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Cpd2012 english

  1. 1. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N TContinuing Professional Development (CPD)A summary of the state of knowledge about physician training 1
  2. 2. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T Members of the Swedish Society of Medicine and the Swedish Medical Association joint working group Kerstin Nilsson Annika Eklund- Christian Löwbeer Annie Melin Grönberg Hans Hjelmqvist Thomas Zilling Turid Stenhaugen A specially appointed group has compiled this document. This group comprised Kerstin Nilsson, associate professor of obstetrics and gynae- cology, former chair of the education delegation of the Swedish Society of Medicine, Annika Eklund- Grönberg, specialist in general medicine, actively involved in issues concerning medical training for many years and affiliate board member of the Swedish Society of Medicine education delegation. Christian Löwbeer, licensed physician, specialist in clinical chemistry, consultant physician at the Department of Clinical Chemistry, Aleris Medilab, Täby. PhD in clinical chemistry at the Division of Clinical Chemistry, Department of Laboratory Medicine, Karolinska Institute, Annie Melin, education secretary at the Swedish Society of Medicine. Hans Hjelmqvist, associate professor and senior consultant at the Karo- linska Institute and department of Anaesthesiology and Intensive Care at the Karolinska University Hospital, Huddinge. A former member of the board of the Swedish Medical Association and former chair of the educa- tion and research delegation of the Swedish Medical Association. He is also vice president of UEMS (European Union of Medical Specialists). Thomas Zilling, associate professor at the Department of Surgery at Lund University Hospital. He is a general surgeon with his special interest inhttp://www.sls.se/Global/cpd/cpd2012.eng.pdf oesphageal- and gastric surgery. He is currently holding the position as senior consultant at Aarhus University hospital in Denmark. Dr Zilling is President of the Swedish Association of Senior Hospital Physicians. Since 1997 he is a board member of the Committee of Education and Research of The Swedish Medical Association as an expert on postgraduate educa- tion and continuing professional development (CPD). Dr Zilling is Chief editor for the Swedish journal The Hospital Physician (Sjukhusläkaren). Since 2004 he is Vice-President of the AEMH. Turid Stenhaugen, investi- gator for the Swedish Medical Association, secretary of the training and research delegation. English version 1 · 2012 · ISBN 978-91-979706-1-7 Svenska Läkaresällskapet · Sveriges läkarförbund 2
  3. 3. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T Preface Continuing education for physicians is a term that summarises the further training and learning necessary for physicians to refresh and develop their professional skills. This is not only a matter of medical knowledge but also encompasses subject areas such as management, communication and ethics. International- ly the term Continuing Professional Development, CPD, is used. The continuing education and development of physicians is fundamental to improving medical care and healthcare, as well as patient safety. The Swedish Society of Medicine and the Swedish Medical Association are pleased to have jointly compiled a review of the current status of the continuing development of physicians. Through this review we want to draw attention to the CPD systems that are currently in place. Our intention is to raise awareness about the continuing development of physicians and to stimulate interest in further development, research and dis- cussion. We would like to thank the working groups and encourage everyone interested in continuing development to read this interesting and inspiring document.Marie Wedin, Chair Margareta Troein Töllborn, Chair Swedish Medical Association Swedish Society of Medicine 3
  4. 4. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T Contents 5 Swedish Society of Medicine and Swedish Medical Association joint opinion on ensuring the competence of specialist physicians to improve quality and patient safety in medical care and healthcare. 6 Introduction 8 Managed continuing professional development: the evidence and the context. Janet Grant 14 How can we achieve and guarantee the quality of efficient continuing development? Stefan Lindgren 18 Regulating the continuing development of physicians from an EU perspective. Hans Hjelmqvist and Thomas Zilling 21 Cataloguing training requirements. Thomas Zilling 24 Rules, standards and policy documents. Christian Löwbeer Continuing development – good examples. 26 General medicine. Sara Holmberg 27 Clinical chemistry. Hans Wallinder 29 Internal medicin. Leif Lapidus 30 Glossary 33 Consensus document 4
  5. 5. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T Swedish Society of Medicine and Swedish Medical Association Svenska Läkaresällskapets och Sveriges läkarförbunds gemensamma Svenska Läkaresällskapets och Sveriges läkarförbunds gemensamma joint opinion on ensuring the competence of specialist physicians synimprove quality andav specialistläkaresmedical care and healthcare syn på säkerställande kompetens för kvalitet och kompetens för to på säkerställande av specialistläkaresoch sjukvården. kvalitet och patient isafety in patientsäkerhet hälso- patientsäkerhet i hälso- och sjukvården. Competent doctors are a prerequisite for high quality in medical and followed up in annual appraisal discussions. Examples of care and healthcare andförutsättningaför för hög of patient hälso- utvecklingssamtal. Exempel på fortbildning är lärande i internal Kompetenta läkare är en förutsättning level kvalitet i safety.Kompetenta läkare är en to maintain high kvalitet i hälso- hög continuing development are learning in daily practice, det det utvecklingssamtal. Exempel på fortbildning är lärande i The continuing developmentupprätthålla hög patientsäkerhet. och sjukvården och för att of physicians over their entireoch sjukvården och för att upprätthålla en en hög patientsäkerhet. education, e-learning activities and auskultation,personal study dagliga arbetet, internutbildning, case studies, självstudier dagliga arbetet, internutbildning, auskultation, självstudier working lifetime, after under hela det fortsatta yrkeslivet, efter Läkares fortbildning having acquired specialist competence,Läkares fortbildning under hela det fortsatta yrkeslivet, efter and participationiin courses and conferences. och deltagande kurser och konferenser. och deltagande i kurser och konferenser. isuppnådd specialistkompetens,därför en nödvändighet för för therefore essential to maintain är därför en nödvändighetanduppnådd specialistkompetens, är and improve medical care There are currently established management systems for fol- att bibehålla och utveckla den svenska hälso- och sjukvården. lowing up operational activities within för uppföljning verk- Idag finns etablerade ledningssystem av verk-atthealthcare och utveckla den svenska hälso- och sjukvården. bibehålla in Sweden. Idag finns etablerade ledningssystem förlaboratory medicine by uppföljning av Specialistläkaresdevelopment of specialist physicians is there- The continuing fortbildningdärför en viktig del del kvalitets- samheten inomvia Swedac, where the competence development är därför en viktig av kvalitets- accreditation samheten inom laboratoriemedicin genom ackreditering viaSpecialistläkares fortbildning är av laboratoriemedicin genom ackreditering via fore inom vården ochoch ska inte ses