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Ophthalmology

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Middle East African Journal of

Apr-Jun 2014 / Vol 21 / Issue 2

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134 Middle East African Journal of Ophthalmology, Volume 21, Number 2, April - June 2014

INTRODUCTION

The first reported continuing medical education (CME) course took place in 1935; however, only in the 1960s did

CME start to be discussed as a coherent body of literature.1 This paper reviews best practices of effective continuing professional development (CPD). CPD’s complexity, relevance, guidelines, and principles and managing a CPD program will be discussed. The four‑step CPD cycle is discussed in the context of three professional behaviors for which doctors and CPD providers have specific roles and needs.

DEFINITION

CME’s concept generally refers to expanding medical knowledge, skills, and attitudes.2 CPD incorporates and exceeds this concept by acknowledging a wide range of competencies needed to practice high quality medicine, including medical, managerial, ethical, social, and personal skills [Table 1].3‑5 Grounded on the well‑developed tradition

of lifelong learning in medical profession, CPD integrates every physician’s ethical responsibility and increases job satisfaction.6‑8

A variety of CPD definitions have been given:“A continuing process, outside formal undergraduate and postgraduate training, that allows individual doctors to maintain and improve standards of medical practice through the development of knowledge, skills, attitudes, and behavior. CPD should also support specific changes in practice.”9

“The wide‑ranging competencies beyond clinical update, research and scientific writing, multidisciplinary context of patient care, ethical practice, communication, management and behavioral skills, team building, information technology, audit, and appropriate attitudinal change to ensure improved patient outcomes and satisfaction.”10

“A range of learning activities through which health professionals maintain and develop throughout their careers to ensure that

ABSTRACT

Continuing professional development (CPD) involves not only educational activities to enhance medical competence in medical knowledge and skills, but also in management, team building, professionalism, interpersonal communication, technology, teaching, and accountability. This paper aims at reviewing best practices to promote effective CPD. Principles and guidelines, as already defined by some professional societies and world organizations, are emphasized as core actions to best enhance an effective lifelong learning after residency. The personal learning plan (PLP) is discussed as the core of a well‑structured CPD and we describe how it should be created. Fundamental CPD principles and how they are integrated in the framework of every physician’s professional life will be described. The value of systematic and comprehensive CPD documentation and assessment is emphasized. Accreditation requirements and professional relationships with commercial sponsors are discussed.

Key words: Accreditation, Appraisal, Continuing Professional Development Clinical Audit, Continuing Medical Education, Personal Learning Plan, Portfolio, Revalidation

Continuing Professional Development: Best Practices

Helena P. Filipe, Eduardo D. Silva1, Andries A. Stulting2, Karl C. Golnik3

Access this article online

Website: www.meajo.org

DOI: 10.4103/0974-9233.129760

Quick Response Code:

Ultrasound Department, Ocular Surface Disease Department, Head of Contact Lens Unit of Institute of Ophthalmology Dr. Gama Pinto, Lisbon, Portugal, UE, 1Ophthalmology Pediatric Department, Head of Genetic Department, Coimbra University Hospitals, IBILI, Professor of the Medicine Faculty of Coimbra University, Coimbra, Portugal, UE, 2Department of Ophthalmology, Emeritus Professor of University of the Free State, Kimberley Hospital Complex, Kimberley, South Africa, 3Department of Ophthalmology, Neurology and Neurosurgery at University of Cincinnati, Cincinati Eye Institute, Cincinnati, Ohio, United States of America

Corresponding Author: Dr. Helena P. Filipe, Rua Sargento José Paulo dos Santos nº 8 1800‑331 Lisboa, Portugal, UE. E‑mail: hpriorfilipe@gmail.com

Ophthalmic Education Update

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Middle East African Journal of Ophthalmology, Volume 21, Number 2, April - June 2014 135

they retain their capacity to practice safely, effectively, and legally within their evolving scope of practice.”11

Each definition shares the broader perspective of CPD, that it:• Isself‑drivenandindividuallytailoredaccordingtoneeds

assessment• Considersthedoctor’scomplexworkingenvironmentasa

“…multidisciplinary context of patient care”.10 Four broad groups are summarized in the Basel Declaration of European Union of Medical Specialists (UEMS): The individual/society; healthcare professionals; health employers; and healthcare fund raisers12

• Isanongoinglearningprocessbuildingoninitialeducationto ensure competence regarding current and future work duties

• Goesbeyondthetraditionaldesignationfordoctor’sCMEafter residency training, a narrower concept, usually only including medical knowledge and skill

