to-five years in communication, patient safety and quality improvement.” CAO CEO Mr Martin McCormack added that he would “like to see greater involvement of employers in the scheme delivery and greater protected time to be provided to doctors to participate in educational activities. Let’s all work together to improve the quality and safety of care delivered to patients.”
The RCPI said the current CPD model and framework in Ireland “is held in high esteem internationally”. It welcomed the opportunity to contribute to “enhancement” of the system by participating in an independent review by Health Care Informed on behalf of the Medical Council during 2019.
Recent anonymous participant surveys involving over 1,400 participants, conducted by the RCPI, showed that participant perceptions regarding CPD were generally very positive, with only 7 per cent reporting it as a bad idea; 81 per cent perceived CPD helps improve practice and patient care; 81 per cent patient safety; 71 per cent their teaching; and 61 per cent perceived that it improves their personal and professional wellbeing.
Prof Sean Tierney, Dean of Professional Practice and Development, RCSI, said the College would like “some flexibility introduced into the credit system so that doctors who are exceeding their requirements in some categories and meeting the overall requirements could use their excess in other categories to ‘compensate’ for other areas”.
“We would welcome further development expansion of the audit requirements and the support of the Medical Council to expand the range of national audits provided by NOCA (www.noca.ie). In addition, local audit requires resourcing both in terms of data collection and data analysis and we would like to see this being resourced by the HSE at hospital level.”
Dr Tony Cox, Medical Director at the ICGP, said the Council continuously reviews the PCS and engages regularly with the College through the Forum of Irish Postgraduate Medical Training Bodies.
“In a welcome response to the situation this year, the Medical Council have modified the CPD requirements due to Covid-19. “The ICGP has encouraged GPs to draft a personal development plan of their annual educational priorities each year, and to include all eight domains of good professional practice drafted by the Medical Council, within their plan,” he added.