som enbart den enskilde arbetet inom vården of employees personalens kompetensutveckling ingår som del del Swedac där is included as part of the auditing procedure. enarbetetan important facet of quality assurance management within Swedac där personalens kompetensutveckling ingår som en For ska inte ses som enbart den enskilde healthcareansvar. läkarens and patient-focussed care therepatientinriktade vården finns också i uppföljningen. För den are also applicable systems for followläkarens ansvar. must not be viewed as being the sole responsibi- i uppföljningen. För den patientinriktade vården finns också lity of the individual doctor. up monitoring in the för uppföljning i form ISO-certifiering. tillämpbara system form of ISO tillämpbara system för uppföljning icertification. form av av ISO-certifiering. Med fortbildning avser vi kontinuerlig professionell utveckling By continuing avser vi kontinuerlig professionell professional Dessa system harhar hittills fått mycket ringa spridning inom development we mean continuing utveckling Dessa system have to date not spread widely throughout the These systems hittills fått mycket ringa spridning inomMed fortbildning development, CPD. Continuingdevelopment, must be Fortbildning healthcare sector. We recommend that there be a uppföljning (eng. continuing professional development CPD). regarded vården. Vi vill rekommendera en mer systematisk uppföljning(eng. continuing professional development, CPD). Fortbildning vården. Vi vill rekommendera en mer systematisk more systematicskaasses ses somobligationåtagande för varje läkare och utgörs allaalla avfollow-up monitoring of continuing professional Att läkarkåren ska ethical ett etiskt for every physician and comprises all of an som ett etiskt åtagande för varje läkare och utgörs av av av den professionella kompetensutvecklingen. den professionella kompetensutvecklingen. Att development. läkarkåren the activities that doctorsdeltar i för förbättra sin sin medicinska aktivt deltar participation of av hälso- ochoch sjukvårdavgörande de aktiviteter en läkare participateatt förbättra their medicalde aktiviteter en läkare deltar i för att in to improvemedicinska The active vid vid certifiering av hälso- the certificationavgörande aktivt deltar certifiering physicians in sjukvård är är of medi- kompetens och utveckla sig i rollen somtheir role as a themselves in läkare. Förutom medi- cal care säkerställa specialistläkares fortbildning continuing competency and to develop rollen som läkare. Förutom doctor. för för säkerställa specialistläkares fortbildning ochoch kompetens. att and healthcare is essential to ensuring thekompetens och utveckla sig i medi- att kompetens. In kunskap, medical knowledge, continuingkompetens inom cinsk kunskap, innefattar fortbildning även development development and competence of specialists. bör former för hur I avtal om upphandlad hälso- och sjukvårdcinskaddition toinnefattar fortbildning även kompetens inom also I avtal om upphandlad hälso- och sjukvård bör former för hur ämnesområden som ledarskap, kommunikation, vetenskap etik, fortbildning skall bedrivas, följas upp healthcare in. includes competency within subject areas such vetenskap etik, fortbildning skall bedrivas,agreements ochoch skrivasprovision In public procurement följas upp for skrivas in.ämnesområden som ledarskap, kommunikation,as leadership/ IT m.m. management, communication, scientific ethics, IT etc. there should be stipulations of how continuing development willIT m.m. För att säkerställa kvaliteten i fortbildningen föreslås inrättande be performed, monitored and recorded. För att säkerställa kvaliteten i fortbildningen föreslås inrättande According to2005:122005:12 (the Swedish föreskrifter om lednings- av någon form av quality of continuing development it is proposed Enligt SOSFS 2005:12 Socialstyrelsens National Board ofEnligt SOSFS SOSFS Socialstyrelsens föreskrifter om lednings- av någon form av extern granskning, ägd och genomförd av To ensure the extern granskning, ägd och genomförd av Health and Welfare’s och patientsäkerhet patient safetysjukvår- system för kvalitet provisions governing i hälso- och andsystem för kvalitet och patientsäkerhet i hälso- och sjukvår- that some formdärexternalför för SPUR-inspektioner kan tjäna professionen, of modellen professionen, där modellen review be introduced, which is owned SPUR-inspektioner kan tjäna quality kap. skall ledningssystemet för för varje sjukvårdande den 4 management ledningssystemetden 4 kap. 3§ 3§ skall systems within medical care and healthcare) varje sjukvårdande and carried out by the profession and whereatt kurser och lik- som gott exempel. Det är också angeläget the SPUR som gott exempel. Det är också angeläget att kurser och inspection lik- Chapter 4, Section 3 § theatt det finns rutiner som tillgodoser att nande arrangemanggood example. It isoch kvalitetsgranskade. verksamhet säkerställa management system for each careverksamhet säkerställa att det finns rutiner som tillgodoser att nande arrangemang är oberoende model serves as a är oberoende och also imperative that courses kvalitetsgranskade. providing organisation must ensure that thereför att utföra arbets- personalen har den kompetens som krävs are procedures topersonalen har den kompetens som krävs för att utföra arbets- and similar events are independent and are quality assessed. uppgifterna, rutiner som anger personalens ansvar och befogen- Inventering avrequirements for theoretical education/courses make certain that the personnel have the competence necessary to Inventering av behovet av teoretisk utbildning/kurser för för upp- Assessing the behovet av teoretisk utbildning/kurser upp-uppgifterna, rutiner som anger personalens ansvar och befogen- perform planer för för personalens kompetensutveckling utifrån rätthållande avadequate kompetens för för specialitetsområdet bör heter, och planer procedures that make clear what responsibi-heter, och work duties, personalens kompetensutveckling utifrån rätthållande av adekvat kompetens for ensuring adekvat competency within specialist areas should specialitetsområdet bör verksamhetens behov. lities and authority members of staff have, and plans for improving görasperformedvarje sektion/specialitetsförening. Fortbildnings- göras inom within every department/specialist association. be inom varje sektion/specialitetsförening. Fortbildnings-verksamhetens behov. staff competencies based on the needs of the organisation. samordnare, eller motsvarande funktion, inom varje specialitet samordnare, eller motsvarande funktion,or equivalent functions, Continuing development coordinators, inom varje specialitet Fortbildning ska således vara systematisk och grundas på en rekommenderas. are recommended within each specialist area.Fortbildning ska således vara systematisk och grundas på en rekommenderas. analys av behoven utifrån aktuella och kommande arbetsupp- Continuing development must therefore be systematic and must We reject mandatory demands for compulsory reporting ofanalys av behoven utifrån aktuella och kommande arbetsupp- be based specialistläkare skaska därför en individuelland fort- gifter. Alla specialistläkare with regard to currentgifter. Alla on needs assessment därför ha ha en individuell future fort- Vi avvisar krav på obligatorisk redovisning av demonstrated Vi avvisar krav or obligatorisk redovisning been CME poäng eller CME credits, på equivalent, as this has notav CME poäng ellerto work duties. som börbör dokumenteras och följas upp i årliga bildningsplan sombildningsplan dokumenteras och följas upp i årliga be associated