• Expands content from clinical to holistic topics suchas interpersonal communication skills, ethics, practice management, professionalism, and extends learning venues from the classical conference room to practice settings13,14

• Embraces new educational domains set by professionalsocieties:• TheRoyalCollegeofPhysiciansandSurgeonsofCanada’s

seven key benchmark competencies (CanMeds): Medical expert/clinical, collaborator/manager, health advocate, scholar, professional, decision maker, and communicator15

• TheMedicalCouncilofNewZealand’sdomainsforrecertification and CPD: Medical care, communication, collaboration and management, scholarship, and professionalism16

• The American Board of Medical Specialitiesevaluation domains: Bedside manner, medical

knowledge, interpersonal and communication skills, professionalism, system‑based practical clinical work, learning, and development efforts17

• TheUnitedKingdom’sGeneralMedicalCouncil’sdomains: Knowledge, skills and performance;safety and quality; communication, partnership and teamwork; and maintaining trust18

• The Royal Australian New Zealand College ofOphthalmology’s framework learning categories: Clinical expertise, risk management and clinical governance, and professional values19

• Is a “self‑evaluationmodel reporting form”necessarilyincluding an evaluation component10

• Shouldproducebehavioralchangeinmedicalpracticeso that healthcare improvement is achieved and measurable13

• Involveslegalaspectssuchasavoidinglawsuitsandpracticingunder compulsory relicensure1

• Promotesthephysician’saccountability.20

RELEVANCE

Emphasis on CPD has been growing due to several factors:• Physiciansareleadinglongerprofessionallives• Globallyincreasingmobilityofbothpatientsandhealthcare

professionals21,22

• Acceleratedproliferationofnewknowledge,newtechnology,and techniques

• Society ’s increased expectations of the medicalprofession

• Publichealthcaresystemsconcerns• Complex healthcare working environments where

doctors are constantly challenged to develop and master multidisciplinary teamwork among peers, allied healthcare personnel, employers, regulators, and healthcare systems authorities

• Increasing requirements ofCPD activities’measure ofperformance.

Despite the increased emphasis on CPD, a variety of barriers must be overcome:• Physician'sworkoverloadandlesstimeallocatedtolearn• Underfunding• Improperlydefinedcommercialsponsorships• Noncompliancewith best practices to design, develop,

implement, and evaluate CPD educational interventions• Biasededucationandconflictsofinterestwithsponsors• Lack of clear definition of responsible parties and their

specific roles in CPD• Effective assessment of CPD activities to gauge

cost‑effectiveness• Coordinationofallstakeholders• Demonstrationofthedoctor’sCPDtosociety.23

Table 1: CME and CPD contrasts

CME CPDEpisodic interventions designed to address the educational needs of groups of learners

Lifelong based on ongoing self‑assessments designed to address the educational needs of individuals

Generally teacher centered/driven

Generally learner centered/driven

Principally encompasses the clinical domain

Comprehensive in scope. Encompasses the clinical domain as well as practice management, leadership, administration, education, and an entire spectrum of professional activities

Lecture based format (passive learning)

A variety of learning formats and delivery methods (active learning)

Most often conducted in formal settings such as lecture halls or conference rooms

Conducted in a variety of different venues including locations other than lecture halls and conference rooms

CME: Continuing medical education, CPD: Continuing professional development

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136 Middle East African Journal of Ophthalmology, Volume 21, Number 2, April - June 2014

PRINCIPLES

Given the increased emphasis and barriers described above, it is obvious that CPD must change to be a systematic process that is credible and transparent to the community.1,13 Though medical school and residency training have long been formally regulated, only recently has CPD garnered such attention.24 Additionally, there is wide variability in the approach to CPD globally.25 Despite this, the UEMS promotes free movement of European medical specialists, while trying to ensure healthcare’s high quality.26 Therefore in Europe, CPD programs’ harmonization among countries would enhance medical care.21 An effective CPD scheme should have three quality components:24,27,28

• Professionalimprovementthatensurespersonallearningrelated to the populations’ changing needs and developing healthcare service

• Effectivelearninginterventionsshouldbedesigneduponclear, attainable, and measurable learning outcomes and offer relevant and evidence‑based content to the physician’s clinical practice

• Itmustbeaccountable,transparent,amenabletoregulation,and useful for assuring quality in the process of relicensure.

