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July 2003, Volume 53, Issue 7

Original Article

Continuous Professional Development - Development of a Framework for Medical Doctors in Pakistan

Z. S. Siddiqui  ( Department of Educational Development, Aga Khan University Hospital,Karachi )
M J. Secombe  ( Department of Educaton, Adelaide University*, Adelaide, Australia. )
R. Peterson  ( Department of Educaton, Adelaide University*, Adelaide, Australia. )

Introduction

The professional development of doctors is a lifelong commitment, which has been considered an obligation on the part of practicing doctors right from early times.1
Many countries worldwide have made major changes in their organizational set up to provide doctors with ample opportunities to develop professionally. However, in Pakistan, where once qualified and registered, the doctor is licensed to practice for life, it is very important to know how doctors perceive the need for their further development and a structured CPD program? This study was thus designed to explore the attitudes of medical doctors towards Continuous Professional Development in Pakistan.

Material & Methods

Based on the literature review and discussions with experts a detailed questionnaire was designed. This comprised open questions as well as closed statements. Respondents were requested to comment if they perceive a need for a structured professional development program and if so, whether it should be mandatory or voluntary and how much time they could conveniently spend on educational activities. Furthermore respondents were asked to identify which organization they thought was best suited for monitoring the CPD program. Questions also explored the current status of an individual's professional development and what motivating and inhibiting factors influence their participation. (These are presented elsewhere). Five hundred medical doctors were randomly selected from the database maintained at the Department of Medical Education at the College of Physicians and Surgeons, Pakistan. This department has been involved with the training of doctors across the country in educational methodologies as well as continuous medical education. This includes doctors representing all specialties and qualifications.
The questionnaire was mailed with a covering letter explaining the purpose of study. A self addressed stamped envelop was provided for the response.

Results

Of 500 total distributed questionnaires, 329 were returned. Twenty of the returned questionnaires were incomplete, therefore not included in the analyses. Overall this constituted a response rate of 62%.
The closed ended responses were analyzed using the Statistical Package for Social Sciences (SPSS) version 10.0 for Windows.
Demographic Characteristics of Respondents
Table presents the demographic characteristics of the respondents. Regarding specialty groups of respondents, 25% belonged to Surgical specialties, 21% to medical specialties, 16% in Psychiatry and 27% Miscellaneous group respectively, while 11% responses came from Obstetrics and Gynecology. This indicates appropriate representation of various specialties considering the number of specialists in each specialty practicing in Pakistan.
Need for CPD
There was unanimous agreement that there is a need for professional development. The reasons provided were the low standard of medical education at undergraduate level, increasingly changing knowledge, to improve patient care, and because CPD is already established in developed countries.
Table. Demographic characteristics of respondents. Sixty seven point three percent of respondents supported a mandatory program to ensure participation by every doctor as compared to 32.7% who favored a voluntary program. Among those who favored a voluntary program 12% of respondents proposed that, initially, a voluntary program should be introduced and depending on the outcome it may be made mandatory.
Time
Thirty five percent of the respondents were willing to spend more than 10 hours per month while 33 percent opined a maximum of ten hours and 32% were not willing to spend more than five hours.
Monitoring and Administration
This was perhaps the only issue that provided a wide difference in participants' responses. Apart from the College of Physicians and Surgeons Pakistan (26%) and Pakistan Medical and Dental Council (17.5%), other groups identified by respondents for monitoring were professional societies (17%) e.g. Pakistan Medical Association (PMA). Twenty four point five percent respondents suggested to adapt a collaborative approach between various organizations rather than delegating responsibility to a single organization. Some respondents (15%) suggested international organizations and non- governmental organizations such as World Health Organization (WHO) to administer and monitor a CPD program.

Discussion

There is a total agreement among all respondents about the need for an organized CPD program, but there is a concern paucity of resource material relevant to the needs of Pakistani doctors if a mandatory program is initiated at this moment. How can a system provide resources to support the learning needs of 14,337 specialists let alone 104,110 doctors presently registered with Pakistan Medical & Dental Council?
The other issue is the monitoring and administration of the process. There is a lack of consensus about which organization should monitor CPD. No one organization has enough resources or the credibility to take the responsibility for administering this program. Some suggested international or non-governmental organizations to monitor CPD. This seemed highly unrealistic under present circumstances. Therefore, a more acceptable


