Empowering the Filipino Physician through Continuing Professional Development in the Philippines: Gearing towards ASEAN Harmonization and Globalization

Knowing is not enough; we must apply. Willing is not enough; we must do.

Goethe

The Global Initiative towards Continuing Professional Development in the Medical Profession

Medicine is a very dynamic field and healthcare professionals need to learn new evidence that increase exponentially over time hence, the need to engage in Continuing Professional Development (CPD).(1) Globally, this is supported by the World Federation of Medical Education (WFME)  in its Trilogy of WFME Documents first drafted in 2003.(2) The overall mission of the WFME is the promotion of "improved health of all peoples".  In keeping with its constitution, as the international body representing all medical teachers and medical teaching institutions, WFME undertakes to promote the highest scientific and ethical standards in medical education, while integrating 21st Century teaching strategies and learning methods, introducing technology-enabled instructional tools, and innovative management of medical education. In accordance with this mandate, WFME in its 1998 position paper launched the programme on International Standards in Medical Education. The purpose was to provide a mechanism for quality improvement in medical education, in a global context, to be applied by institutions responsible for medical education, and in programs throughout the continuum of medical education. The WFME standard is framed in such a way as to specify attainment at two different levels: (a) basic standards or minimum requirements; and (b) standards for quality development.

The WFME Global Standards presented as a trilogy covers all three phases of medical education: basic medical education; postgraduate medical education; and continuing professional development. The process of implementation of the global standards was accelerated when the three documents were internationally endorsed at the World Conference in Medical Education: Global Standards in Medical Education for Better Health Care, Copenhagen, 15 – 19 March 2003.  The third document deals with Continuing Professional Development (CPD) of Medical Doctors: WFME Global Standards for Quality Improvement. A revised version of the WFME trilogy document came out in 2015.(3)  So, how different is the document on CPD different from the documents pertaining to basic medical education and postgraduate medical education? The Working Group on CPD realized that (a) there is no specific institutions, such as medical schools in the case of basic medical education, and postgraduate institutes or other bodies responsible for postgraduate medical training that will be responsible when defining global standards in CPD; (b) the provision and utilization of CPD involves a number of CPD providers, with varied course offerings. Their responsibilities and interactions are subject to great variation around the world, and their roles and competences are normally not well defined.

Section 2.3 of the third WFME document specifies the Content of the CPD. In the Basic Standard statement: "CPD must be diverse and flexible in content to enable doctors to develop their practice" and in the Quality Development statement: "Doctors should select CPD content based upon self-directed plans for learning that are consistent with their various professional roles." Furthermore Section 4.4 establishes the Influence of Doctors on CPD. In the Basic Standard statement: "Doctors must be given the opportunity to discuss their learning needs with CPD providers" and in the Quality Development statement: "Systems should be developed to involve doctors in planning and implementation of their CPD activities." Involvement with the process of planning and implementation would include participation in groups or committees responsible for program planning at the local or national level.

Internationally, legislated revalidation and recertification of physicians are pushing the profession towards mandatory professional development programs. Approaches to CPD, however vary widely across the world.(4)  In Europe, the European Accreditation Council for Continuing Medical Education is the one in charge of pan-European accreditation of activities and mutual recognition of credits, or credit transfers between European countries, different specialties, and the European and the North American credit systems. There is a need however to standardize the number of credit units required across the EU Member States. Across Europe, in the 27 EU Member States (Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, and Sweden) recertification was required only in the Netherlands.(5)  Mandatory CPD requirements lack the force of law in countries like Austria, France and Italy, although physicians in Austria realize that they may be subject to more litigations if they lack the required CPD units. Instead of mandatory requirements, Belgium provides financial incentives in the form of bonus payments for physicians practicing outside hospitals who have accumulated 20 CPD units annually.(6)

Other countries that are not part of the EU in Europe include Albania, Armenia. Belarus, Gibraltar, Iceland, Kosovo, Lechtenstein, Macedonia, Norway, Russian Federation, Switzerland, Turkey, Ukraine, and Vatican City State (Holy See) and the United Kingdom (BREXIT).  Norway does not impose CME requirements for general practitioners, but specialists will lose their specialization and a margin of 20% higher fee if they fail to participate in specialty-specific CME courses.(6)  In the United Kingdom, the Royal College of Physicians (RCP) supports its members and fellows, as well as other physicians and healthcare professionals, with a range of online learning modules that provide up to date, evidence-based training to help them excel in their careers. Senior Medical Staff ought to have an online CPD Diary to help physicians maintain a personalized and validated record of their CPD activities, and a Revalidation e-Portfolio. Workplace-based assessments are likewise carried out to effectively test for competence in task performance.(7)

