6 August 2021

CPD: the ghost of PLAN is hardly a ghost

ACRRM Comment CPD RACGP TheHill

The RACGP seems to be saying that the new CPD regime will not be anything like PLAN, but that doesn’t add up.


Considering the grief that accompanied the introduction of PLAN by the RACGP into its CPD program in late 2016, the confirmation this week that the Medical Board of Australia would be overlaying a broad framework for all doctors’ CPD, of which 50% would comprise activities focused on “reviewing performance and measuring outcomes” from 2023, seemed to slip by with little fanfare.

Perhaps with so many other problems facing GPs at the moment during covid, a start date that is still comfortably into the future (2023) and some statements from the RACGP to the effect that the new regime would be nothing at all like PLAN, GPs haven’t stopped to think how big this change actually is.

You don’t need to do much reading between the lines to recognise that no matter how  much the college has initially tried to position the changes in the minds of its members this week as business as usual, they are at once systemic, and then, a resurrection of sorts, of PLAN.

Of course, it’s not the college doing the resurrecting here, it’s the Medical Board of Australia (MBA),. But the college is doing everything it can to deflect any reference or comparison to  PLAN  (which stood for Planned Learning and Need). Take away new pilot software “tools “that the college is promising will significantly reduce administration and bureaucracy – presumably lessons from the first try at PLAN – and we pretty much have a spade.

Systemic?

  • PLAN  made up 30% of your entire CPD.
  • After PLAN was made non-compulsory, you were not required to do any reviewing or planning of your performance, development of a personal development plan, or measuring of outcomes against such a plan (reflection). You can do some if you choose to, but hardly anyone does.
  • In the new MBA-directed regime starting 1 January 2023 the requirement to do a PDP, measure outcomes against this plan, and review your performance against the PDP with a view to altering your learning objectives and practice moving forward, is precisely one-half of everything you will do in CPD.

So from zero reflective activity to 50%. This is a big change.

To suggest that it has little if any relationship to PLAN has the whiff of spin about it.

PLAN, as awkwardly as it was communicated and introduced, was an early attempt by the RACGP at putting in place what the MBA was always planning and has now mandated be put in place as of January 1, 2023. But this time it is PLAN for 50% of all your CPD, not 30% as PLAN was originally conceived by the RACGP.

The college still begs to differ on the idea that PLAN is making some sort of come back.

Asked to comment college president Dr Karen Price told The Medical Republic that PLAN and what is coming bear no resemblance to each other.

 “PLAN incorporated self-reflection as one of three components but it was fundamentally a different requirement for members.

“I cannot be clear enough: we are not returning to PLAN,” she said.

That seems very clear.

We think that PLAN and the 2023 regime are fundamentally the same.

Here is how the RACGP described PLAN in 2016 to its members in five steps:

  • Complete a practice profile and self-assessment
  • Review the report generated in the first step
  • Identify five key areas for improvement from the report
  • Complete activities throughout the triennium that are relevant to the key areas
  • Reflect and plan ahead

Here is how MBA describes the new regime post 2023.

All practising doctors will need a professional development plan to give their learning purpose. Professional development plans (PDP) will be tailored to each doctor’s needs and target their professional development to improve practice. The Board is not specifying what a PDP looks like or what should be in it. The value of a PDP lies in the thinking each doctor puts into their professional development and learning needs. Developing a plan will help doctors think about their strengths and weaknesses, and map out learning that will help them keep their professional edge.

The college is surely being cute by saying PLAN is gone, never to be heard of again. They seem to be basing this on their developing new online software that they hope will have a lighter administrative burden on its members than PLAN 1.0 clearly had.

But the fundamental concepts behind PLAN and the 2023 changes are exactly the same. You could even argue that 2023 is the same but a more again,  because in 2023 the MBA regime will mandate self-reflection to make up 50% of your CPD, whereas PLAN was mandating only 30%.

Dr Price told Australian Doctor this week that:

“The RACGP has reflected and learned from that experience [PLAN].

“Instead, we are piloting a tool that will support GPs in the development of their professional development plan to satisfy the Medical Board of Australia requirement, without the administrative burden.”

