Background

Continuing professional development (CPD) in medicine, while long considered an important part of the profession, is increasingly becoming mandatory, and is often linked to revalidation or recertification procedures for doctors.1 2 CPD generally refers to the broad range of skills and knowledge needed to effectively practice medicine, including general skills such as management, teaching and leadership skills as well as specific medical knowledge; in contrast the term ‘continuing medical education’ generally refers to medicine-specific knowledge and skills.

Multiple studies have shown CPD to be effective at improving doctor performance and patient outcomes, although this has been found to vary across different CPD activities, with more interactive CPD activities using multiple learning methods typically found to have more positive outcomes than other CPD activities, such as lectures.3 4 However, many doctors must navigate numerous barriers to participate fully and successfully in CPD. While doctors generally accept the need for participation in lifelong medical learning throughout their career, the introduction of formal, mandatory CPD can represent an additional pressure for already overworked doctors.5 6 Therefore, there is a need to determine the barriers and facilitators to successful CPD engagement, in order to maximise outcomes for both doctors and patients.

Previously identified barriers and facilitators to participation

The most frequently reported barriers to CPD participation in the research literature are time, cost and location of CPD activities, likely reflecting the high-pressure, time-constrained nature of medical practice. For example, recent study by Maher et al6 found all three factors to be significant barriers to hospital doctors in Ireland. This pattern has been reflected in the international literature; in a survey of Australasian geriatricians; Etherton-Beer et al7 also found time constraints (both regarding professional and non-professional commitments) to be a major barrier, however, this study did not find cost to be a major barrier, potentially reflecting differences in remuneration for doctors across countries. Similar results were found by Weiland et al8 and a second study by Dent et al,9 which also expanded on these results with qualitative items which indicated that fatigue, staff shortages, valuing family time and a lack of relevant, good quality CPD activities for doctors were also prominent barriers. This pattern of lack of relevant CPD activities, time constraints and the financial cost of CPD activities as being significant barriers to engagement is repeated in numerous studies.10 11

Along with the shift towards mandatory CPD, more negative perceptions and attitudes towards CPD have been found among some doctors, which may contribute to a lack of enthusiasm for participation in CPD activities. For example, Macdougall et al12 outlined the pros and cons of compulsory CPD versus unregulated, self-directed learning, noting the feeling that mandatory CPD may turn into a ‘tick-box’ exercise with more focus on requirements than on whether learning is actually taking place. They also note that reflection is often a requirement of CPD schemes, but question whether ‘reflection by rote’ as part of accreditation is as valuable as the kind of reflection that arises spontaneously as part of everyday practice.12 After the recent implementation of a CPD system that is integrated into the process of medical revalidation in the National Health Service (NHS), while noting that they considered the appraisal process to be valuable, UK doctors expressed fears that by integrating the appraisal process (including CPD, reflection and audit) into revalidation, it could become a bureaucratic tick-box exercise.13

This perception that CPD is more ‘for show’ than of any real value for patient outcomes has been found more explicitly in a study of paediatricians in the USA, which found that under half of participants agreed that participating in mandatory CPD activities helped them to meet their lifelong learning goals, while only 1 in 10 agreed that participation helped their patient care.11 These negative perceptions toward CPD are notable, as negative attitudes have been found to impact motivation and engagement with activities, especially when the activity is seen as burdensome. For example, Deitrich et al14 found that tasks with a low perceived value and a high perceived cost are associated with less motivation and effort. It may be the case that if doctors see mandatory CPD as an expensive, time consuming burden with little benefit, then this may act as a barrier to their participation.

However, these perceptions are at odds with the research literature which show that high-quality CPD activities can be effective at improving both doctor and patient outcomes, with CPD activities that are more interactive and which involve multiple learning methods generally found to be more effective than either didactic lectures or online courses.3 4 15 The results of the above studies indicate a need to emphasise to doctors the importance of CPD in the rapidly changing world of medicine and also the need for access to high-quality relevant learning activities.

