Continuous Medical Education (CME) is a process of life-long continuing education within the fields of knowledge of medical practice.
Continuous Professional Development (CPD) is a lifelong journey from the first day of graduation to retirement. It is therefore, a continuous learning process that complements formal undergraduate and postgraduate education and training. In most countries, CPD is a mandatory requirement with both professional and legal implications.
WHO definition: The continuous education of health workers is defined as all the experiences, after initial training, that help health care personnel to maintain or learn competencies relevant to the provision of health care.
CPD comprises of purposeful, systematic activity by individuals and their organizations to maintain and develop the knowledge, skills and attributes, which are needed for effective professional practice. For example, CPD is a professional obligation for all doctors in the UK.
In public health, the overall aim of CPD is to ensure that those who work in the field of health care delivery and practice develop and maintain the necessary knowledge, skills and attitude to practice effectively and work towards improving the health of the population.
Recertification is a process by which specified demands must be met on a periodic basis by any physician and other health care professional wishing to retain his or her specialist qualifications.
The term Continuing Medical Education describes education which continues beyond that directed specifically at training as medical specialist. However, it is clear that CME|CPD, as a continuing life-long process of learning, must also apply to doctors who are undergoing specialist training. A number of studies have shown that doctors achieve life-long learning by further education throughout their professional careers. This is an ethical duty for each doctor; doctors are also legally responsible for keeping themselves professionally updated. Therefore, the right of all doctors to participate in CME must be secured. There are no valid methods to measure a doctor's clinical competence that are simple enough to be generalized nor are there any reliable measures of what constitutes a good or a bad doctor.
This guide describes the concept and key elements required to develop national CME/CPD in Afghanistan. It would also serve as a user-friendly reference to ensure both sustainability as well adherence to internationally recognized standards for maintaining acceptable level of competencies in clinical and administrative practice of health care professionals across the country. Furthermore, the guide defines the specific steps related to the structure and functions of CME/CPD system.
Meanwhile, a detailed description of the process of developing and maintaining an effective tracking system to continuously monitor compliance of health professionals to pre-determined standards of practice. This will be achieved by using a minimum credit rating to determine such compliance. An inventory of all health training institutions to be carried out and a list of accredited institutions will should be developed and used for targeted training. In the meantime, a mapping of master trainers should be developed and certified for the delivery of continuous training. A special secretariat with a committee is being established under the patronage of the medical council to oversee the administrative and clinical operations of the CME/CPD system. It is anticipated that the secretariat will be using a database to store and update records of enrolled health professionals electronically. Furthermore, studies will be conducted on a regular basis to generate evidence about state of continuous training in Afghanistan with lessons learned and demonstration of best practices.
II. Background and global best practices
Although, the demand to ensure professional competency of health workers, particularly physicians and other clinicians is growing by all sectors and large segments of the Afghan society, there is no formal system of continuous training with binding policies and regulations. Therefore, the establishment of Afghanistan Medical Council has been viewed as a national priority and one of the overarching strategies for the Government of Afghanistan. One of the key components to ensure acceptable healthcare quality and patient safety by the medical council is to establish an effective CME/CPD system which is widely acknowledged by policy makers and national stakeholders as a pressing need. Accordingly, evidence-based methods to restore, develop, maintain and continuously improve core competencies of health care workers is considered as a strategic necessity at this historic juncture, to achieve the unity government objectives.
The general public has a legitimate right to know how and to what extent doctors and other health service providers keep themselves professionally updated in developing their competency as long as they are providing health care services to the communities served. Thus, the government and all service providers have a special duty to facilitate the development and sustainability of CME|CPD. In fact, the determinant factor of its continuity ultimately remains with the moral and professional responsibility of health provider for ensuring the quality improvement of practice. Needless to say, that such system could enable society to check that health care practitioners actually participate in continuing education. The fact that a doctor for instance takes part in courses, conferences and other CME|CPD activities does not constitute a guarantee of quality control. It is therefore, a common misconception that a system for CME/CPD and recertification in particular would contribute to the identification of unsuitable doctors. Thus, many countries faced with an important educational task vis-à-vis politicians and the general public with regard to the objective of CME|CMD.
One of the critical questions facing many low-resource countries is the feasibility factor and the ability to sustain CME/CPD functions. Therefore, one of the risks and assumptions in building an effective and sustainable system for continuing training in Afghanistan is the resource allocation and generation of membership fees for CME/CPD. In some countries, the system did survive primarily due to the financial support of the government, private sector, foundations and international partners.
As for the legal ramification of CME/CPD, there are some legal challenges relating to linking CME|CPD to licensure. The main challenge is the legal consequences of failure to meet mandatory criteria and maintain legal right to practice. In addition, another challenge arises if the reasons for failing are beyond the control of the individual doctor and are related, for instance, to the employer’s unwillingness to provide adequate time or opportunity for CME|CPD.