This is hardly an argument that PLAN is gone.  

PLAN was an online tool, as the college’s new “pilot” for 2023 is an online tool. 

So far, all that the college is indicating in respect to this new self reflection regime is that they are  working hard at a much more efficient tool for members to manage the process.

Some hint as to what the RACGP might want to clarify but hasn’t yet, comes from what ACRRM told us when we asked how they were responding to the new regime versus what they thought of plan.

An ACRRM spokesperson told us that:

“A key difference for ACRRM’s CPD program and what PLAN was, is again that we do not mandate the manner in which members may complete this requirement, but instead ask them to choose what type of planning process best suits them. We provide a simple-to-use and intuitive option for doctors to undertake and record this reflective component, one that integrates with our framework and activities. 

Although it hasn’t been made clear yet, we are going to assume that the RACGP is building that flexibility in as well.

The rest feels like a diversion: as of January 1 2023 “self-reflection and self-measurement” will be front and centre of all your CPD activity, whereas the day before January 1 2023, self reflection was nowhere to be seen in your CPD requirements.

It’s a massive change.

You may be told that in your 25 hours a year of self-reflection you can do lots of normal learning activities and that somehow doesn’t make the self reflection component so big. You can do learning activities which are traditional, but only in context. Your learning will all have to be chosen to meet the needs you have identified in a PDP, which you will need to assess yourself against.

No matter what anyone says, half of your CPD is directed at identifying weaknesses, making a plan to fix them, doing learning or practice that aligns to fixing them, and then assessing yourself.

Well designed and implemented self reflection isn’t a bad thing. There’s a lot research to suggest it is a key success factor in good CPD>

Every bit of research (of which there is a lot, if you look at the Australian Medical Council [AMC] history of developing this idea) and thinking that prompted a previous RACGP executive to try to introduce a form of self-reflection in 2016, is the same now as it was when PLAN was originally developed. That is because the MBA always intended to overlay the framework on all doctor CPD and the college had taken much of their lead in 2016 from the MBA work.

But the college was different back in 2016.

Back when the RACGP first introduced PLAN, its executive was riding high on its own power.

The executive had developed PLAN largely in concert with the AMC and the MBA, not in proper consultation with its members.

Although PLAN was probably very awkward from an administrative perspective, the ideas underlying it were all evidence based, sound and had been researched and developed by good operators within the college.

PLAN was essentially a good idea, well intentioned, very poorly executed in terms of member communication and consultation.

Because the MBA had already published its intention and ideas, the executive didn’t seem to think that members would push back much.  And when they did, the arrogance of the executive and its perceived power led them to ignore how upset their members became.

When members arced up, the executive claimed that they had consulted widely, but all they had really done was present it at the college AGM, just a couple of months before the program was due to start.

The issue was probably one of the key factors that caused a big upset at the following college presidential election.

Candidate Dr Harry Nespolon had identified PLAN as a very sore point and had as a key campaign plank that he would ditch it. He won in a landslide, surprising both the executive and some very high-profile candidates.

Although Dr Nespolon went on to become one of the best presidents in the history of the college, you suspect that, at the time, dissing PLAN was an election tactic, a little bit like Mediscare. Dr Nespolon wasn’t opposed to doctors self-reflecting and working on their weaknesses.

Importantly, PLAN was always hated more for how it became a symbol of the college executive’s arrogance and power over the members, rather than the fundamental ideas and logic of the program itself.

One of the side-effects at the time was a noticeable downward blip in membership of the RACGP as some members jumped ship to ACRRM on principle. ACRRM didn’t have any self-reflection components that were compulsory.

Which means, of course, that ACRRM is facing off a similar challenge now to the RACGP in bringing their membership on board with the concept that half of their CPD will soon be about directed self- improvement.

ACRRM sent us the following statement in respect to how it was approaching the change:

It is ACRRM’s view that, while the MBA mandates the PPF, and ACRRM sets the standard, it is our doctors who can determine what types of activities are most relevant to their own individual professional practice. We believe they are best informed to tell the College how we can best support them to meet the CPD Standards, not the other way around. 