In the USA there is a centralized accreditation of providers related to recertification for practice in medical specialties. The American Academy of Family Physicians, the American Medical Association and the American Osteopathic Association are the three organizations that own the three major CME credit systems. The description of these advances include the evolution, although not yet completed, from a time metric to a value metric as the way to quantify involvement in CME on the part of physicians. The credit systems have evolved from accepting participation to requiring a higher level of achievement or active involvement in the activity in order to receive CME credit that highlights the Performance Improvement CME as one of the learning formats recognized for CME credit.(8)  Canada has a mandatory completion of the maintenance of certification that started in January 2000. They also have a publicly accessible white list of physicians certified for maintaining competence.(9) 

In Latin America, the many policies regarding continuing professional education are under the purview of the professional organizations. Argentina’s medical societies have long been responsible for accreditation and provision of CPD. In Mexico, a large number of specialty boards require CPD for members to maintain specialty certifications. Moreover, credentialing in many private-sector hospitals and clinics require physicians to participate in CPD/CME courses. The Mexican government is considering a compulsory program.(10)

In Oceania (Melanesia, Micronesia, Polynesia and Australasia), Australia and New Zealand has a maintenance of professional standards program that requires both continuing medical education and quality assurance activities. In New Zealand, continuing professional development is mandatory in order to hold vocational/specialist registration.(11)

Across Africa, countries are at varying levels of developing CPD systems. In most African countries, no systematic approach to regulating CPD programs exist, and documentation of CPD completion is not required for re-licensure.(12)    In some countries, such as Uganda and South Africa, regulatory bodies require a specific number of professional development credits in order to re-register or re-license  healthcare workers. In 2006, Ndege(13) further avers that for CPD Programs to succeed in Africa, there ought to be a legal framework for CPD with clear policies and structures in place.

Requirements in Asia are likewise diverse. In East Asia (China, Japan, Korea and Taiwan), China has adopted a national credit system that is necessary for career advancement and re-registration.(14) Japan has no mandatory system, but the Japan Medical Association conducts a voluntary certifying program. Approximately 70% of its membership is certified.(10)  In Korea, the requirements for successful transition from CME to CPD are the primary concern for Korean Medical Association (KMA).(15)16)

In Southwest Asia (Armenia, Azerbaijan, Bahrain, Cyprus, Georgia, Iraq, Israel, Iran, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syria, Turkey, United Arab Emirates and Yemen), the Abu Dhabi Health Authority in the United Arab Emirates requires physicians to attain at least 50 hours of CME per year for license renewal, of which half of the time must be spent in the form of formal education from either an accredited medical school or a professional body.(17)  In Iran, the CME programs are besieged by the inadequate integration of educational programs with the professional requirements and milieu of the physician thus making implementation of the programs ineffective.(18)

In South Asia (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka), India tried to create a national credit system for continuing medical education (CME) but succeeded only on a state-by-state basis, whereby only 9 out of 28 states have developed systems that are tied to re-registration.(14)  With different requirements across states none has been in place long enough to evidence compliance.(10)

With increased professional migration and facilitated cross-border recognition of qualifications afforded by the MRA, ASEAN Member States must ensure that their national policies promote international accountability of physicians.

Engendering the Continuum of Education in the Medical Profession

Education in medicine occurs in a continuum from basic undergraduate medical education to continuing postgraduate medical education and on to continuing professional education. CPE is the means by which individuals maintain their knowledge and skills related to their professional lives. It is continuing education as applied to Continuing Professional Development (CPD).  To gain the most benefit from the CPD process, every physician must create a personal professional development plan for career progression; engage in relevant CPD activities aligned to their scope of practice; allow external monitors to audit the impact of both the process and the product of the CPD activity on practice; and reflect about how the CPD activity has improved his professional competence and how he has translated knowledge gained into his clinical practice.

