Dauphinee, W. Dale MD; Tamblyn, Robyn PhD; Cruess, Sylvia R. MD; Cruess, Richard L. MD
Dr. Dauphinee is adjunct professor in medicine and member, Clinical Health Informatics Research Group, McGill University, Montreal, Quebec, Canada. He is also senior scholar and institute senior member, Foundation for Advancement of International Medical Education and Research, Philadelphia, Pennsylvania.
Dr. Tamblyn is professor of medicine and of epidemiology, biostatistics, and occupational health and director, Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, Canada.
Dr. Sylvia Cruess is professor of medicine and member, Center for Medical Education, McGill University, Montreal, Quebec, Canada.
Dr. Richard Cruess is professor of surgery and member, Center for Medical Education, McGill University, Montreal, Quebec, Canada.
Correspondence should be addressed to Dr. Dauphinee, Clinical and Health Informatics Research Group, McGill University, 1140 Pine Avenue West, Montreal, QC H3A 1A3; telephone: (514) 934-1934, ext. 32990; e-mail: firstname.lastname@example.org.
The current debate about health insurance coverage and the need for improved access in the United States has been front and center for most of 2009. Much of that debate has been highly emotional and political. Many of the assertions and reactions are confusing to the public. Going beyond the multiple vested interests and their attempts to maneuver public opinion into their camps and to their advantage, there are some underlying principles and philosophy that the profession of medicine must stress as this debate progresses, whatever the outcome. In seeking to be seen as aware of their traditional roles as healers and professionals in an era of questioning and possible reform, physicians must be cognizant of and loyal to the origins of their profession and the basis of its privileged role in society.1 This is not a matter of physicians' advancing their personal careers. To honor their origins, in the eyes of the public and their individual patients, they must maintain and promote trust in the execution of their roles as professionals. Whatever happens, without trust and, therefore, by extension, without recognition of physicians' ultimate accountability to their patients, the profession risks becoming dominated not only by the bureaucracy of governments but also by the insurance industry or any other third-party payers. Ironically, whatever the outcome of the current debates in Washington or elsewhere, the profession's fundamental desire should be to promote its values and act in a trustworthy manner. How can the profession address this higher goal?
In this commentary, we challenge the profession of medicine to take more direct routes to improve the quality of its practitioners' professional “work” and ultimately promote public trust in times of uncertainty and vested interests. This can happen only if the profession undertakes an evidenced, informed, and collaborative revision of its approaches to continuing professional development.
Background Concepts and Context
To offer context and to illustrate the irony of the current situation, consider the writings of Onora O'Neil. In 2002, this distinguished British philosopher gave a series of public lectures on the importance of public trust for the health professions.2 The origin of her concerns was in the events surrounding a series of lapses in professional accountability in the United Kingdom. They led to public investigations about the murder of over 200 elderly patients by a general practitioner, Shipman, and the failure of the system to act on a series of preventable deaths on the pediatric cardiac surgery service at the Bristol Royal Infirmary. What ensued included serious questioning of the effectiveness of self-regulation in the United Kingdom and the subsequent imposition of new layers of accountability. In O'Neil's view, the resulting reforms were a series of new regulations and detailed oversight via auditors and inspections that were making it more difficult for health institutions and health professions to serve the public. She offered a more practical view of trust. Her key message was that we are entering a culture of accountability that is aimed at achieving perfect control of undesired events, institutions, and professions but that, in reality, is achieving the opposite. The culture of accountability is leading to a culture of suspicion. The current health debate in the United States has certainly demonstrated this phenomenon. O'Neil argued for “intelligent accountability” based on good governance, independent inspection, careful reporting, and transparency in the accuracy of the information reported to the public. The aim should be to promote intelligent accountability rather than spreading suspicion while pursuing an impossible dream of immunity from breaches of trust.
In framing our argument, five elements of professional accountability are assumed: self-regulation, professionalism and ethics, continuous quality improvement (CQI), patient safety, and continuing professional development (CPD). To achieve advances in these elements as part of our public accountability, our professional bodies must align their strategies to achieve the closer coordination of self-regulation and CPD activities. When the Organization for Economic Cooperation and Development (OECD) issued its document, Improving the Performance of Health Care Systems: From Measures to Action,3 in 2002, the issue of balance between professional self-regulation and accountability for monitoring and improving care was discussed. It was suggested that finding a new balance is a priority for the policy makers and health professions for many member countries. It offered three policy suggestions or directives: strengthen and modify the institutions for self-regulation, use improved information from external regulation, and provide consumers with more information about the performance of providers.