withdet inte visats vara kopplatand quality. motsvarande då professional development till professionell motsvarande då det inte visats vara kopplat till professionell All specialist physicians must therefore have an individual utveckling och kvalitet. utveckling och kvalitet. continuing development plan that should be documented For the members of the Swedish Society of Medicine and the Swedish Medical Association joint working group in Stockholm läkarförbunds 2009 För Svenska Läkaresällskapets utbildningsdelegation och Sveriges on September För Svenska Läkaresällskapets utbildningsdelegation och Sveriges läkarförbunds Utbildnings- och forskningsdelegations gemensamma arbetsgrupp Utbildnings- och forskningsdelegations gemensamma arbetsgrupp Kerstin Nilsson, ordförande Hans Hjelmqvist, ordförande Kerstin Nilsson, ordförande Hans Hjelmqvist, ordförande Svenska Läkaresällskapets Kerstin Nilsson, chair HansSveriges läkarförbunds Utbildnings- Hjelmqvist, chair Svenska Läkaresällskapets Sveriges läkarförbunds Utbildnings- Utbildningsdelegation the Swedish Society of Medicine och Forskningsdelegation the Education and Research Delegation of Utbildningsdelegation och Forskningsdelegation Delegation for Education the Swedish Medical Association SVENSKA LÄKARESÄLLSKAPET SVERIGES LÄKARFÖRBUND SVENSKA LÄKARESÄLLSKAPET Klara Östra Kyrkogata 10 · Box 738 SVERIGES LÄKARFÖRBUND Villagatan 5 · Box 5610 Klara101 35 Kyrkogata 10 08-440 88 60 Östra Stockholm · · Box 738 114 86 Stockholm ·5610 Villagatan 5 · Box 08-790 33 00 101 35 Stockholm · 08-440 88 60 5 114 86 Stockholm · 08-790 33 00 www.sls.se www.slf.se www.sls.se www.slf.se
  6. 6. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T Introduction Skilled physicians are a prerequisite for high quality healthcare and to maintain high standards of patient safety.These are the introductory words in a statement on continuing development where the Swedish Society of Medicine and the Swedish Medical Association take a joint stance on the need to establish a syste- matic structure for the further training of physicians such as the continuing profes- sional development of physicians that takes place throughout their entire working life. Kerstin Nilsson In contrast to first cycle medical training (AT) provide more in-depth information on the con- and specialist medical training (ST), which are cept of the continuing development of physici- both regulated, there are no current provi- ans. The texts also provide a coherent concep- Kerstin Nilsson sions governing the continuing development tualisation of the CPD process encompassing is a lecturer in of physicians. Continuing development must the three subcomponent aspects of quality obstetrics and gynaecology be regarded nevertheless, despite the absence improvement, quality assurance and quality at the School of formal directives, as both a duty and a right control as a continuous process for continuous of Health and of the individual physician. It is an ethical professional development in a wider sense. Medical Sciences obligation for every physician to continuously The introductory section provides a back- (Hälsoakademin) improve his or her competency and to develop ground and analysis of further training and at Örebro Univer- sity and consul- competency based on the demands set by his or continuing professional development from tant physician at her working duties. It is also a right to be given various perspectives. the Department of opportunities to gain access to the competence The first part of the review concerns quality Obstetrics and Gy- development measures required for current improvement. In the section entitled ”Mana- naecology at the University Hospi- and future activities. There is also a legitimate ged continuing professional development; the tal in Örebro. She demand that physicians, similarly to other pro- evidence and the context” Janet Grant des- has previously ser- fessional groups working in societal areas, must cribes the evidence for expedient continuing ved as chair of the be able to demonstrate that they are highly development; what this is and how it can be Swedish Society of competent to perform the tasks entrusted to accomplished in a systematic and transparent Medicine’s educa- tion delegation them. way that is also possible to audit. In addition to and represents the In the light of this it is obvious that some being inspiring text, this section also contains Swedish Society form of systematic process is needed for the several very useful references. of Medicine on the continuing development of physicians that is Stefan Lindgren discusses the demands impo- Swedish National credible and transparent to the surrounding sed on physicians to be able to cope with con- Board of Health and Welfare’s community. This may be seen increasingly in tinuously changing professional role and the Committee for Na- the form of demands for compulsory docu- importance of being equipped with the correct tional Specialised mentation of hours of training (CME credits) tools for lifelong learning already as a student. Medical Care. and even in some cases in the form of propo- The WFME standards for medical training at sals for follow-up evaluations and certification. all levels, in part the minimum level and in part It is our absolute conviction that this would the level representing continuing development, be best accomplished in line with the delibera- are presented in the chapter, something that tions concerning further training that are em- those interested in medical training at all levels bodied within the framework of the pedagogic will surely find thought provoking. term of continuous professional development The second part of the text concerns quality (CPD). assurance and monitoring continuing develop- In this document we present a number of ment from a regulatory authority perspective. texts that all contribute to the discussion and Thomas Zilling, discusses how the require- 6
  7. 7. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N Tments for learning may be catalogued and the circums- Continuing development within general medicine istances that have led to demands for mandatory follow-up presented from a professional perspective, managementevaluations from certain circles, as well as how a Swedish responsibilities are presented in the area of CPD in clinicalmodel could be established based on this, without the need chemistry, and an example of continuing development into introduce bureaucratic models that are too unwieldy. internal medicine is presented from a regional perspective. Hans Hjelmqvist and Thomas Zilling then document the The review also includes a glossary of terms and the jointinternational views on continuing development and sys- statement on continuing development from the Swedishtems of evaluation in one section, and Christian Löwbeer Society of Medicine and Swedish Medical Association, asdescribes the regulations that apply today within licensed well as a translation of the document about CPD that hasorganisations, as well as the standards that are suitable for been adopted at the European level with the support of theclinical care application. With regard to the third aspect EU Commission.of CPD, quality control, there is consensus agreement that We hope and believe that this review, which is the pro-if one works actively with the first two quality aspects, as duct of a joint collaboration between the education delega-described in this review then there is no need for quality tion of the Swedish Society of Medicine and the trainingcontrol in the form of direct knowledge testing. and research delegation of the Swedish Medical Associa- We are also happy to be able to present three good tion, will be inspiring reading will be able to contribute toexamples of continuing development activities from three creating a sustainable Swedish model for how the conti-different specialist areas with different perspectives. nuing development of physicians can be performed and documented based on our professional obligations. Stockholm on September 2011 Kerstin Nilsson 7