The intent of the PPF is to make CPD more relevant to individual doctors. We have designed our program to be flexible enough to meet individual doctors’ needs regardless of their professional work environment or clinical scope of practice, as well as meet the mandated requirements of the MBA. 

Specific to the Reflective Practice component, there are many types of activities that will be relevant to this category. We know that our doctors are already undertaking reflective activities in their everyday practice. Therefore, we have developed systems and structures that support members to undertake and record these activities in a simple manner and given them?guidance and tools to develop new activities that are relevant to their particular work. 

Unlike PLAN, ACRRM at least doesn’t have to take the heat for making it compulsory. The MBA can be scapegoated here if that helps selling it. All they have to do now is design something that suits their members and is acceptable to the MBA.

Selling the idea that you have to “self-reflect” upon your own practice and professional competence, make plans to improve yourself, and test and measure yourself against those plans was never going to be an easy sell to doctors to start with, especially in the shadow of “revalidation” horror stories coming out of the UK.

In the case of PLAN, the RACGP executive ignored all these starting issues and attempted to bulldoze their members.

The result was predictable.

The problem the RACGP now has is “the ghost of PLAN”.

It’s a problem ACRRM doesn’t have, although if ACRRM doesn’t learn from the RACGP experience they could end up with similar issues

The RACGP is possibly courting trouble if they continue to maintain that PLAN has nothing to do with the regime in 2023. If they’ve learnt anything from 2016 it should be to give their members a little more credit for not being stupid.

Dr Price points out that there is a substantial evidence base to support the concept of self-reflection as it applies to learning.

“On its own, self-reflection may not seem to have a patient-centred purpose. However, the purpose of this reflection is to drive action that leads to a quality improvement in ongoing patient care,” she said. 

The evidence says that more and more basic learning modules (which is substantively where CPD has developed until now for GPs) does just about nothing to keep a doctor up to date and to improve their knowledge and practice of medicine.

The evidence also says that such learning sticks only if such a traditional learning practice is put in the context of making a doctor identify and reflect on their weaknesses somehow, develop a plan to address those weaknesses, and benchmark their progress against those weaknesses over time.

Dr Price that says in reference to the new regime that “this is not an unusual ask for our members”.

In one way it’s highly unusual: all members of both colleges have never really been exposed to a meaningful “self-reflection” regime ever before. Now it’s 50% of their CPD.

In another way, however, it’s not an unusual ask.

Just about every employee in a well-run company and every other professional sector practises self-reflection and professional development in their organisations with some sort of formal learning mechanism.

Why not GPs?

GPs have never formally done it in the past. No one likes change. And this is a lot of change.

Additionally, while in a company a PDP can be dangled as a career development carrot to an employee, that’s much harder to do in general practice.

In a company when you push a PDP on an employee, you are most often offering an employee a quid pro quo in assisting their career development and earning potential. A lot of company-based PDP programs are tied to income. Well-done performance management can result in happier employees and better company performance.

The 2023 CPD regime isn’t going to offer a GP a better career path necessarily and certainly not more income. But well managed and sold, it could offer a lot more job satisfaction and fulfilment.

You can see why a GP might not be enthused by the idea, though.

Which brings us to the key issue for January 1 2023.

Self-reflection will not work again if the RACGP and the MBA don’t do a lot more to consult, sell and communicate the benefits of it for a GP’s career and their patients, and partner their members in the process of designing the change.

The RACGP loves to throw around the term “co-design”. To. be fair, everyone does these days, especially consultants, which is probably where the college gets it from.

This is a serious co-design job that needs to start now because 2023 is only 18 months away and that is very little time for such a systemic change in how GPs learn and practise. Members need in on it.

Given the core mandate of the college, it’s got to be up there with building a decent training regime as one of the most important jobs over the next 18 months.

But at this stage, what we have from the RACGP is very little in terms of how they will be getting their members involved in helping to design something that is suitable.

What we have so far is a fair bit of “nothing much to see here, move along” and  “oh, and don’t worry guys, this isn’t PLAN”, when, if you strip away all the politics of what has happened and the bad execution of PLAN by the college in the past, this is wholly PLAN in concept.

Yes, it’s a very difficult change to how GPs learn and practise medicine but if you believe the evidence base for the change, it’s a very important change to make work.