CPD in Ireland

One country which has made the change to a formal system of CPD in the last decade is Ireland. In the Irish medical system, since 2011, all doctors are required to enrol on a Professional Competence Scheme (PCS). Doctors in Ireland must complete 50 hours total of CPD per year, along with a minimum of one audit or quality improvement activity.16 Doctors choose their own CPD activities based on their needs and scope of practice within an adaptable framework. A minimum of 20 credits must be recorded in the internal category (practice evaluation and development), 20 in external (maintenance of knowledge and skills), 5 in personal learning and at least 5 more in a category of their choice, including the research and teaching category, which is optional. In addition, at least one credit must be recorded across each of the eight domains of good professional practice over a 5-year period, with the domains spanning areas from patient care and clinical skills to professionalism and collaboration.16 17

The types of CPD activities for which doctors can claim CPD credits range from attendance at international conferences to journal clubs, clinical case presentations, review groups, team meetings, expert lectures, online learning and specialised training in both clinical and non-clinical skills, such as leadership, management and communication.6 18

The present study

While there has been an increase in research into CPD participation in recent years, the vast majority of studies focus on USA, Canadian or Australian samples. Few studies have examined perceptions of CPD participation in the context of the Irish health system, which has faced severe challenges, precipitated in part by the global economic recession, with budget cuts and staff shortages across the health service resulting in a stressful working environment for many doctors.19 This crisis has coincided with the introduction of mandatory CPD, highlighting the need for a focus on the perceived benefits and barriers to CPD among doctors in Ireland.

In addition, almost all the studies discussed above exclusively used forced-choice quantitative methods, in which doctors rated or ranked the significance of prechosen barriers. Such studies may fail to capture the full breadth of potential benefits and challenges experienced by doctors, and lack the depth necessary to fully understand the complex and often interacting factors which influence doctors’ participation in CPD.

Therefore, a qualitative study investigating doctors’ perceptions of the Royal College of Physicians of Ireland (RCPI) PCS was carried out as part of a larger survey-based study into doctors’ future learning needs, and experiences and attitudes toward PCS. The study included participants working in both hospital and non-hospital-based settings, in order to explore the full spectrum of doctors’ experiences in Ireland. The quantitative results of that study showed that over 80% of participants report that participation in PCS was a good idea, with the majority reporting positive experiences engaging with the process, and indicating that they felt PCS helped to improve their practice across a wide range of practice areas.20 A minority of participants reported experiencing difficulties, including a lack of time to participate and difficulties obtaining evidence of their participation in activities.20 The present study concerns the qualitative component of the survey measure. It was hoped that the open-ended nature of the question would allow for greater understanding of benefits, barriers and potential improvements to PCS in Ireland.

Theme 1: evidence of CPD participation

The first major theme in the data relates to the evidence of participation in CPD activities. Two distinct subthemes were found within this theme.

Theme 2: the structure of PCS

The second major theme to result from the analysis relates to perceived structural issues with the design of the PCS. This theme can be split into two main subthemes relating to both the content and quantitative requirements of the PCS.

Theme 3: benefits of PCS versus criticism of formal CPD

Doctors also comment on formal CPD in general. Central to this theme is the perception that CPD is generally valued and seen as important, but for some, formal CPD is perceived as little more than a bureaucratic exercise, which creates more work for doctors; ‘I have always been keen on my own professional development…. Keeping up to date is my own professional interest and pride. Documenting those is a pure political interest.’

Doctors express understanding and positivity towards the need for continuous professional development, while questioning the need for a formal, credit-based system, noting that ‘The PCS scheme relies too much on collecting points with insufficient evidence of learning or improvement’ A number of doctors express scepticism that CPD in its current form has any benefit to either doctors or patients, and question whether there is sufficient evidence to support the practice; ‘I have major reservations about the benefits of this whole process to the public’.

One doctor implies that the formal CPD process takes doctors away from patient care ‘This controlling will not help improve professional practice. It rather stimulates doctors to do paperwork and detach from patient care.’

In addition to questioning the benefits of CPD participation, doctors also note that the added workload of CPD participation and recording only serves to exacerbate an already stressful career:

The burden of extra activity and work and demands on medical staff is enormous, only adding extra stress. I would advise not to increase demands on individuals

One doctor who had to engage in CPD during maternity leave describes the extreme stress the process caused her:

I feel that the system let me down and put a shadow of worry over my time at home with my baby that did not need to have been there. Also, it is very difficult to attend for CPD whilst breastfeeding a baby…The requirement to get CPD points during ‘maternity leave’ impaired my ability to optimally and safely nourish my baby.