Furthermore, it is essential that skillful CPD management is clearly articulated based on the various CPD stakeholders’ needs.1

Additionally, there must be way for the physician to monitor and report CPD activities.29 Many schemes and recommendations exist as to how best to award credit to CPD programs. These schemes typically have the following key components, which can coexist to a certain extent:• Creditbased,whereonecreditisusuallyawardedforeach

hour of educational time spent. A minimum should be achieved over a defined time period30

• Documentbased,whereanorganizedflowofdocumentshelp to demonstrate and assess CPD.1

As examples of good CPD practices we suggest the guidelines to administer and manage a CPD program compiled by the InternationalCouncilofOphthalmology(ICO).Additionally,the ICO has suggested that ophthalmology societies’ CPDcommittees should take responsibility for CPD activities. Committees should be responsible for designing, implementing, and evaluating a CPD program according to specific criteria.13

PARTICIPANT PERSPECTIVE

The personal learning planPersonally designed, CPD reflects adult learning principles of autonomy, self‑direction, goal orientation, and practice‑based learning.27 PLPsdocument accomplished educational events,

behavior changes in practice, and how career aspirations were enhanced.

TheICOhassuggestedaquestiontemplate13 to guide doctors willingtobuildaPLPaspartoftheirprofessionaldevelopment.Itisathree‑stagestepwiseprocedure:• DevelopmentofthePLP,inwhichdoctorsarerequiredto

reflect on their learning professional needs• Completionofactivities,inwhichdoctorschooseactivities

to meet their professional needs, and• Submissionofareport,forwhichdoctorsmustreflectand

write about the effectiveness of their learning.

CPD’s practice can be conceptually organized around three fundamentalquestions:WhatwillI learn?HowwillI learn?andHowwellhave I learned?These threequestionscanbethoughtofintermsoftheCPDcycle:(1)Identifywhattolearn;(2) plan how to learn; (3) learn; and (4) follow‑up14 [Figure 1].

What will I learn?A learning need is a gap between current personal competencies/population health status and the desired state. 14 Well‑designed educational interventions fill these gaps and remove barriers to change in behavior. Perceived needs may be identified during an appraisal; whereas, unperceived needs may demand direct knowledge testing.1,14Learninggapsmaybe identifiedduring direct patient care, in interactions with the clinical team and department, in nonclinical activities (readings, scientific conferences), in quality management and risk assessment (audits, patient satisfaction surveys), in specific needs assessment (self‑assessments and revalidation), and in peer review.1

Clinical auditA clinical audit is a systematic staged cycle of review of one’s own patients’ charts and surgical outcomes.31 Audit criteria

Figure 1: The continuing professional development cycle steps (in blue) and the triggering questions to professional behaviors in practice (in orange)

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owner and those entitled to interact with it, thus offering meaningful learning experiences.38,39

How well have I learned?Assessment closes the CPD cycle and involves two components:1

• Reinforcementorfindingopportunitiesinclinicalpracticeto apply new knowledge and skills

• Dissemination of new learning to colleagues at practicesettings (e.g., rounds, clinical meetings, and unplanned moments during clinical practice).

Portfolios as portable collection of artifacts can also be valuable assessment tools amenable to appraisal discussions, peer‑review, and revalidation.39 Within their regulator function, societies and colleges are encouraged to establish CPD guidelines and provide theirmembersaPLPandaclinicalaudittemplatetoincludeintheir personal portfolio. This material can be available online and should ideally include the designation and description of the chosen learning activity, planned date to undertake the activity and completion date, CPD points awarded, personal reflection about learning goals fulfillment, effective learning achieved, and its impact in practice.13 Medical teaching organizations are increasingly adopting their own e‑portfolio systems such as the free user‑friendly online portfolio of the British Medical Journal.40

PROVIDER PERSPECTIVE

Methods and toolsCME has traditionally been concerned with disseminating information, but CPD has shifted the emphasis to demonstrating change in behavior in clinical practice.1,14 Adults participate in educational events when motivated by the identification of a specific learning need and a pragmatic desire to apply knowledge

must be best practice evidence‑based and clearly presented beforetheaudittakesplace.Recommendationsfromclinicalpractice guidelines may be useful to develop criteria and standards. Criteria are explicit statements defining what the outcomes of care will measure. Standards are the threshold of expected compliance for each criterion. Data is collected and results compared to criteria and standards. Change should be implemented by formulating recommendations. Clinical audits are an important component of medical professional accountability and can serve as a method of determining gaps in knowledge.32‑35