  8. 8. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T Managed continuing professional development: the evidence and the context Janet Grant Continuing professional development (CPD) 1. WHAT MAKES CPD EFFECTIVE? has some key purposes: THE EVIDENCE Janet Grant BA, In 2000, a review of the literature concer- MSc, PhD, • to ensure the standards of professional ning the effectiveness of CPD for the United CPsychol, FRC practice, Kingdom’s Chief Medical Officer3 , found that: Professor of Education in • to demonstrate to the public and employers Medicine, The that each doctor is up-to-date with modern The key to effectiveness of CPD is not to be Open University, practice and knowledge, thus ensuring found in the learning methods adopted. Walton Hall, Milton patient safety, There is not a best learning method and no Keynes, UK • too be accountable to regulatory authorities best approach to learning. Instead, the key to Janet Grant was and to the profession. effectiveness is to make sure that the process lecturer in medical of CPD is effectively managed to have the education at CPD also has the effect of increasing job satis- following components: King’s College faction1 and is an important aspect of profes- Hospital Medical sionalism in medicine2. 1. A stated reason for the CPD to be under- School. She then became assistant The context of CPD is therefore one of inte- taken. This might be specific (for example, director of a World gration with professional practice development, a need to develop a new skill). Or it might Health Organiza- in a demonstrable and accountable manner. be a general professional reason (for ex- tion (WHO) Col- The most common model of CPD worldwide, ample, a wish to undertake general profes- laborating Centre however, is one which simply sets out the types sional updating with colleagues at a con- for Medical Educa- tion. She is a spe- of activity that would be accepted by regulators ference). It might also arise from the needs cial adviser to the (or record keepers) as CPD, in tandem with a of the service (for example, to develop the World Federation system of counting the hours spent per year in skill to offer new areas of care to patients). for Medical Educa- undertaking such activities. tion and to WHO on implementing But is there an evidence-base that would 2. An identified method of learning which global standards support this simple, common approach? might be formal or informal. for medical educa- The answer seems to be that there is not. tion. In addition The evidence-base suggests that there is a 3. Some follow-up after the CPD for re- to serving as a better way. inforcement and dissemination of the faculty member for the FAIMER So CPD systems should be designed to take learning that can also demonstrate its Institute, Janet has into account: benefits. This might be actions such as served as a faculty reporting back to colleagues, developing member for the new services, demonstrating new skills, • The evidence Brasil-, CMCL-, GSMC-, PSG-, and • Integration with professional practice or simply feeling more confident. Southern Africa- • Accountability FAIMER Regional These conclusions match those of Davis et Institutes. al4 in their review of randomised controlled trials5 of CPD. 8
  9. 9. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N TThe more recent review conducted for the UK Academy of 2. INTEGRATION WITH PROFESSIONMedical Royal Colleges and the General Medical Council, PRACTICEreaches the same conclusion8. Such a conclusion would For CPD to be an integral part of the development ofalso support the Swedish Medical Association’s four-step professional practice, it must tap into those processesguidance6 which advises to: whereby doctors already reflect on their experiences and determine to improve. This involves us in making the cor-1. Analyse the need and start the process rect assumption that doctors, as any profession, are indeed2. Develop supporting functions lifelong learners already and do reflect on their practice3. Collaborate without having to be trained to do so. Indeed, Schön’s4. Follow up and evaluate work explained that professionals do reflect – not that they need to be taught to do so!10In the wake of increasing interest in CPD, other reviewshave been conducted since 2000. They reach the same So what professional processes should be the basis of anconclusions about effectiveness. effective CPD system? There are many competing and complementary defini-tions of CPD, depending on the main perspective; thus, for The Good CPD Guide5 identified three sets of existingexample, CPD can be: professional behaviours that are reflected in the three steps of an effective CPD system identified above. These areA continuing process, outside formal undergraduate and summarised in Table 1 below. The AoMRC-GMC report10postgraduate training, that allows individual doctors to identifies some of the same behaviours. From that table wemaintain and improve standards of medical practice through can see evidence of the rich continuing professional educa-the development of knowledge, skills, attitudes and beha- tion strand that runs through professional life as a whole.viour. CPD should also support specific changes in practice.7 The question we must now ask is:Or it is: How can we build on this to create a managed and effec- tive CPD system that will satisfy the doctor, the profession,…a continuing learning process that complements formal the public and regulators?undergraduate and postgraduate education and train-ing. CPD requires doctors to maintain and improve theirstandards across all areas of their practice … CPD shouldalso encourage and support specific changes in practice andcareer development”.8Or it can have a number of purposes, as outlined by theBasel Declaration of the UEMS 9 :i) improve the safety and quality of medical practiceii) to encourage lifelong learningiii) to make transparent the outcomes, processes and systems required.These definitions are not objective, but simply depend,partially, on the agency, whether that is a professionalbody, a regulator or an educationalist. Whatever the definition, however, they have in commonthe safety and improvement of a doctor’s practice. Thatbeing the case, we should consider how CPD can be a partof this inevitable developmental process. 9