You don’t do that by pretending that this change isn’t PLAN, so no one has to worry.

It is PLAN.

Well, think of it as PLAN 2.0 … hopefully a much better version and execution of PLAN (hopefully because no one has seen it yet).

Almost certainly that is what the college is working on in their new online management tool for PDP.

Unfortunately, at this point, it has no detail or examples it can provide us with that might demonstrate how much better and different their tool for PLAN 2.0 might be.

The college may end up working out some neat tricks to take out all the bureaucracy and red tape from PLAN 1.0, but the administration burden was only ever a small part of the objection that GPs had with the program.

The idea of “self-reflection” is a difficult idea for everyone.

It’s made much easier in the corporate world by tying self-reflection programs to career development and pay.

But the colleges don’t have this luxury, unfortunately – maybe the MBA should think about the idea, though.   

The starting position for most people, GP or otherwise, will usually be to take a position that they already self-reflect as an important part of their work anyway, and therefore anything extra is just going to amount to some form of bureaucracy.

My experience is that almost every employee benefits from help with self-reflection and formal programs well executed can benefit both a company and their employees hugely.

As a boss who went through multiple 360-degree performance reviews over the years, some which included having to have my family, my bosses, managers and clients all provide feedback, I can happily admit that I was on every occasion a long way from being self-aware. These programs, though scary and at times harsh, were almost always helpful in developing my skills and management (my family still maintains they haven’t).

We aren’t asking GPs to do 360-degree performance reviews here. That’s much closer to the UK idea of “revalidation” and both the RACGP and the MBA have been quick to say we are never going there. No one is going to do formal checks on performance. This is all a self-help thing.

The next best thing to formal checks (a 360-degree performance review) is self-reflection well designed and executed.

It’s a very high degree of difficulty for the colleges, given the obstacles described above.

But it’s coming, and someone has to sell the evidence base and the concept of a more formalised self-reflection regime to the broader GP community and soon.

It’s not as though most GPs don’t want to improve themselves. The colleges need to find a way in not design something formal from afar.

One technique that might work in getting the process accepted is to engage membership deeply from the beginning in the design process.

The college didn’t do this with PLAN, and it doesn’t look like they are doing it yet with CPD 2023.

The college is already saying it has a new pilot tool, so it has certainly been working on the future in some way.

But who with?

Has it got the members involved systemically with designing this new tool?

One of the big traps that some big corporations fall into setting up self-reflection for their employees is establishing highly standardised programs with lots of forms to fill in online. It’s efficient, sure, but by itself it’s also almost universally ineffective.

It’s because, at the heart of this process, you are trying to effect some sort of cultural change in your employees. You can’t do that with online tools alone.

You need to approach the problem far more holistically.

That’s going to be one of the challenges for the colleges.

Once I was bonussed on how many of my employees filled out their PDP in the year in the company I ran. It was a ridiculously high bar. Over 90%. No one was checking what was in the PDPs, or how effective they ever were. We just had to show that 90% had been completed. I’m pretty sure I nailed that part of the bonus that year.

In the following years, as our management regime changed and forgot about their PDP crusade, we entirely disbanded the system we had set up, and developed something far more agile, human and practical. It did involve online tools but only as a component of something far more day-to-day operational in the way our managers interacted with their staff.

One significant worry to emerge this week in this new regime announcement was the possible disconnect between the MBA and the RACGP on how the program would be audited.

Dr Price told TMR that “the personal [sic] development plan will not be audited or checked by the RACGP as it is an MBA requirement and sits outside of our CPD Program. The RACGP considers this a GP’s personal information”.

Which goes to the fear that many GPs have around the idea of writing down their weaknesses or past mistakes, and what might happen with that information. It’s a reasonable fear.

So the college is hoping, I guess, to put that fear to rest.

But how does that work?

Especially when Dr Anne Tonkin told Australian Doctor earlier this week that the Board didn’t want to see any self-reflection and that such information would “be confidential between the doctor and their CPD home” (usually their college) but that the CPD home would “be expected to maintain high levels of confidentiality”.

