Internists' views of maintenance of certification: a stages-of-change perspective

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.

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.

Definitions of Physician Certification Used in the North American Literature: A Scoping Review

INTRODUCTION

The authors sought to identify how physician specialty certification is defined in the North American literature.

METHODS

A rigorous, established six-stage scoping review framework was used to identify the North American certification literature published between January 2006 and May 2016 relating to physician specialty certification. Data were abstracted using a charting form developed by the study team. Quantitative summary data and qualitative thematic analysis of the purpose of certification were derived from the extracted data.

RESULTS

A two stage screening process identified 88 articles that met predefined criteria. Only 14 of the 88 articles (16%) contained a referenced purpose of certification. Eighteen definitions were identified from these articles. Definitional concepts included lifelong learning and continuous professional development, assessment of competence and performance, performance improvement, public accountability, and professional standing.

DISCUSSION

Most articles identified in this scoping review did not define certification or describe its purpose or intent. Future studies should provide a definition of certification to further scholarly examination of its intent and effects and inform its further evolution.

Attitudes and Experiences of Early and Midcareer Pediatricians With the Maintenance of Certification Process

OBJECTIVE

Maintenance of certification (MOC) value and relevance have been recent topics of controversy and discussion in medicine. Systematically assessing pediatrician's attitudes and experiences to encourage and inform future modifications is important.

METHODS

We surveyed 866 pediatricians in 2014 who graduated from residency 10 to 12 years ago and are part of a larger longitudinal study. Cross-sectional quantitative and qualitative data on understanding, attitudes, barriers, and needs specific to MOC part 2 (self-assessment/continued learning activities) and part 4 (quality improvement projects) were analyzed. McNemar tests compared responses on questions specific to part 2 with those specific to part 4. Multivariable logistic regression considered differences in participants who did and did not have positive part 4 attitudes.

RESULTS

A total of 77.8% completed the survey. Comparing part 4 to part 2, there was less understanding of requirements (59.9%, 72.9%, P < .001), more agreement that relevant available activities is a barrier (67.6%, 44.0%, P < .001), stronger agreement that more choices would be helpful (72.8%, 53.8%, P < .001), and less perceived impact on patient care or lifelong learning (12.5%, 47.2%, P < .001). Participants reporting that part 4 improves care were less likely to agree that time to fulfill requirements (adjusted odds ratio = 0.30, 95% confidence interval 0.18-0.51) and relevant available activities (adjusted odds ratio = 0.22, 95% confidence interval 0.13-0.39) were barriers. Qualitative analysis revealed themes including time, cost, and relevance.

CONCLUSIONS

Pediatricians expressed significant frustration with the MOC process, poor understanding of requirements, and barriers with the process, especially for part 4. Increasing diplomate education on the process and increasing available and relevant activities may be important to optimize physician's continuous learning.

An Interhospital, Interdisciplinary Needs Assessment of Palliative Care in a Community Critical Care Context

AIM

There is a paucity of data on the provision of palliative care in the critical care settings of smaller community hospitals. This study aimed to identify the gaps that affect the provision of palliative care in a community critical care setting.

SETTING

The study was set in a 10-bed, open intensive care unit and emergency department at a community hospital.

METHODS

Mixed methods were used. Quantitative data included those drawn from databases and surveys; qualitative data included those collected from interviews, focus groups, and onsite walk-throughs and were analyzed with inductive coding techniques.

RESULTS

Gaps were identified in palliative care, goals of care and end-of-life discussions, and resources. Community hospital healthcare professionals did not fully appreciate their essential contribution to the provision of palliative care in the intensive care unit. In addition, there was a lack of expertise, and a lack of interest in gaining expertise, in palliative/end-of-life care.

CONCLUSION

Interrelated needs in a complex interprofessional, interhospital context were captured. Further studies are required to obtain data on palliative practice in the care of critically ill patients in various community hospital contexts.

What's in It for Me? Maintenance of Certification as an Incentive for Faculty Supervision of Resident Quality Improvement Projects

PROBLEM

Residents are required to engage in quality improvement (QI) activities, which requires faculty engagement. Because of increasing program requirements and clinical demands, faculty may be resistant to taking on additional teaching and supervisory responsibilities without incentives. The authors sought to create an authentic benefit for University of California, San Francisco (UCSF) Pediatrics Residency Training Program faculty who supervise pediatrics residents' QI projects by offering maintenance of certification (MOC) Part 4 (Performance in Practice) credit.

APPROACH

The authors identified MOC as an ideal framework to both more actively engage faculty who were supervising QI projects and provide incentives for doing so. To this end, in 2011, the authors designed an MOC portfolio program which included faculty development, active supervision of residents, and QI projects designed to improve patient care.

OUTCOMES

The UCSF Pediatrics Residency Training Program's Portfolio Sponsor application was approved by the American Board of Pediatrics (ABP) in 2012, and faculty whose projects were included in the application were granted MOC Part 4 credit. As of December 2013, six faculty had received MOC Part 4 credit for their supervision of residents' QI projects.

NEXT STEPS

Based largely on the success of this program, UCSF has transitioned to the MOC portfolio program administered through the American Board of Medical Specialties, which allows the organization to offer MOC Part 4 credit from multiple specialty boards including the ABP. This may require refinements to screening, over sight, and reporting structures to ensure the MOC standards are met. Ongoing faculty development will be essential.