  10. 10. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N TTable 1: Existing professional behaviours that reflect the three steps of an effective CPD cycle STEP 1: STEP 2: STEP 3: A stated reason for the CPD An identified method Follow-up after the CPD for to be undertaken of learning reinforcement, dissemination, measuring outcomesThe clinician’s own experiences of Academic learning: • Accreditation/certification of the individualdirect patient care: • Medico-legal work • Accreditation of services• Blind spots: technical and knowledge • Reading • Appraisal deficiencies • Writing service and research protocols • Assessment of learning• Clinically generated unknowns: Meetings: • Assessment results of trainees an unrecognisable clinical picture • Clinical meetings • Audit• Competence standards • Conferences • Changes in person specification• Dairies • Case reviews • Changing practice• Difficulties arising in practice • Post-mortems and clinico-pathological • Clinical effectiveness• Innovations in practice conferences • CPD credit points• Knowledgeable patients • Telephone conferences • Collaborative assessment• Mistakes Learning from colleagues: • Confidence levels• Other disciplines’ knowledge • Collaborative learning • Corporate image• Patient complaints and feedback • Consulting other professionals • Decreasing professional isolation• Post-mortems and clinico-pathological • Joints ward-rounds and clinics • Educational culture conferences • Library professionals • Educational records and log-books• PUNs and DENs (patients unmet • Peer review • Effects on the team needs and doctor’s educational needs) • Multi-professional peer review • Enhancing practice• Reflection on practical experience. • Peer tutoring • Learning diariesInteractions with the clinical team and • Professional conversations • Learning portfoliosdepartment: • Visits and travelling clubs • Networking• Clinical meetings Learning from practice: • New services• Department business plan • Diaries • Obsolete and inappropriate practice• Departmental educational meetings • Evidence-based medicine • Peer review of the doctor’s CPD• External recruitment: new people • Experiential learning • Peer review of the medical team• Junior staff • Mistakes • Personal invigoration• Management roles • Professional conversations • Protection from successful litigation• Mentoring others • Visits and travelling clubs • Recruitment of medical staffNon-clinical activities: Technology-based learning and media: • Reduction in burnout and early retirement• Academic activities • Audio-visual presentations • Referrals to the doctor• Conferences • Communication and information • Remunerative benefit• International visits technologies (e-learning) • Reporting back to colleagues• Journal articles • Computer support systems • Reputation as a trainer• Medico-legal cases • Distance learning • Research• Press and media • Mass media • Risk management• Professional conversations • Simulations • Self-assessment• Research • Telemedicine and telemonitoring • Time-efficient working• Teaching • Videoconferencing • Video assessmentQuality management and risk assessment: • Video review of performance • Video-stimulated recall• Audit Management and quality processes: • Written reports• Morbidity patterns • Accreditations• Patient adverse events • Audit• Patient satisfaction surveys • Inspection visits• Risk assessment • Quality assurance schemesSpecific needs assessments: Specialty-arranged events:• Critical incident surveys • Attachments and secondments• Gap analysis (Where do I want to be? • Sabbaticals Where am I now?)• Knowledge and skills assessments• Observation• Revalidation• Self- assessment• Video assessment of performancePeer review:• External peer review• Informal per review of the doctor• Internal peer review• Multidisciplinary per review• Physician assessment 10
  11. 11. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T3. AN EFFECTIVE CPD SYSTEM 1. DEFINING THE NEEDIt is clear that an effective CPD system for today’s context This can be defined in any of the ways listed in Table 1, ormust not only ensure personal learning, but must also others that might arise. This would best be discussed withhave some effect on practice and be amenable to regula- a colleague at an appraisal meeting. The need can be generaltion, or be accountable and transparent. Fortunately, the or specific, based on past experience, future preparation orevidence on effective continuing learning aligns well with general professional developmentthe ways in which doctors do actually continue to learn,and these can, in turn, be aligned with the requirementof regulators or the profession to show that CPD is beingundertaken. It is a fortuitous combination. 2. PLANNING THE LEARNING:The Good CPD Guide5 , more than ten years ago and now HOW WILL IT BE LEARNED?in its 2nd edition, sets out an approach to CPD that is The doctor can plan to undertake the learning in any waymanaged and meets all these requirements. that seems appropriate – those listed in Table 1 suggest a wide variety of possibilities. The learning plan should be3.1 The steps in a managed CPD cycle recorded in the doctor’s Personal Development Plan.The evidence, as presented in The Good CPD Guide litera-ture review, shows that there must be at least four steps in PERSONAL DEVELOPMENT PLAN (PDP)the process of a well-managed CPD cycle. These are:• A stated reason for undertaking the CPD 3. UNDERTAKE PLANNED LEARNING: LEARN• A planned method of learning Any of the formal or informal learning methods shown in• The learning itself Table 1, or other methods, might be followed. There is no• Active follow-up of the learning best learning method.Each of these steps fits in well with existing professional RECORD LEARNING EVENT IN PDPbehaviours and the need for clarity, transparency andaccountability. 4. FOLLOW UP THE LEARNING: USE Any of the methods shown in Table 1 might be used, or any other appropriate methods.4. ACCOUNTABILITY RECORD FOLLOW-UP IN PDPThe purpose of systematising this rich collection ofactivities into a managed CDP system is partly to REVIEW CYCLE AT NEXT APPRAISALimprove CPD by ensuring that all the necessary stepsare present, but it is also to make the profession and theindividual doctor accountable for their CPD. How does This cycle requires only streamlined documentation,this happen? (available in The Good CPD Guide, 2nd edition, in press),We can present the four steps of managed CPD in the is integrated with doctors’ normal ways of learning andfollowing illustration: with a process of peer review. It reflects the evidence concerning effective approaches to CPD. 11
  12. 12. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N TTable 1. The system of managed CPD STEP METHOD EFFECT Ensures that intended 1. IDENTIFY • Reflection learning derives from: what TO LEARN • Appraisal • personal need, • Context factors • professional developments, • QA processes • needs of the health service • Personal 2. PLAN how development plan A rational and TO LEARN or other record transparent record is created In any way that is 3. Learn appropriate to the Learning is personally need, the person, effective and the context 4. Use THE • Dissemination to others Learning is carried LEARNING AND • Incorporation back to the workplace SHOW EFFECTS into practice • Further learningManaged CPD is a systematic approach to continuing • Records are streamlined and easily submitted, if requiredlearning and development for medical practitioners which • It is based on evidence of effective CPD, with peerwill: appraisal to confirm the process• Relate CPD to needs of the changing and developing • The CPD cycle is clearly set out, comprehensible because health care service it relates to existing practice, and can be supported by• Ensure the personal and professional development of accessible documentation the individual doctor • Records of the CPD cycle are straightforward• Provide an accountable and transparent system which • It fits in with existing practice can be used for regulatory, quality assurance, and reli- • Regulators are not required to introduce new systems censure purposes. or alien processes specifically for regulation.The approach to managed CPD presented is based on the In those countries, such as the UK, where regulators arepublished literature, on the established practice