approach perhaps may be a collaboration among key organizations such as Ministry of Health, medical institutions, Pakistan Medical and Dental Council (PMDC) and the College of Physicians and Surgeons, Pakistan (CPSP) along with professional societies to form a network for CPD. A national policy document on professional development may act as a stimulus for initiating CPD at various levels with a direction to participate, and having relevant professional associations delegated administration in institutions across the country. This may be more feasible because if institutions are involved they will be more likely to provide participants, time to participate. Similarly professional associations can play a key role in providing resources and opportunities to participate. This network could make efforts to provide CPD activities and resources to doctors and ensure there is no duplication of resources and learning by effective collaboration. A framework for collaboration is presented in Figure. Sixtyfive percent of respondents in the study can devote 5 hours per month for professional development. If a three-year cycle is introduced initially with 200 points to be accumulated (one point for each contact hour of an educational activity) not exceeding 75 points per year it may be acceptable to a wider population of practicing doctors.
Undergraduate Medical Education
Although there are three distinct phases of medical education moving from undergraduate to post graduate and continuing medical education, efforts are being made to create a true continuum of medical education thus merging the educational experiences of the physician from admission in medicine through professional life.2 It is widely accepted that CPD is a process to enable doctors to become lifelong learners.3 This process could be initiated at the undergraduate level in the areas of critical appraisal, healthcare, ethics and the law, self-directed problem based learning, communication skills, and information technology skills.
In its updated publication Tomorrow's Doctors4 the General Medical Council, UK recommends that undergraduate curricula should "foster the knowledge and understanding, attitudes and skills that will promote effective lifelong learning and support professional development." Although development of lifelong learning skills is mentioned in the general educational objectives lay down by the Pakistan Medical and Dental Council (PMDC, 2001)5, there are no guidelines or strategies suggested for the medical teachers and administrators on how these can be developed and evaluated. The curricular instruction and assessment practices currently in use in most of the medical colleges in Pakistan do not promote lifelong learning attributes. Learners are placed in an environment which is based on a pedagogical model rather than treating them as adult learners. A very clear picture of this scenario is given by Jayasanghe6 where he describes how humiliating a teacher can be at times thus inhibiting all attempts of a learner progressing towards self directed learning. Similarly the traditional, pedagogical techniques, which are still in use such as lectures, have also been discredited as having no role in preparing doctors for lifelong learning.7
CPD is a process as well as philosophy that is nurtured through a culture of lifelong, self directed, problem based learning right from the entry into medical training.8 This implies changes in the entire learning environment.

Conclusion

Finally the need for professional development is unanimously recognized. We have a number of examples in developed countries as well as developing countries to learn from their experiences.9 Although an obligatory system seems unachievable at this time, individual professional associations could lay down some criteria in terms of credits to introduce a program. This may then form a national consensus statement on CPD. In this context a framework is proposed which identifies possible role of key organizations, professional associations and individuals towards development of a structured professional development scheme.

References

1. Norcini JJ, Dawson - Saunders E. Issues in re-certification in North America, In The certification and recertification of doctors: issues in the assessment of clinical competence. Newble D, Jolly B, Wakeford R, (eds). Cambridge: Cambridge University Press, 1964.
2. Mann KV. Educating medical students: lessons from research in continuing education. Acad Med 1994;69:41-7.
3. British Medical Association. Revalidation and continuing professional development. London: BMA 2000.
4. General Medical Council. Tomorrow's doctors. London: GMC, 1998.
5. Pakistan Medical and Dental Council [Online accessed 13th Oct.2001] URL: http://www.safety.net/pmdc
6. Jayasanghe S. Learner centered approaches in medical education: its relevance in developing countries (letter) BMJ [accessed online 5th April 2000] www.bmj.com/cgi/eletters/318/7193/1280#3455, 8 Jun 1999
7. Shaughnessy AF, Slawson DC Are we providing doctors with the training and tools for lifelong learning? BMJ 319:1280 -6.
8. American Medical Association. The Physician's Recognition Award Handbook. Chicago: AMA, 1986.
9. Siddiqui ZS. Lifelong learning in medical education: from CME to CPD. J Coll Physicians Surg Pak 2003;13:44-7.

Abstract

Objectives:
To explore how doctors in Pakistan perceive the need for their continuous professional development in order to develop a framework for implementation.
Design:
A cross sectional random survey in which quantitative and qualitative data was collected using self-administered questionnaire survey.
Setting:
500 medical doctors across Pakistan
Results:
There is a unanimous need for structured and organized Continuous Professional Development program. However, opinion differs on the issue of Mandatory versus Voluntary professional development (67.3% vs. 32.7%) as well as monitoring and administration of the program.
Conclusion:
Based on the responses received a framework for planning a structured continuous professional development program is proposed identifying various issues that need to be addressed in the planning and implementation (JPMA 53:290;2003).

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: