Physician practice improvement

Dear Colleagues,

At its June 2015 meeting, the Federation of Medical Regulatory Authorities of Canada approved the physician practice improvement (PPI) framework for the purposes of consultation. The CFPC has been a collaborator in the work that led to the framework’s creation. Much of the philosophy behind PPI is consistent with the principles that have guided us up to now: namely that the maintenance of competence is a dynamic process, influenced by a physician’s context and scope of practice; that it must be based on a physician’s identified learning needs; and that, above all, it must have an effect on practice and ultimately benefit our patients and communities.

The PPI framework is notably improved from earlier work around revalidation in 2 distinct areas: there is a shift in focus toward quality improvement; and there is coverage of several dimensions of a physician’s practice—administrative, educational, and research roles as well as clinical roles. As outlined in documents circulated at the June meeting, the 5 steps in the PPI process are as follows:

• Understand your practice.

• Assess your practice and determine your learning needs.

• Create your plan.

• Implement your plan.

• Evaluate the outcomes.

The final step guides the beginning of the next cycle.

The 7 principles of PPI include transparency (processes and procedures are clear and can be understood by all stakeholders, including physicians and the public); relevance (PPI applies to the physician’s competence within the scope of his or her practice, and uses fair and consistent tools and processes); inclusivity (PPI applies to all licensed physicians and participation is mandatory); transferability (it is recognized by all licensing authorities in Canada and will not inhibit mobility within Canada); formative nature of the process (it is constructive and educational); efficiency (there is consideration of cost and administrative burden for physicians and redundancy is minimized); and integration (it relies on collaboration by and among stakeholders).

The CFPC’s Maintenance of Certification has consisted, up to now, of meeting our requirements for continuing professional development (CPD) by participating in the Mainpro^® program. Is this enough? Should there be a separate recertification process, which could include Mainpro participation as one of its components?

This area of exploration was recently stimulated by a meeting of the leadership of the CFPC and the American Academy of Family Physicians. In the United States, family physicians recertify every 10 years.¹ Regular assessment modules are completed online throughout the 10-year cycle, with a multiple-choice recertification examination as the culmination of all these activities. The assessment tools allow evaluation of knowledge. Given the variety of contexts and scopes of practice, there is concern that assessment of knowledge is only one facet of competence. In the United Kingdom, physicians must recertify every 5 years through a process that includes quality improvement initiatives, patient surveys, and multisource feedback, done yearly.² Anecdotally, some express concern that while the recertification cycle in the United Kingdom has increased transparency and accountability, and aims to improve patient safety, the relatively short cycle and the volume of demands on the average GP can challenge their daily work and elements of the clinical care they provide.

Meeting the CFPC’s CPD requirements is associated with satisfactory performance in practice.³ The medical profession widely accepts CPD as an important component of maintaining competence but it is also beginning to recognize that our standards need to be strengthened. Peer reviews, audits, multisource feedback, specialty-specific clinical indicators, personal development plans, implementation of clinical guidelines, formalized peer networks, and analysis of and reflection on incidents and complaints, are some of the tools and approaches that have been suggested.⁴

Internal preliminary discussion at the CFPC (written communication with I. Oandasan, P. Eisener-Parsche, J. Meuser; July 2015) on this topic is generating definite viewpoints. We are mindful that competence is not maintained; “it evolves, and changes over time, experience, and setting.” You will be glad to hear that there is no appetite for examinations; given the complexity I have described, “to find a single set of assessment elements that could be applied to the validation of the diversity of practices that characterize our discipline seems difficult to imagine.”

The need for us to consider these questions arises in part owing to a changing environment, where patient safety, transparency, and accountability are more prominent than ever before. We are early in our reflection on this journey and welcome your feedback at info{at}cfpc.ca.

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