of doctors thinking about revalidation of doctors every few years towho have integrated their own continuing learning and continue their licence to practise, CPD will be a crucialdevelopment with the provision of patient care, and on the element of this revalidation process. So, for example, theprofessional and regulatory environments which operate 2004 GMC guidance indicated their thinking about thein different countries. These all share the requirement for relationship between CPD and regulation:doctors to be transparent about their CPD activities and to You must keep your knowledge and skills up to date th-keep records. roughout your working life. In particular, you should take We can see that managed CPD, especially when integra- part regularly in educational activities which maintain andted with the appraisal process, does include record keeping further develop your competence and performance .and a clear indication of the decision-making and activity More recently, it is clear that CPD will play a significantprocess. part in revalidation of the doctor’s registration which is a It is fortunate that the demands of the regulatory envi- primary regulatory function.ronment will improve the effectiveness of learning. Mana-ged CPD fits into the demands of regulators by having the We must conclude, therefore, that an evidence-based,following features: managed approach to CPD, complies with all good principles of regulation, education, and professional development and practice. 12
  13. 13. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N TREFERENCES1. Hojat,M., Kowitt,B., Doria,C. and Gonnella,J.S. (2010) Career satisfaction and professional accomplishments. Medical Education, 44, 10, 969–976.2. Veloski, J.J. and Hojat,M. (2006) Measuring specific elements of professionalism: Empathy, teamwork, and lifelong learning. In; Stern D.T. ed. Measuring Medical Professionalism. Oxford University Press, Oxford.3. Grant,J. and Stanton,F. (2000) The Effectiveness of continuing professional development. A Report for the Chief Medical Officer’s Review of Continuing Professional Development in Practice. Association for the Study of Medical Education, ISBN 0-9044–732604. Davis, D. A., Thomson, M. A., Oxman, A. D. and Haynes, B. (1995) Changing physician performance: A systematic review of the effect of continuing medical education strategies JAMA, 274, 700–7055. Grant,J.(2011) The Good CPD Guide. A Practical Guide to Managed CPD. 2nd edition. In press. oucem@open.ac.uk6. Swedish Medical Association (2000) Better continuing professional development – An action programme in four steps.7. Academy of Royal Medical Colleges (1999) Ten Principles for CPD. http://www.aomrc.org.uk/8. General Medical Council (GMC) April 2004. Guidance on Continuing Professional Development. http://www.gmc-ukorg/education/pro_development/ pro_development_guidance.asp#principles9. European Union of Medical Specialists. Basel Declaration. UEMS Policy of Continuing Professional Development. Brussels 2001.10. Schön,D. (1991) The Reflective Practitioner: How Professionals Think in Action. Ashgate Publishing Limited. ISBN 185742319411. Eve, R. (2003) PUNs and DENs. Discovering learning needs in general practice. Radcliffe Medical Press.12. General Medical Council (2006) Good Medical Practice. http://www.gmc-uk.org/guidance/good_medical_practice/ maintaining_good_medical_practice_up_to_date.asp13. General Medical Council. Proposals for Revalidation. http://www.gmc-uk.org/Framework_4_3.pdf_25396256.pdf 13
  14. 14. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T How can we achieve and guarantee the quality of efficient continuing development? LIFELONG LEARNING period to provide the knowledge and skills For the majority of physicians the compe- and approaches that can subsequently be tency acquired during their basic training applied throughout a physician’s entire are revisited and developed.Their work working life. Instead the basic training period environment also develops continuously, must prepare the physician in training for a Stefan Lindgren with concomitant demands for management variable working role and at the same time skills, participation in professional teams and provide the competency necessary to be interdisciplinary collaborations. It is there- able to perform work tasks during the initial fore no longer possible for the basic training period after qualifying as a specialist, as well Stefan Lindgren as for future training stages. is a professor of medicine at the University of Lund. Lifelong learning He is president of the World Federa- Under- ! ? ?? ??? tion for Medical graduate Education and chair of the educa- (40 years) tion delegation of Professional activities the Swedish So- ciety of Medicine. CPD Figure 1. Phases during CPD. The key to succeeding with this difficult development that has occurred within basic mandate is to focus on core competence. This training and built on this to a greater extent. competence must encompass insight into the necessity for lifelong learning and a scien- FROM GOAL-ORIENTED LEARNING tifically critical approach, even to personal TO INDIVIDUAL RESPONSIBILITY development needs. If this is not accomplished While both basic and specialist medical train- there is a great risk that the knowledge and ing is governed by regulations and is super- skills acquired during basic training will pro- vised, the primary responsibility for continu- gressively deteriorate and will be replaced by a ing professional development as a qualified less critically analytical professional role where specialist lies in the first instance with the decisions about development and change are specialist himself or herself. There is nothing deferred to others. Much of the work to change controversial in this per se; the responsibility the processes of basic medical training is in for the development of a profession always lies fact aimed towards augmenting this long-term with the members of that profession. It is the perspective of the perception of the role of the individual physicians who have the ultimate physician. responsibility to ensure that they have the de- The new specialist training programme, with velopment and tangible competency required aspects of management, communication and to be able, in the light of current knowledge, to science, is a distinct step towards establishing offer their patients optimal help and support, this general and long-term competence. Ef- as well as being able to contribute to further fects could however have been even greater if, knowledge development. during the planning of specialist internships, Physicians find the motivation to develop in consideration had been given to the strong their own efforts to offer patients optimal care, 14