Im not sure how these two statements reconcile. Surely someone has to do a bit of checking to make sure this new regime is being taken seriously and is leading to improvement in practice.

The program must have some form of audit and as the MBA suggests, that’s probably better done by the CPD home. It just seems like nonsense to suggest that no one will check a GPs PDP or self assessment, because of confidentiality. If that were the case, then no one will have any idea ever if the self reflection is working or not. There needs to be some form of audit.

We assume that the problem will be solved in two ways.

Some sort of contract between the CPD Home and the GP that protects the GP should anything seem awry in their data during an audit, and, the more sensible approach, proper engagement and training of the GP so that in filling out their self-reflection data, no such issue can ever be formally identified.

Now I think about it I can’t remember ever reading a manager PDP in which the manager admitted to some sackable offence as a part of what they wanted to improve in themselves. It might be that there is a bit of over thinking creeping into what could happen.

The position of both the MBA and RACGP so far, that they won’t even look at a GP’s PDP or “self-reflection” component (surely someone has to look and check?), probably goes some way to identifying how much work there is to do still in engaging GPs in the process and ironing out some obvious and rather large flaws that currently exist in the lead-up to this major change.

You suspect that 18 months isn’t much time to undertake this process and all the colleges need to get a move on.

No one wants a bomb dropped on GPs without enough forewarning of the implications,  or the development of suitable plans to manage any possible fall-out come January 1,  2023.

In terms of CPD, moving forward, January 1, 2023 is a bomb currently if you compare it with what our current CPD demands of GPs are and to what their perceptions probably are, especially given that the college is steadfastly saying no PLAN, when to all intents, a lot of what is coming has many of the elements of PLAN.

It’s a huge change and one that naturally would create some fear and stress among any professional.

Both colleges need to engage their members quickly and deeply in planning and even “co-designing” how they will manage their CPD from 2023, where half of it is all about identifying your weaknesses, making a plan to work on them, and then measuring your progress in that journey.

Something to say?

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9 Comments on "CPD: the ghost of PLAN is hardly a ghost"

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Jonathan Levy
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Jonathan Levy
1 year 9 days ago
I left the RACGP over PLAN. Not PLAN itself (which is a good idea) but how I believed they may use the information gleaned from the first triennium of PLAN to clobber those GPs not ‘general’ enough (like me, doing skin cancer work). At that time the RACGP was making all sorts of noises that were anti-special interest, some quite derogatory (“….skimming the cream off General Practice….”. There was widespread concern that PLAN was a way of holding us special-interest GPs to ransom to do more ‘general’ practice in order to qualify for VR recognition. I believe that this iteration… Read more »
Sandra
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Sandra
1 year 11 days ago

It sounds inevitable …. I think I’ll just choose to be grateful the RACGP is coming up with something to make it easy for me to do. And continue on trying to improve myself… as we all have been doing anyway.

Philip Morris
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Philip Morris
1 year 11 days ago
Jeremy, you note that: Dr Price points out that there is a substantial evidence base to support the concept of self-reflection as it applies to learning. “On its own, self-reflection may not seem to have a patient-centred purpose. However, the purpose of this reflection is to drive action that leads to a quality improvement in ongoing patient care,” she said. I am not convinced that there really is a substantial evidence base supporting this concept, at least not an evidence base that compares other professional development activities with the self-reflection model as proposed. The professional development research field in medicine… Read more »
Joe Kosterich
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1 year 11 days ago

Such a change was inevitable once the board decreed that it would “ consult stakeholders “. However there was never a reason for the RACGP to pre-empt by six years.
Meanwhile more busy work for bureaucrats will make general practice even less appealing to graduates. Sad.

Ian Kamerman
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Ian Kamerman
1 year 11 days ago
Hi Jeremy, If I might point out that ACRRM’s CPD has already made the change to an MBA Professional Performance Framework model with significant member input. What was discovered was not that GPs did not undertake these tasks, but many of them already do it, within their usual practice and within their day to day professional and personal lives. A CPD Home must provide the tools and mechanisms to capture the activity that we all undertake as seamlessly as possible. That remains the challenge for ACRRM, the RACGP and any potential CPD Home. It certainly is not purely a repository… Read more »
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