Theme 4: workplace challenges

The fourth major theme refers to specific workplace-based challenges to participation in CPD, which relate strongly to the current difficulties being experienced in the Irish healthcare system. This theme also reflects the barriers frequently reported internationally in previous research; namely, lack of time and financial cost of participation.8

The first barrier identified within this theme is lack of time, both to participate in and record CPD activities. This lack of time was particularly pronounced for non-consultant hospital doctors (NCHDs); as summarised by ‘As with everything in medicine… time is an issue!’

In addition to noting the general lack of time given the demands of work, participants also specifically mention staff shortages and the related lack of protected study leave in contributing to the time pressure. Indeed, even when the perceptions of CPD are positive, time is seen as a barrier, with one doctor noting ‘The professional competency scheme is an excellent opportunity to avail of external/personal learning opportunities. However, there is a lack of time as an NCHD to complete these tasks and this is often done in my leisure time to ensure my portfolio is up to date’.

Accordingly, a number of doctors express a desire for more online-based CPD, in order to allow time-stretched doctors to complete activities in their own time (‘One should be able to get all CPD points via online courses as it is extremely difficult and causes huge work problems for NCHDs to take leave to attend courses’).

Doctors also highlight the financial cost of participating in CPD activities, with numerous doctors noting the fact that CPD is just an added cost on top of other administrative financial burdens ‘I am frustrated by the annual cost of enrolling in a Professional Competence Scheme. I have yet to encounter any satisfactory explanation as to why I must pay this additional cost on top of my licence retention fee with the Medical Council’.

Theme 5: access issues

The final theme ‘Access Issues’ describes a number of specific factors which result in lack of access to high quality relevant CPD activities.

The first of these factors is the location of CPD activities, with doctors stating that the majority of existing activities are too Dublin-central, to the neglect of non-Dublin-based doctors by CPD providers; ‘The CME programmes…are totally geared towards Dublin based doctors and makes it easier for them to attend and gain points more regularly’.

The second of these factors relates to technical and organisational difficulties as a barrier to accessing online CPD, on multiple fronts; slow internet on office computers, bad quality connections to webcasts, etc: ‘There needs to be a method for ensuring that webcast presentations are technically of better quality, l am referring to the quality of both the visual and audio components of the webcast as all too frequently these are inadequate, at least in some locations, and so reducing their value.’

In addition to location and technical difficulties impeding access to CPD, some doctors note that there is a lack of relevant CPD activities themselves, particularly in niche specialty areas; ‘Specialist practice makes accessing relevant CPD more challenging’. These findings indicate that doctors find it difficult to find relevant meaningful CPD activities in Ireland for smaller specialties, potentially due to smaller numbers of doctors within each specialty resulting in lower overall demand for niche courses. It is worth noting that that if people cannot access relevant CPD they still must fulfil their requirements, and therefore may have to devote significant time and effort into participating in non-relevant CPD. Indeed, one doctor working in a small specialty states, ‘I find it a challenge to get meaningful professional development and so much of what I do is generic.’

General discussion and implications

While the vast majority of the 1408 doctors who responded to the larger RCPI survey-based study reported CPD ‘a good idea’ and that it improves patient care and safety,20 of the 434 doctors who responded to the open- ended question, a number of barriers and also suggested improvements were reported.

All five major themes (figure 1) related primarily to barriers and potential improvements to PCS participation, despite the open-ended question being phrased to allow comments on positive aspects and benefits to PCS. Taken together, the five themes outlined in this study give a wide-ranging, in-depth picture of the challenges faced by Irish doctors in 2018, which expand on ‘established’ barriers such as time constraints, to illustrate a series of complex, interacting factors.

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Figure 1

Five major themes relating to benefits, barriers and potential improvements to PCS. CPD, continuing professional development; PCS, Professional Competence Scheme.