How will I learn?Following a gap’s identification, a learning activity should be planned and undertaken–CPD cycle steps 2 and 3 [Figure 1].1,14 Sometimes an educational event is undertaken by doctors not for the sake of advancing factual learning, but for boosting their confidence on a particular topic or skill.1 CPD activities should be chosen according to the type of the identified need whether it be knowledge and skills updating, competency assurance, or performance demonstration in practice.14

CPD activities can assume a variety of formats characterized as practice improvement, independent professional development, or research/self education. Table 2 presents several examples of educational events according to this categorization.13

A portfolio is a record of what its creator has to offer in terms of range, quality of knowledge, and level of skill attainment.36,37 An e‑portfolio documents the individual’s professional progressionasaweb‑basedcollectionofartifacts:Reflections,resources, demonstrations, accomplishments, and time periods. e‑portfolios encourage exchange of ideas and feedback between

Table 2: CPD activities

Practice improvement meetings and courses

Independent professional development Research and self‑education

Clinical audits Clinical or surgical traineeship or fellowship Principal investigator of approved clinical trial or research project

Surgical audits Postgraduate study relevant to ophthalmology Preparation of grant proposalsMortality and morbidity meetings Risk management (e.g., communication, ethics) Author of peer‑reviewed journal articleQuality assurance meetings Self‑development courses

(e.g., business management, computer skills)Author of a textbook or a book chapter

Participation in accreditation of a practice

Personal learning projects (e.g., derived from the personal development plan)

Presentation of a paper or poster to peers at a recognized scientific meeting

Participation at seminars, conferences, workshops

Presenter at a workshop or course related to ophthalmology

Self‑Assessment activities (e.g., reading journals or interactive online courses)

Participation at grand rounds, journal clubs, case conferences

Supervising or mentoring ophthalmology residents/registrars or fellows

Audiovisual educational activities

Participation at radiology or pathology meetings

Lecturing residents/registrars or medical students College‑approved educational visits to other institutions

Examiner to residents/registrars/medical studentsSupervisor of postgraduate studentsDevelopment of CME materialsReviewer for journalsEditor of a multi‑authored textbookReviewer for scientific research grants

CPD: Continuing professional development

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and skills gained.27,41 Unplanned learning that occurs in daily workplace cannot be disregarded and is usually reinforced and disseminated.1 CPD providers must design educational interventions to meet identified gaps considering the participants priorknowledge.Learningobjectivesmustbedesignedfromthe learner’s perspective and clearly map the content in terms of expected outcomes. Well‑written learning objectives will suggest the best CPD delivery method and format concerning theeducationalevent’sgoal:Knowledgeupdating,competencydevelopment, or performance demonstration. Consideration of the size and the type of the audience (e.g., generalists versus subspecialists) may also dictate appropriate methods.

Regardlessoftheselecteddeliverymethodorformat,interactivepractice‑based learning formats are the most successful.14,42,43

Incorporating at least 25% of interactivity into a learningintervention; such as a lecture by ensuring time and opportunity for questions and discussion, shifts the educational focus from passive teaching to active learning.44

Time and space boundless and web‑based CPD events are now being widely used in medical education incorporating even remotecommunities.Iftutor‑ledandinteractivityopportunitiesare provided, passive learning situations will be avoided. Social media (social networks, wikis, blogs, virtual worlds, and simulations) is being increasingly considered by educators/organizations for its potential in medical education. The medical community is changing from having conservative and reluctant stand on this issue to embracing and leveraging these tools into formal education. Online tools improve research efficiency and social media enhances professional networking.45‑48

AccreditationCPD must be amenable to external evaluation to become transparent, demonstrable, and accountable.1,13,14Ifconsistentlyplanned,undertaken,andrecorded;CPDcanbeassessed.Ideallyalways as a self‑assessment including regular discussions with peers or a formal examination. More than a process to meet accreditation requirements or to be credit awarded, assessment should be envisioned as a higher value to bring effectiveness to learning.49 A set of international standards was defined by World Federation of Medical Education to work as a global tool for quality assurance and development of CPD.24

Measuring CPD activities’ effectiveness is crucial and should start during the CPD program, but ultimately to include effects on population health status. These assessments can be used to justify cost effectiveness of educational events’ outcomes.10 CPD program’s assessment should provide information on whether:• Targetaudienceneedswereaddressed• Learningobjectivesweremet• Participantswereengaged• Behaviorchangeswereachieved.