Mapping the Personal Professional Development Plan

Integral to the concept of Continuing Professional Development (CPD) is the Personal Development Plan (PDP) of every physician who graduates from a postgraduate residency training program. For the physician, the aim of creating a personal development plan is to document a process of self-analysis, personal reflection and honest appraisal of one's strengths and weaknesses. This should enable the individual physicians to evaluate the value of the specialty and subspecialty training they have received, and to consider their future career and leadership development.  Although earlier criticized by some authors(24), the PDP has evolved through the years to  provide a framework for examining personal strengths and weaknesses, clarifying goals, and establishing future directions as the  physician sets out into clinical practice after undergoing a structured residency training program.(25)(26)    In creating a PDP, physicians need to follow three stages: (a) Stage 1 – Personal Analysis. The first stage is designed to analyze one's strengths and weaknesses. Physicians should be able to envision their career path/s and evaluate the alignment of the outcomes of courses that they may have attended with their intended career path. These should be augmented by seizing and creating opportunities that may be derived from their experience and coping with threats to their success and sustainability. (b) Stage 2 – Setting Goals. This involves setting new, clearly definable and measurable goals for oneself. At this stage, physicians may draw inspiration from role models during their postgraduate training days, who may provide guidance in setting future career direction. (c) Stage 3 – Personal Objectives. This stage involves setting out one's personal objectives. These can also be set in context within specialty or subpecialty, which will be helpful in reinforcing its value. When CPD is undertaken in the context of a PDP, then it becomes a deliberate and meaningful effort toward self-improvement and not just for compliance and credit accumulation.(25)

Engaging in Relevant CPD Activities

Continuing Professional Development should be competency-based and should include all activities that physicians undertake, formally and informally, following completion of formal training and involves the continuous acquisition and development of professional knowledge, skills, values and practice aimed at keeping abreast of evolving medical evidence, enhancing expertise in existing skills, broadening competence to new responsibilities or changing roles in their leadership, managerial, social, personal and professional lives.(27) In the Royal College of Physicians and Surgeons of Canada competency framework, the CanMEDS model includes leadership, communication, professionalism, collaboration, scholarship and advocacy.(28) The intent is to enable physicians to work legally and effectively while achieving the goals of professional performance standards in providing better health care that redound to patient safety, i.e., gaining knowledge that translates to practice change.(29)  Physicians engaging in CPD fulfil a professional obligation motivated by the will and desire to maintain professional quality. An ongoing commitment to continuing professional development is a major component of the CPD process that encompasses (a) organizational/professional or external activities such as live courses, seminars, meetings, conferences, audio and video presentations, (b) practice-based/work-based or internal activities such as case conferences, grand rounds, journal clubs, teaching, consultation with peers and colleagues, (c) formal educational activities in Masteral or Doctoral programmes,  (d) lifelong self-directed learning in print or in internet-based materials, possibly based on a curriculum, with pre-tests and post-test assessments; with or without compulsory recertification or revalidation, and (e) learning outside one's scope of practice which includes topics that promote professionalism, strategic thinking, leadership and management skills, financial literacy, etc.

In the context of Continuing Professional Development (CPD) for the medical profession, “scope of practice" means any role in which physicians use their skills and knowledge as a health practitioner. For the purposes of registration standard, practice is not restricted to the provision of direct clinical care. Physicians should participate in CPD activities that cover the whole scope of their professional practice. This includes work in government and private practice, voluntary work that involves patients and non-clinical professional activities such as education, management and research, peer review, advisory, regulatory or policy development roles, and any other roles that impact on safe, effective delivery of services in the profession. CPD is intended to help physicians to update what they have learned at medical school and during postgraduate training to reflect changes in practice.(29)

Monitoring the Effectiveness of a CPD Activity

The evidence review undertaken by the Institute of Medicine (IOM) in 2009 revealed that an effective CPD system should prepare health professionals to provide patient-centered care, work in interprofessional teams, employ evidence-based practice, apply quality improvement, and use health informatics.(30)  

The effectiveness of a CPD activity, in terms of achieving its educational objectives, can only be apparent after the event. To evaluate the effectiveness of a CPD activity, organizers may use pre- and post-tests to measure changes in the knowledge and skills of the participants. Questionnaires are given out to participants after each program to enable feedback about the organization of the CPD activity and to gather suggestions for improving future CPD activities. But so far in most countries no effort has been initiated to relate CME to physician performance or patient health status.(14)

In countries with developed CPD systems that are performance-based, the effectiveness of CPD activities are monitored by an appraiser (through the appraisal process) or by the provision of data that specifically considers professional behaviors or outcomes. For their part, physicians should also engage in self-assessment (through reflection) to ensure that they maintain a balanced portfolio containing evidence of their ongoing CPD activities.

The overarching goal of monitoring CPD for the medical profession includes: (a) promoting and upgrading the practice of the profession; (b) improving the competence of physicians in making judgment in cases they encounter by improving knowledge and skills; (c) checking whether individual physicians update their knowledge and skills by attending accredited CPD courses; (d) continuously improving the competence of the physicians in accordance with international standards, thru evaluation/monitoring feedbacks; (e) checking if measures that continuously improve the competence of the professionals are in place; and (f) improving patient safety, reducing medical errors to a minimum if not nil, and subsequently decreasing the occurrence of medico-legal suits.

There is ongoing debate and discussion as to whether mandatory continuing education for re-licensure of physicians leads to more professional growth and enhanced performance. Regulatory agencies may mandate strict compliance by physicians to CPD requirements based on credit units but this comes with a caveat: that the CPD activity will be counterproductive if it does not answer a felt need, is irrelevant to their practice setting and is taken only to meet regulatory requirements.(18)(31)  Learning becomes successful and makes an impact in practice when it is based on an identified need to close a competency gap, when a CPD activity is geared toward improving a skill for which there is a demonstrated need and when learning is reinforced.(1)(3) Some physicians may attend CPD activities only because they receive per diem anyway or because they are allowed to attend on official time or because they need to fill lacking credit units prior to renewal of license.(12)  Therefore, while continual learning is necessary for health workers to provide quality care, having a CPD program that is inneffective, wasteful, or demotivating can be counterproductive, especially when implemented in low-resource settings. The IOM Report found that ill-designed and ill-planned CPD activities could in fact exacerbate rather than mitigate health workforce issues.(30)

The purpose of recertification in ensuring safe and high-quality healthcare has gained primacy in recent years brought about by the cross-border movement of physicians and other allied health professionals. Recertification intends to provide the platform to periodically attest to the physicians' professional proficiency in their field. A review of the assessment formats revealed that a great variety exist between countries in terms of assessment formats used. Recertification procedures and requirements also varied significantly, ranging from voluntary participation in professional development modules to the mandatory collection of multiple performance data in a competency-based portfolio.(32)  Differences between systems partly reflected different goals and primary purposes of recertification. Knowledge assessment was fundamental to recertification in most countries. Another difference concerned the stakeholders involved in the recertification process: while some systems exclusively relied on physicians' self-assessment, others involved multiple stakeholders. Interestingly, there are also many changes in the needs of patients, changes in patient care, and changes in society’s expectations of the way physicians work: yet, the perspectives of the patients who are the ultimate beneficiary of physicians' professional competence, are rarely involved in the assessment.(33)

Reflecting as a Critical Element in Learning for Life

As part of the supporting information, the physician should provide reflection on what has been learned from the CPD activity, and how this has influenced his practice.(34)  Most CPD activities are based on an hour-related credit system, instead of on a performance-based or outcomes-based system. (Lewis 2015) It is important however, that we focus less on the process and instead shift our focus on the outcome of CPD. Time spent on a CPD activity is useless, unless the physician engages in the process of reflection focused on learning outcomes to determine the importance and alignment of the CPD activity to the physician's personal development plan and career and how the CPD activity can benefit him in improving clinical practice. Important questions that an accreditor/monitor of CPD should consider and the corresponding self-reflective questions that a physician ought to remind oneself prior to seeking the accreditation of CPD  activities should be: (a) What is the physician's job? (Self-reflection: What does my work as a physician entail? Which of the dimensions in my portfolio need development? ); (b) Have you considered the description of the scope of practice in the appraisal documentation? (Self-reflection: Have I undertaken CPD activities to enhance my teaching and mentoring skills in my practice as an educator in medical school or as a trainer in a residency training program? Have I undertaken CPD activities to enhance my management skills in my practice as a hospital administrator? Have I undertaken CPD activities to enhance my research skills in my practice as a researcher, advisor/key opinion leader/resource person, as a member of a regulatory agency or as a health policy advocate?); (c) Is the CPD relevant to the current and emerging knowledge, skills and behaviors required for the physician's specialty or practice, professional responsibilities and proposed areas of professional development and work? (Self-reflection: Have I undertaken CPD activities unique to my field of clinical expertise?) (d) Have you considered current guidance in the physician's specialty from the relevant College/Faculty or specialty association? (Self-reflection: Have I undertaken CPD activities to enhance my knowledge about clinical practice guidelines applicable to my field of clinical expertise that will redound to safe, evidence-based and cost-effective clinical care to my patients?). 

Self-reflection is anchored on the constructivist approach to learning(35) and it posits the concept of heutagogy or self-determined learning as opposed to simply andragogy or adult self-directed learning. Heutagogy builds on andragogical principles but is a more holistic approach to learning and teaching that shifts the focus from the teacher to the learner.(36) One of the differences between andragogy and heutagogy is that heutagogy further expands upon the role of human agency in the learning process. Thus, the physician as learner in a CPD activity, is seen as “the major agent in their own learning, which occurs as a result of personal experiences”.(37) Heutagogy and its child, technoheutagogy or simply technagogy recognizes the transformative role of technology integration in a learner-centered approach to learning in the 21st century. Through self-assessment, physicians are well on their way to mapping their career path while learning for life in the profession.(38)