The barriers outlined in themes 1 (evidence of participation), 2 (structural issues with PCS) and 4 (systematic issues, such as lack of time) likely interact with and contribute to the negative perceptions and beliefs that CPD activities are of limited benefit outlined in theme 3, and result in a number of doctors feeling that mandatory CPD is irrelevant to practice and see it as an added stressor.

Theme 1 illustrates that it may be the case that doctors are attending relevant and useful CPD activities, but due to difficulties or delays in obtaining credits, they are unable to put them forward toward their end-of-year totals. In addition, the lack of a simple method for recording CPD credits further impedes doctors’ ability to meet the requirements of their PCS. The perceived difficulties with obtaining and recording evidence of participation in CPD activities represent a unique barrier to engagement with CPD that has not frequently emerged in previous research. Past studies have shown that doctors can view mandatory CPD as a bureaucratic hurdle,13 and it is conceivable that constant difficulties in gathering evidence of participation may add to this perception. In contrast to potentially more systemic issues impeding CPD engagement, such as a lack of time, the barriers outlined in theme 1 are relatively easily addressed. By streamlining the process and improving the ease at which doctors can obtain and submit evidence of their CPD activities, then a major barrier to successful engagement could be removed. Such changes have already begun to be implemented in various ways; an improved electronic platform and revised e-Portfolio which allows doctors to record their CPD and Audit activities in real-time was launched by RCPI in 2019.

The two subthemes of theme 2 emphasise a perceived lack of flexibility, little accounting for ‘unusual circumstances’ and retirement, and perceived bias in the PCS toward women on maternity leave. In general, theme 2 points toward criticism of a ‘one-size-fits-all’ approach to CPD, both in terms of specific category and yearly requirements, and a desire for a system that is more open to individual medical specialties and which takes into account the realities of life. Any future revisions of the PCS system might take these requests for more flexibility both in terms of CPD categories and allowances for extenuating circumstances into account when setting CPD requirements.

Again, like theme 1, theme 2 represents a novel area in the context of existing research, with respondents highlighting a perceived inflexibility of the formal system and an inability to adapt the CPD framework to their individual scope of practice, a potential impediment to their meaningful engagement with relevant CPD. As mentioned, a large proportion of previous studies use forced-choice methods in which participants rate or endorse a range of predetermined potential barriers. Such methods necessarily miss out on more nuanced responses which can result from open-ended questions. Theme 2 then indicates that there may be more complex, less obvious barriers involved in formal CPD programmes other than the more immediate barriers of time pressure and financial cost.

The perception that formal CPD is of questionable benefit outlined in theme 3 is in line with previous research demonstrating that some doctors feel that CPD is merely a ‘tick-box’ exercise.9 12 As mentioned, previous studies have demonstrated that when people hold low task values toward a particular activity, they are less intrinsically motivated to engage with that activity.14 These negative perceptions of CPD as being an administrative burden without clear benefit could potentially impact doctors’ motivations to participate in PCS, along with the additional perceptions that PCS participation can be a significant source of stress.

As previous research has consistently demonstrated CPD to be effective at improving doctor performance and patient outcomes, it is clear there is a gap between the observable impact of CPD and the beliefs of some doctors about its benefits. This may be partially accounted for by the kinds of CPD activities doctors in Ireland are participating in—for example, numerous review studies have shown interactive activities that use multiple methods over a longer period to be most effective at producing change than traditional didactic presentations.3 4 For doctors working under conditions of staff shortage and financial restriction, access to relevant high quality and more intensive, longer-term CPD activities may be reduced. If doctors are engaging more often with less relevant and less-effective kinds of CPD activities, this could contribute to the perception that the costs of mandatory CPD outweigh its benefits.

It is likely that the other themes found in the data add to these perceptions of CPD as simply being an added burden. The perceived difficulties in obtaining and recording CPD credits put forward in theme 1 may contribute to frustration and negative attitudes, as even after completing CPD activities, an ‘arduous’ process must still be completed. Similarly, the perceived inflexibility of PCS described in theme 2 may contribute to negative perceptions of mandatory CPD, as those in niche-area and non-clinical practice may feel they are spending time and money completing CPD activities that they feel are not relevant or meaningful to their practice. Similarly, the perceived lack of accommodation for unusual circumstances such as sick leave may add to stress for doctors. Essentially, theme 3 outlines the perceived costs of participating in formal CPD; adding to an already overworked, highly stressed workforce with additional requirements and little perception of benefit.