With respect to the issue of recertification, and based on the global experience, it builds primarily upon the fulfillment of quantitative requirements about participation in activities for which credits or points are awarded. The requirement for the accumulation of points can entail considerable participation in point-giving activities, but no evidence exists thus far, as to the quality, outcome, or relevance of these activities with regard to medical practice. The focus in such systems is directed toward formal training activities. This means that one of the greatest and most valuable parts of the professional's learning, consisting of informal activities such as collegial discussion, is not included.
Recertification is being viewed widely as a control system involving considerable consumption of resources. In some cases, undesirable side effects have been seen where the recertification system has led to significantly increased costs and the creation of an entire industry whose exclusive aim is to prepare participants to pass obligatory tests. Rapid medical advances underline the importance of securing conditions that enable doctors to update their professional knowledge and skills. This issue is on the political agenda in many countries across the globe and in the Middle Eastern region as well. The discussion is related to a general wish by politicians and the public at large to see evidence for the competence and up-to-date professional knowledge of doctors and other health professionals.
As for the global and regional experience and best practices, there are some reported success stories worth sharing. In Eastern Mediterranean region of WHO, in which Afghanistan is a member state, the mandatory CME/CPD systems have been introduced and effectively developed. For example, in Jordan the medical council of the MOH is directly responsible to monitor and track competency of doctors and other health professionals with close involvement of key partners such as professional associations, line ministries and relevant government institutions as well as private sector. The system in Jordan started with punitive approaches to medical errors but gradually was transferred to a fair and balanced system with acceptance of doctors and others. For example, a multi-sectoral Committee was created representing key stakeholders which is responsible for review and evaluation of medical errors. Once the scope is determined, an opportunity is given to the doctor to rectify his or her errors; further practice will be supervised by assigned senior doctor(s) based on the nature of the error. Similar systems are also operating to some extend in countries like Lebanon, Egypt, Sudan and Tunisia among others.
In other regions as Europe, the general principles are almost the same, but with clear differences in terms of law and regulatory schemes for CME/CPD and recertification. For instance, in the Netherlands recertification, in addition to being a professional requirement, has now been enacted by parliament into a legal requirement. The Royal Dutch Medical Association is in charge of the implementation of this legal requirement. The Swiss Medical Association has also made recertification mandatory for membership. In Norway, there is a kind of recertification system within the specialty of general practice. Specialists in general practice must be recertified every five years by taking part in different CME|CPD activities of their own choice, such as learning in groups, courses, visiting training in hospitals etc. The Norwegian Parliament has also suggested mandatory recertification in other specialties. The Danish Medical Association is developing an Internet based system for documentation of CME/CPD activities for doctors in Denmark. The UK General Medical Council has decided in future to revalidate all specialists, based on recognition that the existing specialist examinations cannot guarantee the competence of the specialist. Revalidation should not be an isolated examination and each individual specialty has been invited to consider how the arrangement could be implemented. All the specialist Royal Colleges have systems of CME/CPD points, which specialists are expected to achieve.
CME|CPD activities in Europe are financed in several different ways. Foundations, the pharmaceutical industry, the employers and the individual doctors all take part in funding CME|CPD activities. In the US, recertification of specialists is on a voluntary basis. In Canada, a voluntary CME/CPD program (Maintenance and Competence Program, MOCOMP) is practiced as a training program created by the Royal College of Physicians and Surgeons in order to support the specialists' effort to secure continuous training of their own skills and knowledge. The program includes a training logbook. Junior doctors recognize the impact that CME|CPD will have on their working lives. As the body representing those who will have to live with the consequences of these new systems, one of the fundamental aims of all university education is to teach students to assume individual responsibility for their life-long learning.
Today, there is a universal consensus that continuing education of doctors and other health care providers is an ongoing process, and there is no practical or educational dividing line before or after the date of becoming a health care practitioner or specialist. By supporting the introduction of formalized CME/CPD, the key emphasizes are directed to the right of health providers to take part in CME|CPD activities throughout their entire career. This will contribute positively to postgraduate (specialist) training. Employers will have to be more proactive and assume responsibility for the conditions covering the professional development of doctors and other health care professionals. Employers, including governments and MOHs will thereby become more aware of their responsibility to adapt employment conditions to both postgraduate training and continuing education. CME/CPD is therefore a joint concern for both junior doctors and qualified specialists.
One of the best global practices has been that any system design of CME/CPD is based upon a thorough understanding of the concept of quality improvement as distinct from quality control. Processes like quality control, quality assurance and clinical audit, which are the core of accreditation systems, may be useful when addressing the issue of incompetence, but they have less to offer when discussing CPD. Considering the process of medical care as a whole, the concept of Continuous Quality Improvement (CQI) which has shown to offer greater advantages, as it combines the process of learning with peer interaction and patient care, while allowing for the development of a documentation system.
Therefore, it is widely acknowledged today that the ultimate aim of CME|CPD is to provide doctors with an opportunity to achieve and maintain a high level of competence. Accordingly, the, CME/CPD must be perceived as an essential activity in the continuous quality improvement of health care practice.