Based on business and industry widespreadKirkpatrick’sevaluation model, Dixon has defined four CME levels of evaluation that should match teaching strategies and learning event outcomes:• Perceptionandsatisfaction• Competencies• Professionalperformance• Healthcareoutcome.50

Two more levels were later added:• Participationrelatedtoaneducationalevent’sattendance• Returnofinvestmentrelatedtocost‑effectiveness.14

There are a variety of ways to perform the evaluation. Clinical audits suit patient outcomes assessment; whereas, CPD credit accumulation, learning portfolios, criterion reference methods, computer diaries, peer review, and chart audits can be used for performance evaluation. Grant describes an exhaustive list of different assessment methods according to the evaluation object.1 Davis contrasts a list of assessment tools to factors affecting their choice as cost, validity, reliability, acceptability, and feedback opportunity.14

Several professional societies and world organizations and colleges51‑60 provide accreditation guidelines including:• Onlinestandarddocumentationtemplatesandapplication

forms, available in a transparent and practical presentation for all interested

• Accreditationcriteriaforprovidersincluding:• Goals and learning objectives clearly built on an

identified learning gap• Content/formatdeliveryinaccordancewiththegoal

of the educational event• Assessmenttypeinaccordancewiththepreestablished

learning objectives• Assessmenttypeandresultssharedwiththeparticipants• Assessment resultsmade available for futureCPD

program improvement• Clear guidelines to avoid commercial sponsorship

conflict.

The growth of e‑learning CPD has led to accreditation criteria for this format. The European Accreditation Council of Continuing Medical Education (EACCME) has established criteria to ensure e‑learning interventions’ accreditation.61 The same goal was pursuedbythee‑CPDTaskForceoftheRoyalCollege.62 These criteria add items specific to e‑learning such as:• Confirmprivacyandconfidentialityofthelearner• Staterevisionofcontentandexpirydate• Contentmustbeevidencebased• Follow adult learning principles such as problem‑based

learning, reflective learning, and task‑based learning• Contentdeliverymustcomplywithmultimediaprinciples

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• Shouldhaveengagingstrategiespromotinginteractionandmeaningful learning

• Providefeedbackoflearning.

Sponsor relationshipsMinimizing potential conflict of interest from sponsors is imperative. To gain approval for industry sponsorship the CPD provider should make an application to the ophthalmology society’s CME committee and follow criteria.63,64 The Canadian Medical Association Policy indicates that: “Organizations providing financial support to accredited CPD events cannot have any role or influence over any aspect of the CPD planning process. Physician’s organizations that receive ‘educational grants’ should provide a statement of account to each sponsoring organization for how funding was allocated or spent”.65 TheRoyalCollegeApproval of AccreditedGroupActivitiesApplication Form contains items related to fiscal matters and requires a declaration of conflict of interest. A letter should be sent to the sponsor(s) indicating that funds will be received as an educational grant.66 Speakers may verbally disclose any conflicts of interest or provide written documentation in the event’s brochure.

InGeneral,CPDprovidersshouldbemadesolelyresponsiblefor designing, implementing, and assessing the educational inter vention. The sponsorship and its terms must be communicated to the local/national professional society/healthcare authority. Content should be unbiased, commercial sponsorship acknowledged, and speakers’ conflict of interest disclosed.

CPD sponsorship guidelines should enforce the physician’s understanding that they must:• Keeptheirprimaryobligationtotheirpatientsandduties

to society• Ensureanunbiasedparticipation incollaborativeefforts

between their interaction and pharmaceutical companies (health supplies, research, and education)

• Avoid/managesituationswithconflictofinterest• Promoteclearphysician‑developedguidelinesforinteraction

of physician‑industry.

CONCLUSIONS

CME is a lifelong learning process pursued by doctors from medical school until retirement, and has traditionally been viewed in terms of knowledge updating.

CPD demands professional skills that extend beyond medical knowledge such as management, education and training, information technology, audit, communication, and team building. There is great variability in how CPD is being conducted globally. We believe that whether a legal obligation or

an unregulated voluntary option, all physicians should undertake some form of CPD. Coordination and harmonization of CPD management will bring efficiency to the process and overcome barriers discussed.

Though customization is needed according to local needs, there are universal guidelines and principles to develop and maintain CPD complying to best practices. Societies and colleges should accept responsibility for both CME and CPD of doctors, establish effective CPD schemes and develop strategies to meet the needs of doctors, the populations they serve, and the organizations where they work.

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Cite this article as: Filipe HP, Silva ED, Stulting AA, Golnik KC. Continuing professional development: Best practices. Middle East Afr J Ophthalmol 2014;21:134-41.

Source of Support: Nil, Conflict of Interest: None declared.