Live by the clock, die by the clock. Making CPD requirements time-based will reward inefficiency.
Something bugs me about the new CPD regulations for doctors that come into force in January 2023.
I applaud the move towards raising the profile of reflective learning. The specified CPD categories “reviewing performance” and “measuring outcomes”, while largely overlapping, are essential ongoing skills.
Reflective competence is the highest stage of skill mastery. It yields inner richness and provides reassurance to colleagues and the public. It nurtures a growth mindset and creates trust, the currency of care.
Unfortunately, I think the new requirement is massively flawed by making time the prominent measure. Profound reflective moments are not time-bound. They usually occur in short instances of revelation through nurturing processes.
According to a recent Healthed survey, the majority of GPs are not happy with the changes. This is a requirement on which your practice and livelihood depend, so it triggers a stress response. Stress is a killer of joy and curiosity which are essential ingredients of the growth mindset.
It is also an energy depleting form of motivation. In respect to Maslow’s hierarchy of needs it traps us in “Safety Needs”, a barrier to developing the meta-cognitive skills at the top of the pyramid.
Respected behavioural economist Dan Ariely has provided research on the effect of “market mind” versus “social mind”. The market mind of bean counting switches the mental state towards individualism, self-reliance and cost-benefit analysis and once invoked won’t go back easily.
Surely the qualities the new CPD theory is attempting to engender map better to the social mind of relationships, cooperation and the greater good? Using a technique that fosters the opposite mindset is counterproductive.
Prioritising time spent, or quantity, actually inhibits quality reflective learning. It transforms it into a crude mathematical exercise.
Let me provide a few pragmatic CPD examples (and bear with me as I need to be pedantic to catch the essence of the problem).
Some of the most profound reflective learning moments I have experienced have been in response to patient satisfaction questionnaires and 360 degree appraisals. These tools have been devalued under the new system.
The process of doing a patient satisfaction questionnaire is as follows: I sign up to an accredited PSQ body online and pay a few hundred dollars in fee (10 minutes). I wait for the materials to arrive at the practice. I hand the questionnaires to the practice manager and explain what I am doing (10 minutes). The reception hopefully hands the questionnaires to my patients and hopefully the patients complete them.
The replies are posted back to the accredited body. A few weeks later, I receive an analysis of the data. I read it for approximately 30 minutes and gain a wealth of information and feedback that changes my practice forever. It provides 50 minutes of time towards my 50 hours. On the other hand, I could sit with a group of colleagues and discuss a patient over lunch and get a one hour credit.
Similarly, a 360 degree appraisal involves emailing colleagues the questionnaire with periodic badgering to remind them to complete it (5 minutes initially then multiple 30 seconds of badgering).
Again, 30 minutes of reflection on the data analysis produced usually leads to great insights that change performance. However, this only provides 40 minutes to clock on the CPD chart. I’ll go with a random case analysis for one hour thanks. Or a yearly BLS course for four hours.
The case with audit is similar. The feedback from the NPS prescriber audits was fantastic. Your prescribing data was presented in context with your local peers and paired with appropriate learning materials to nudge future change. It usually took about 30 minutes but stands out as reflective learning gold.
NPS has gone now, and I lament its loss. However, it would have been little help anyway in this era of time bean counting. It is not in your interest to have a slick application that can draw down the data easily from the practice software; it is far better to take 5 hours laboriously collecting the data from patient records yourself. Maybe spend some time on expensive software creating colourful pie charts.
The majority of my learning is actually in 10 to 20 minute snippets most days. Based on patient events that day, or trigger articles in my email, I will read up on areas of my knowledge that are deficient.
Now I need to make this learning count towards the data trail. I now need to add another 10 minutes onto these events where I record what I have just done and submit it to the CPD home.
My learning has just become 50% less efficient. But I have generated data. I estimate I will create over 230 new pieces of data per year, one for each working day, with links to the web article or podcast I have ingested and the things I have learnt.
A lot of extra effort and data is going to be produced by the 100,000 doctors in Australia. It would be great if this effort was going to produce something at the end. In actual fact, no one is going to read the vast majority of it; rather, you are typing to yourself.
CPD homes need to audit 5% of records. You need to pass this audit otherwise your livelihood is at threat. Data and the quantity of it will be your friend in this process.
I feel sorry for the auditor who is faced with over 230 pieces of data to verify. In actual fact, I think they will reasonably take a 5% sample of these pieces too, so even if you are audited most of the information will never be read. I’m not going to read it ever again since it’s in my head.
In Yuval Noah Harari’s book, Homo Deus, Harari postulates that the era of humanism is giving way to a new epoch of “data-ism”. Data being more important than humans.
The ancients understood how to harness effort to build great monuments such as the pyramids. We are metaphorically hauling vast stones at random into the outback and leaving them there. Madness? Which parts of our practice do they want us to not do instead? One less patient?
It is easy to see there is a certain loss to patient care. The AMC need to be transparent about the outcomes that they are measuring this intervention with, and the time period when this will be published, so they can be held to account for the price we, our families and our patients are paying.
The feedback loop in this intervention is long so their chance of having gotten it right is low. We, the grass roots labourers, need to be part of the iterative process.
I am proud to belong to a profession that understands the importance of meta-cognition and the power of reflective learning. I would like to see this rolled out to other areas of society where lives are at stake, such as to politicians, police, teachers and car drivers. A yearly review of car driving performance would undoubtedly save lives. However, it would be costly, hard to administer, onerous and a vote loser.
And this is the crux. Doctors are a minority that are being dictated to with little power of retort. We have been colossally let down by our multi-million-dollar representative societies. They could have harnessed the principles of behavioural economics and evidence-based wisdom to counter the flaws.
We are important professionals in society and our voice does count. It just needs to be unified. A Facebook page “CPD Quality not Quantity” has been set up, I have noticed. I think it is borne of the desire to be counted to harness the discontent so the process can be improved.
Dr Colin Coward is a GP with a special interest in behavioural economics.