III Concept of CME/CPD
Health care workers in Afghanistan bear both moral as well as professional obligation to make sure they are not performing any given act that might lead to unnecessary risks and harm to the public and patients seeking preventative or curative care, and that is in the core concept of the continuous training.
CME|CPD is a prerequisite for quality improvement in most countries. Society's demand for increased evidence of doctors' continuing education is part of a general trend necessitating improved control and quality assurance within the medical profession. Most countries have laws requiring doctors to maintain their professional knowledge. This is linked to the criteria established for practicing medicine. Today, the evolving demands for ever-increasing efficiency, coupled with rapid medical advancements, further underline the importance of the doctor being assured of his or her right to continuous professional updating and CME/CPD. The trust of the population in the doctor depends on his or her being perceived as constantly maintaining high professional standards and conduct. The profession must continuously stress the importance of not protecting colleagues who fail to maintain sufficient professional standards, but rather to adopt and publish methods that ensure the identification and removal of doctors who are not fit for practice. This must be done in close cooperation with the relevant national authorities. In addition, systems need to be developed to support colleagues who are failing but willing and able to learn. These should be aimed at preventing doctors from reaching the stage where removal from practice becomes necessary. However, systems and methods used in these instances must be completely different from those concerning formalized CME/CPD. The importance of introducing a formalized system for CME/CPD has been widely recognized by most countries but for Afghanistan it may take time to introduce a formalized CME program, therefore, at initial stages only homework and guidance can contribute to maintain CME in the doctor’s society.
The concept of continuing training has been evolving to cover such areas as formalization, under which the doctor should be professionally autonomous and has a duty to practice in accordance with ethical principles that include continuous development of knowledge to meet the patient's needs. The strongest motivation for life-long learning is the aim for high professional standards, where the health care provider personally defines the CME/CPD activities required in order to broaden and deepen his or her skills and competence, including medical skills as well as leadership, social and personal proficiencies. Health care practitioners in general are capable of identifying their individual educational requirements in relation to the needs of the patient. Similarly, it is natural to define the needs for continuing education in consultation with the employer, since the employer has a responsibility for the overall activities. It is the responsibility of the profession to plan and execute CME/CPD activities in line with those needs.
Thus, CME/CPD must be lifelong and suited to the individual doctor’s work situation. Continuing education must include planning for the acquisition and evaluation of knowledge to secure positive competence development. Authorities, professional organizations and employers have a collective responsibility for establishing the framework for continuing education activities. Health practitioners have a particular responsibility for developing its content and form. Each health practitioner is responsible for his or her actions, regardless of whether he or she is employed or in public, private or NGOs practice and should not be held responsible for systemic faults, whether national or local, that is beyond the doctor's control.
IV Rationale and added value of CME/CPD
Evidence has shown that in countries where CME/CPD is not developed, malpractice, defensive practice, and unnecessary medical interventions are quite high. On the other hand, in countries where an obligatory and strict system for CME/CPD does exist, number of medical errors and other incompetent practice is proportionally low. However, it is not enough to develop continuing system for training because of a number of other factors that may potentially undermine the system, including cultural and social norms and most importantly the quality of initial undergraduate trainings provided. While any CME/CPD system is by definition an obligation, the professional role and responsibilities of the individual health professional is what makes or breaks any effort to develop and sustain CME/CPD system. The added value of developing and sustaining CME/CPD system in Afghanistan includes the following:
• Gaining new competencies for life. Global studies have shown such as the Lancet Commission on Medical Education (2009) that knowledge gained in undergraduate or postgraduate studies is insufficient to practice medicine and other health care practices. What physicians and other health workers learn should be updated throughout their entire careers. Experience in many countries shows that know-how capability with up-to-date skills development is continuously required in order to maintain acceptable level of competence and performance.
• Promoting a new culture of learning and thus, CME/CPD is being seen as an asset for the institution, individual and societies at large, and not liability in terms of punishment or merely an administrative burden.
• Helping to make a paradigm shift of thinking at the individual level as well as the organizational memory in moving health care professionals to conscious competence.
• Engaging key stakeholders in the design, implementation and the continuous monitoring and evaluation of CME/CPD system. Thus, the CME/CPD in Afghanistan should be integrated with the health care and educational systems with full use of the capacities and resources available at the universities, health and specialization councils and training institutions.
• Assisting in the creation of informed community demand in all provinces of Afghanistan for competent health professionals and safe health services practice.
• Enhancing personal responsibility for professional growth via development of CME/CPD personal annual plan for health professionals in with an agreed upon threshold to be required according to the CME/CPD credits.
• Linking CME/CPD schemes to a quantitative system for performance appraisal and recognition in which best performers are rewarded.
Overall, CME/CPD requires combined support for both formal and informal efforts to meet or exceed CME/CPD minimum credits. CME/CPD can be seen overtime as the most legitimate revalidation to proof that health workers are competent and can be trusted to treat people in their communities.