Returning to the stated goal of promoting trust in times of change, where might we, as a profession, begin? We should begin with issues and challenges that we can influence, that recognize our values as a profession and our traditions of learning, our success in improving care, and our traditions of promoting trust. In North America, the United Kingdom, and perhaps elsewhere, one area where we still have leverage to effect change and to promote public trust is effective self-regulation. By self-regulation, we mean professional self-regulation—that is, profession-led regulation as a collective process that is framed in a societal context of accountability to the public. Historically, accountability of a profession to the public has been executed within the legal framework of licensure. Yet despite the changing times, self-regulation remains a more acceptable and workable approach for many analysts.4,5 They challenge the profession to seize the opportunity for significant change in its regulatory processes. After all, profession-led self-regulation, in both a legal and a sociological sense, is a collective responsibility, within the grasp and influence of the profession. In fact, participating in the collective process of self-regulation by the profession as a whole is part of every practitioner's obligation to society as a licensed professional, in return for the privilege of practicing medicine in a responsible and accountable manner.
A second point of leverage, again well within the purview of the profession, is a neglected mechanism for informing and improving self-regulation: CPD. In fact, recent evidence indicates that CPD and self-regulation should be focused on both the systems and individual practitioner levels. Thus, it is clear that with current technology and the push for systems-level accountability, the separate worlds of professional self-regulation, collegial professional organizations, and traditional CPD must begin to work together.
Reorienting CPD: Fallacies in the Core Assumptions
Following on the recent calls for change in CPD,6,7 how effective are current CPD practices in light of evidence from the medical, social, and behavioral sciences? The polite answer is “Slow to respond.” One can start with the promotion of self-assessment and self-reflection as valid, individually executed CPD goals with no collective, or peer, component. The fallacies of these individually oriented tactics have been well summarized by Eva and Regehr.8,9 They have clarified that the framework of individualized self-assessment and self-directed learning is not supported by the literature on personality development and social psychology. They remind all physicians that those who most need to improve their performance are likely to be the ones who will be unable to respond to the use of individualized self-assessment to do so. One explanation is the Dunning–Kruger effect.10 These authors documented that many individuals who have weak knowledge or skill in a particular activity or domain of learning believe that they have more knowledge or greater skill than they actually do. In comparison, those who have more knowledge and skill than others tend to believe that they know less or perform more poorly than they actually do.10 Thus, the effect constitutes a “self-serving bias” wherein underperforming individuals attribute their successes to themselves but often attribute their failures to factors outside of their control. Individual-based self-assessment is not an innate ability of any given individual. Hence, Regehr and Mylopoulos11 argue, it is risky to depend on self-assessment as a primary determinant of self-directed learning and improved performance without it being executed in the context of a learning system involving others!
Work in other fields where the use of self-assessment has been carefully studied supports Regehr's point of view that self-assessment is oversold. Yet, the application of individual self-assessment and self-regulation practices appears regularly in the life and social sciences literature. Typically, they are used for behavior modification in rehabilitation, social psychology, and management sciences. In keeping with our attention on revamping CPD, social cognitive theory outlines the presumed sources and mediators of behavior and behavior change.12 These sources and mediators constitute a defined outcome expectation, but, most critically, they occur with social support from family or friends, or within a system of training support.
In his address at the International CME Congress in 2008, Regehr submitted that the common attitude of “ceding self-regulation to the individual practitioner” is no longer acceptable.11 He also reminded the attendees that it is risky to promote self-reflection as a dependable strategy in defining knowledge or skill gaps. Solo self-reflection does not work when gaps or errors in performance exist, unless objective external input and appropriate peer feedback exist also.11 For example, Sargeant et al13 and Goulet et al14 have shown that, in primary care, the solution is for CPD to promote “directed” self-learning with practice based on feedback from structured professional and educational environments, and to include peer evaluation as opposed to self-evaluation. These elements offer initial criteria for a systematic and integrated plan for improving CPD!
Changes in the Context of Delivering Care: Implications for CDP
Most physicians now work in a team or group environment. On the basis of this trend, consider the evidence from empirical work on team training for CQI and patient safety. Baker and colleagues15 have addressed the qualities of highly reliable organizations. Such organizations are ones wherein the work takes place in a high-risk environment and wherein the consequences of error are great. He has shown that team training improves CQI and safety results. In addition, at the Annual Meeting of the Association of American Medical Colleges in 2008, Salas and colleagues16 outlined the empirical evidence that they have gathered concerning whether or not teams optimize patient safety and care. They have offered “evidenced-based principles for the effective planning, implementation and evaluation” of team training programs in the health field. At a time of primary care reform with larger teams for delivery of health care, these principles and practices, applied in properly developed team working environments, can lead to improved patient safety and care. Their approach and recommendations have been cited in the Joint Commission on Accreditation of Healthcare Organization's journal and are in keeping with both Institute of Medicine reports on quality and safety. These developments are another reason for the profession to redefine its CPD objectives and framework.
To support these empirical studies, consider the successful outcomes of the team-based, collaborative, data-driven peer analysis of the Northern New England Cardiovascular Disease Study Group. Nugent,17 from the Northern New England Cardiovascular Program, concluded that by using structured processes and process outcome data from each institution, their group derived the evidence and thus the means to steadily reduce mortality for cardiac bypass and to eliminate variances of outcomes across the participating institutions. This is CPD and CQI being carried out in a voluntary collaboration with members of the profession who “left their egos at the door”!