  15. 15. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N Tas well as in their desire to meet the expectations of their for example the Institute for the Professional Develop-employer and to achieve job satisfaction. Continuing deve- ment of Physicians in Sweden (IPULS). External courseslopment can therefore be viewed as a continuous process and training programmes selected according to the needsof reflection. of the organisation and the individual are an important There are no scientifically structured studies that have complement to learning on the job. But these can never beattempted to illuminate general effects, in terms of measu- more than supplementary. It is therefore not particularlyrable changes in routines or standard practices, of continu- interesting or constructive to define continuing develop-ing development within the entire CPD area. There is how- ment only as a number of hours of external lectures.ever evidence that initiatives targeting special problems To be effective continuing development must be targetedor needs do have the expected effects, at least over limited to all aspects of professional skills and not just theoreticalfollow-up durations. At the same time it is apparent that knowledge. This is the concept behind the use of the termcontinuing development has such effects, as in principle all continuing professional development (CPD) instead ofof the extensive advances in medical care and healthcare continuing medical education (CME). CPD encompasseshave their origins in the research and development efforts all formal and informal activities that physicians practiceperformed within the profession itself. and that contribute to developing knowledge, skills and attitudes based on patient needs. Commitment to CPD isPRACTICAL LEARNING FOR PHYSICIANS both a professional obligation and a prerequisite for theContinuing development for specialist physicians must development of medical care and healthcare. Even thealways be based on perceived needs in daily medical most experienced specialists need constant professionalpractice. Development should therefore have daily clinical development to maintain professional competence.practice as the starting point and it should contribute to For the majority of physicians undergoing specialistimproving and facilitating clinical tasks and should also training, or for already qualified specialists, case-methodilluminate and critically evaluate the supporting theoreti- studies work well, with validation of suggestions forcal and scientific data available. Without sufficient links to solving problems and treatment options from currentclinical issues there is a risk that continuing development scientific literature as a good pedagogic model. In contrast,will be arrested at the knowledge level. Without concomi- seminars where themes are selected by those providingtant association with underlying theory, mechanisms and the education programme have limited effects in clinicalrationale there is a risk that continuing development will practice, regardless of the quality of the presentation.become a programme of action guidelines at the practice Direct knowledge transfer can fulfil a need for state-of-level, without answering the question ’why’. the-art competence within an area, but group learning There is overconfidence in the belief that guidelines with discussions supported by literature, preferably incan encompass all conceivable paths of development in conjunction with personal research, is even better. Non-complex and novel situations and that revision of proce- structured participation in international symposia is a lessdures can prevent erroneous decisions and interventions. efficient method for non-scientific practising physicians toInstead the safest course of action should be to expand the develop personal clinical competency, with regard to timeknowledge about and understanding of how the patients’ and costs. See Davis et al JAMA 1999.problems and disease presentation have arisen, which An efficient and essential complement to these typesunderlying mechanisms and requirements are affected and of organised educational activities is regular reading ofwhat scientific support exists for our interventions. clinical scientific journals within personal areas of interest, to familiarise the physician with developments in that area.THE LEARNING ENVIRONMENT Discussions with colleagues at journal clubs are naturallyAdult professionals learn independently of their teachers even better, but not an essential prerequisite.and in close association with job-related experiences. This The planning and performance of continuing develop-presupposes a good and stable collegial environment that ment must have its origin in both the needs of the physici-can provide feedback and refection in a structured way, an and the medical practice. If this is not the case there isbased on scientific and proven experience. In this res- a distinct risk that continuing development will be limitedspect it is likely that senior physicians are not currently to areas where the physician is already highly skilled andfully utilised. Development of method support for such that activities acquire more of a character of networkingfeedback and reflection should be an important duty for, than continuing professional development. Attempts to 15
  16. 16. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N Testablish structured continuing development plans have at all levels, has developed standards for quality assurancebeen made in several different contexts but have found it and quality development in basic training, specialistdifficult to achieve lasting success. Such attempts are sig- training, continuing development and recently also innificantly more constructive, however, than just counting research education. The standards define the minimumCME credits for attending training activities and sympo- requirements and can be used among other things for ac-sia, even if it can be cohesively argued that CME credits creditation purposes, but standards are also provided forare better than nothing at all. continuing quality development. The continuing development document has nine areasFOLLOWING UP CONTINUING with standards for the structure of training, processes,DEVELOPMENT content, learning environments and results. These areThere is no self-evident method for following up the quali- widely internationally accepted and have been documen-ty of continuing development. Formal competence testing ted to function well, after having been adapted to localis both reasonable and necessary for quality accreditation situations in many places around the world.of a newly qualified specialist, but recertification of practi- Continuing professional development (CPD) is a neces-sing specialists is significantly more complicated. Qualified sary and self-evident part of the professional life of a phy-specialists are seldom active within the entire spectrum of sician. CPD is in the first instance a professional obligationtheir specialist area and can therefore function with high for the individual physician and must be adapted to thecompetence even if knowledge gaps can be demonstrated special needs of the medical practice and the physician,in some aspects of the specialist area. Instead a system for and should utilise many different learning methods, withon the job assessment is needed. Such models exist inter- a focus on independent and active learning. At the samenationally, but are very resource-demanding. time preconditions must be created for continuing profes- One example is the American Board of Medical Specia- sional development to become a natural and integratedlities, which evaluates practising specialists every seven part of daily working routine. For this reason financing ofyears with respect to: CPD must be included in the medical care and healthcare budget.• Bedside manner• Medical knowledge• Interpersonal and communication skills A model of Competence• Professionalism, including compliance with ethical regulations• System-based practical clinical work• Learning and development efforts based on personal Does practice needs. Behaviour Professional authenticity Shows howIn Sweden augmenting the profession’s own primaryresponsibility for continuing development and the deve-lopment of good methods for both on the job learning Knows howand external learning activities, together with individual Cognitiondevelopment plans, follow-up and obvious support from Knowsthe employer for continuing professional developmentshould be a more achievable and expedient path. Miller GE. Assessment and follow-up with the help of international The assessment of clinical skills/competence/performance.standards can also contribute to quality assurance. The Academic Medicine (Supplement) 1990;65: S63-S7.World Federation for Medical Education (WFME), aglobal organisation working with medical training issues Figure 2. Millers’ Triangle 16