Theme 4—relating to workplace challenges to PCS participation—is best understood in the context of the Irish healthcare system in 2018; in which hospital staff are overworked, with severe staff shortages and hospital overcrowding adding to the stress experienced by doctors. It appears that many doctors perceive CPD participation to be restricted by their current working environment. These barriers—time and cost—are the barriers most likely to be mentioned in previous research, especially in working environments experiencing staff shortages.6–8

The desire for more online-based CPD as a result of time restrictions is interesting, given the perceptions that CPD activities are of limited benefit outlined in theme 3. Previous research has shown online CPD to be the least effective in changing doctor behaviour or patient outcomes when compared with more interactive in-person activities, suggesting that doctors may favour CPD activities which have fewer tangible benefits to their practice. However, the reality is more complex; online CPD activities which involve discussion and have higher levels of interactivity and involve practice exercises have been found to improve knowledge and skills.15 A recent review of the efficacy of online forms of CPD spanning 88 studies found that online learning was of comparable effectiveness to face-to-face learning with regard improving knowledge, skills, and physician behaviour and patient outcomes,22 so it may be the case that the quality of online CPD activities is increasing. The authors note that regardless of the format of CPD, effective activities must be evidence based, interactive, involve some form of self-assessment activity, and multiple exposures to the learning material.22 Online CPD providers in future should aim to incorporate these factors, to maximise the efficacy of their activities while providing doctors with the benefits of cheaper and more accessible CPD.

It is possible that the access issues described in theme 5 only serve to compound the frustration felt by some doctors. Theme 5 highlights the sentiment that CPD activities focused mainly on urban centres may exclude many rural doctors. This perceived geographical disparity in service provision likely reflects the fact that Dublin, as the capital city, has the highest concentration of doctors in Ireland. This issue is also likely related to the barriers of time and cost outlined in theme 4—rural doctors have increased travel time and costs to get to CPD activities compared with doctors already situated in major cities. The experience of technical difficulties in accessing online CPD is important to note given the fact that many doctors offered location as a barrier; these doctors may be particularly impacted by being unable to engage in online CPD, which could otherwise help to make up lost CPD points due to being geographically distant from CPD activities. Similarly, the perceived lack of access to CPD activities for those who are not providing direct patient care and working in niche specialties reflects the beliefs throughout theme 2 that PCS schemes may be reflective of the ‘average doctor’ with less provisions for the outliers. By nature, formal CPD schemes need to cater for a large group of doctors and cannot account for every unique case and an adaptable CPD framework is provided, however the findings outlined in this study suggest that provision of a balance of learning activities is required to help ensure that niche groups—be it specialty, location or unusual circumstances—do not fall through the cracks. In addition, special allowances should be made for doctors who are ill, on maternity or compassionate leave.

As a result of circumstance, the nature of CPD activity in 2020 is radically different from that in 2018, when data were collected for this study. The COVID-19 pandemic has led to almost all CPD activities moving to a virtual learning format including a wide range of relevant interactive webinars which include national and international experts. Many formal ‘traditional’ activities, such as large, in-person international conferences have also moved online, offering global access to interactive learning activities with international experts along with a wide range of educational activities involving combinations of large and small group activities. This essentially eliminates many of the barriers identified by participants in this study; increasing accessibility for doctors in more remote locations, and reducing the time commitment and cost required to attend. The impact of this change on doctors’ experiences and challenges engaging with PCS should be investigated in future research.

Finally, it is worth noting that it is encouraging that running throughout the dataset was a general consensus that CPD and lifelong learning are worthwhile and essential components of the practice of medicine. It is clear that in the future, that while learning from excellence is important, efforts must also be made to target the more negative perceptions of CPD, while also tackling the structural and financial barriers to CPD participation, such as lack of study leave. The barriers highlighted by doctors in this study are broadly in line with those found by another recent study based in Ireland.23