To summarize: The trend to practice medicine in teams and collaborative groups provides an opportunity for improved care and can be used transparently to promote greater trust in the public's eyes. The evidence we have presented above indicates that a focus on single practitioners is too narrow. With more physicians practicing in group or collaborative environments and who are willing to reform their group practice settings, what is needed next is for the broad regulatory community to define accreditation-based educational incentives that will push CPD vendors and programs toward group and team clinical situations. Positive results are more likely, and, equally important, this shift to groups can demonstrate to the public that medicine's practitioners understand accountability, derived both from their membership in a profession and from their institutional or hospital responsibilities.
Working Together for Public Trust
O'Neil2 spoke of intelligent accountability. She argued for promoting trust based on good governance, independent inspection, careful reporting, and accuracy of the information reported to the public. The linking of profession-led self-regulation with established profession-led educational frameworks and with CPD approaches is based on empirical solutions that offer problem identification, group-led feedback and support, practice, and reassessment. The emergence of simulation, with the use of regular, simulator-based, deliberative practice with feedback, has dramatically improved outcomes in anesthesia. The simulation laboratory is now recognized as a key contributor to reducing errors and improving the recognition of high-risk but rare situations in anesthesia during surgery.
Obviously, this perspective needs to be placed in the wider context of possible strategic partnerships amongst the key regulatory and professional organizations involved in the profession's collective responsibilities and public accountability. We noted that the OECD's policy recommendations to strengthen and modify the institutions for self-regulation make use of improved information from external regulation and provide consumers with more information about performance of providers.3 Does this approach not sound like O'Neil's argument?
Historically, change often has been driven by the certifying bodies and professional associations. All professional bodies involved in certification need to seek new approaches and work collaboratively with logical partners, all of whom have a clear degree of social responsibility in linking the activities of the new CPD and self-regulation. Recently, Woollard6 and Miller and colleagues7 suggested that it is time to redirect our attention to the CPD challenges at hand, beginning with institutions and existing group situations, by outlining a system of policy incentives to promote those changes. This is the “intelligent accountability” that the self-regulatory community, continuing education leaders, and health providers need to adopt. Greater trust will follow.
Other disclosures: None.
Ethical approval: Not applicable.
1Cruess RL, Cruess SR. Teaching medicine as a profession in the service of healing. Acad Med. 1997;72:941–952.
2O'Neil O. A Question of Trust. Cambridge, UK: Cambridge University Press; 2002.
3Organization for Economic Cooperation and Development. Improving the Performance of Health Care Systems: From Measures to Action. (A Review of Experiences in Four OECD Countries). Labour Market and Social Policy—Occasional Paper No. 57. Paris, France: OECD; 2002.
4Stacey M. The case for and against medical self-regulation. Fed Bull. 1997;84:17–25.
5Friedson E. Professionalism: The Third Logic. Chicago, Ill: University Press; 2001.
6Woollard RF. Continuing medical education in the 21st century. BMJ. 2008;337:469–470.
7Miller SH, Thompson JN, Mazmanian PE, et al. Continuing medical education, professional development, and requirements for medical licensure: A white paper of the Conjoint Committee on Continuing Medical Education. J Contin Educ Health Prof. 2008;28:95–98.
8Eva KW, Regehr G. Self-assessment in the health professions: A reformulation and research agenda. Acad Med. 2005;80(10 suppl):S46–S54.
9Eva KW, Regehr G. I'll never play professional football and other fallacies of self-assessment. J Contin Educ Health Prof. 2008;28:14–15.
10Kruger J, Dunning D. Unskilled and unaware of it: How difficulties in recognizing one's own incompetence lead to inflated self-assessments. J Pers Soc Psychol. 1999;77:1121–1134.
11Regehr G, Mylopoulos M. Maintaining competence in the field: Learning about practice, through practice, in practice. J Contin Educ Health Prof. 2008;28(suppl 1):S19–S23.
12Anderson ES, Winett RA, Wojicik JR. Self-regulation, self-efficacy, outcome expectations, and social support: Social cognitive theory and nutrition behavior. Ann Behav Med. 2007;34:304–312.
13Sargeant J, Mann K, van der Vleuten C, Metsemakers J. “Directed” self-assessment: Practice and feedback within a social context. J Contin Educ Health Prof. 2008;28:47–54.
14Goulet F, Gagnon R, Gingras M-E. Influence of remedial professional development programs for poorly performing physicians. J Contin Educ Health Prof. 2007;27:42–48.
15Baker DP, Day R, Salas E. Teamwork as an essential component of high-reliability organizations. Health Serv Res. 2006;41(4 pt 2):1576–1598.
16Salas E, Diaz-Granados D, Weaver SJ, King H. Does team retaining work? Principles for health care. Acad Emerg Med. 2008;15:1002–1009.
17Nugent W. Building and supporting sustainable improvement in cardiac surgery: The Northern New England experience. Semin Cardiothorac Vasc Anesth. 2005;9:115–118.