  17. 17. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T Table 1 Global Consensus for Social Accountability of Medical Schools (2010) • Respond to current and future health needs and challenges in society • Reorient their education, research and service priorities accordingly • Strengthen governance and partnerships with other stakeholders • Use evaluation and accreditation to assess performance and impact Table 2 WFME Trilogy of global standards in medical education: Areas Basic Postgraduate Continuing Professional Medical Education Medical Education Development (CPD) 1. Mission and objectives 1. Mission and outcomes 1. Mission and outcomes 2. Educational programme 2. Training process 2. Learning methods 3. Assessment of students 3. Assessment of trainees 3. Planning and documentation 4. Students 4. Trainees 4. The individual doctor 5. Academic staff/faculty 5. Staffing 5. CPD-providers 6. Educational resources 6. Training settings and 6. Educational context and educational resources resources 7. Programme evaluation 7. Evaluation of training 7. Evaluation of methods and process competencies 8. Governance and 8. Governance and 8. Organisation administration administration 9. Continuous renewal 9. Continuous renewal 9. Continuous RenewalREFERENCES 6. MEDINE: WFME Global Standards for Quality Improvement in Medical Education, European Specifications. http://www.wfme.1. Atlay RD, Wentz DK. CME or CPD? Postgraduate Medical Journal 1996; 72 (Suppl 1), 66. 7. Maintenance of Certification Competencies. American Board of Medical Specialities. http://www.abms.org2. UEMS, Basel Declaration: UEMS Policy on Continuing Professional Development, http://www.uems.net 8. Towle A. Changes in Health Care and Continuing Medical Education for the 21 century. BMJ 1998; 316:301.3. Wentz DK, Paulos G. Is now the time for Continuing Medical Education to become Continuing Physician Professional 9. Cooke M, Irby DM, O`Brien BC. Educating Physicians. A call for Development? Journal of Continuing Education in Health reform of medical school and residency. The Carnegie professions 2000;20:181. Foundation for the Advancement of Teaching. Jossey-Bass, San Francisco, 2010.4. Davis D et al. The Continuing Professional Development of Physicians: From research to practice. Chicago, American 10. Davis D, Thomson O’Brien MA, Freemantle N, Wolf FM, Medical association, 2003. Mazmanian P, Taylor-Vaisey A. Impact of Formal Continuing Medical Education, Do Conferences, Workshops, Rounds, and5. WFME Global Standards for Quality Improvement in Medical Other Traditional Continuing Education Activities Change Education. http://www.wfme.org Physician Behavior or Health Outcomes? JAMA 1999;282:867–874. 17
  18. 18. C o N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T Regulating the continuing development of physicians from an EU perspective Hans Hjelmqvist During the 1990s an intensive debate began which approves credit points for 145 different within the Swedish medical profession about specialist training qualifications in the USA. University Hans the advantages and disadvantages of introdu- In the USA we can now see there is a distinct Hjelmqvist, associ- cing compulsory recertification of physicians trend in moving away from the CME credits ate professor and senior consultant based on CME (Continuing Medical Educa- system and towards CPD (Continuing Pro- at the Karolinska tion) credit points, in accordance with the fessional Development). A good example of Institute and North American model. This discussion was this is provided by the general qualification department of already well developed in Europe and the issue requirements of the Accreditation Council for Anaesthesiology and Intensive Care was actively driven by individual specialist as- Graduate Medical Education (www.acgme.org), at the Karolinska sociations within UEMS (the European Union which include: University Hospi- of Medical Specialists), an umbrella organisa- tal, Huddinge. tion for specialist associations throughout 1. Patient care A former member Europe. The official policy of the organisation 2. Medical knowledge of the board of the Swedish Medical is against compulsory recertification based on 3. Practice Based Learning and improvement Association and CME credits due to the lack of evidence that 4. Interpersonal and Communication Skills former chair of the a system of mandatory continuing education 5. Professionalism education and re- that is solely based on participation at sympo- 6. System Based Practice search delegation of the Swedish sia provides any guarantee that competency is Medical Associa- maintained and developed1,2,3. To be able to understand why certain countries tion. He is also vice have elected to introduce mandatory continu- president of UEMS EACCME,THE EUROPEAN ACCREDITA- ing education requirements when others have (European Union TION COUNCIL FOR CONTINUING not it is important to understand who it is who of Medical Specia- lists). MEDICAL EDUCATION – CME CREDITS has the right to issue specialist qualifications. Despite this the authorities in a number of In Sweden this is the National Board of Health European countries have introduced legislation and Welfare, but in many countries the task of concerning the recertification of physicians regulatory authority responsibility is delegated based on the CME credit system. This was the to the profession, through its own organisa- reason for the UEMS founding the EACCME tions. Examples of this are the Academy of (European Accreditation Council for CME) for Medical Royal Colleges in England and the the purpose of accrediting international cour- German Medical Association (Bundesärzte- ses and conferences and awarding CME credit kammer) in Germany. For these associations/ points. The UEMS now considered it a duty to colleges there are financial incentives to take use the EACCME to make it easier for physici- responsibility for monitoring the continuing Thomas Zilling ans in countries demanding the accumulation development of their members. As can be of CME credits to participate in international seen in table 1, the picture throughout Eu- Associate profes- courses and conferences. The Council has rope varies. Continuing development from a sor and specialist national collaboration partners and it is the regulatory authority perspective is a matter of in general surgery, Institute for the Professional Development of everything from a voluntary system, such as chair of the Swe- Physicians in Sweden (IPULS) that has the in Sweden, to a legislated mandatory system. dish Association mandate to award CME credits when interna- This is based on accumulation of CME credits of Senior Hospital Physicians and tional courses and conferences are arranged in in some countries and in others there is a vice president of Sweden. The EACCME also collaborates with comprehensive process for renewal of qualifica- the AEMH (Euro- The American Board of Medical Specialities, tions or recertification. There are also financial pean Association of Senior Hospital 18 Physicians).