Putting professionalism and delivery of value‐added healthcare at the heart of physician training and continuing professional development

Recent initiatives of the Royal College of Physicians (RCP) and the American College of Physicians (ACP) recognise that physicians, both now and more so in the future, need to be much more than specialists delivering expert clinical care to individual patients. We will be required to be system leaders, policy advocates, champions of innovation and providers of value-added, cost-conscious care. In short, we need to be responsible stewards of the healthcare system, and a generator and enactor of system of care improvements. This means more than simple awareness of, and casual participation in, quality and safety improvement activities. It means being prepared to challenge and transform entrenched clinical practices and long-held traditional beliefs about specialist care. It means being prepared to identify, and disinvest the healthcare system from, ineffective or outmoded clinical processes and policies while at the same time advocating for the speedy introduction of new, effective interventions and models of care. Such major reform will be necessary if future healthcare is to cope with the rising demands of an ageing population with complex conditions amid increasingly constrained healthcare budgets. The physician community risks being marginalised and perceived as irrelevant (or worse) by government and society if it fails to assume a leadership role in driving such reform. The Royal Australasian College of Physicians (RACP) has responded to these imperatives in creating the Professional Qualities Curriculum (PQC) that formalises key professional attributes that underpin high-quality care. It has convened the Professionalism in the 21st Century: Fit, Safe and Competent seminar in Melbourne in March 2012 and has released, in partnership with the Royal College of Physicians and Surgeons of Canada, and the Royal Australasian College of Surgeons, a statement that defines the contemporary characteristics of professionalism.1 At its annual Congress in May 2012, it launched the Supporting Physicians' Professionalism and Performance (SPPP) program (http://www.racp.edu.au/page/sppp) that provides guidance around how professional attributes might be assessed and enhanced. In keeping with these initiatives, it is of interest to see what is happening in other jurisdictions. In the UK, the RCP has established a Commission on the Future Hospital to look at how the organisation, processes, and standards of hospital care can be best configured towards optimal treatment of medical inpatients in the future. It will investigate the role of people (medical teams, handover, communication), data (patient records, medical information, audit), place (medical wards, the patient pathway, generalists and specialists), planning infrastructure (radiology, laboratory, pharmacy and support staff, interfaces with community and primary care), and patients and compassion (leadership and responsibility, multidisciplinary teams, end of life care). This work will cover the main areas of care that most physicians said that the commission should focus on: high quality of care 7 days a week, continuity of care as the norm, and stable medical teams for patient care and education. It will deliver its report in early 2013 and will prompt the profession to radically rethink its role within the healthcare system. Other RCP documents have emphasised the importance of physicians adopting a broader scope of practice. In its Doctors in society: medical professionalism in a changing world2 released in 2005, medical professionalism was redefined with the aim of revitalising a profession that at the time felt itself to be under siege from a variety of external and internal forces. In a subsequent document Understanding doctors: Harnessing professionalism,3 it advocated for greater medical engagement in quality and safety improvement, more clarity in the role of the doctor and better leadership to make this vision for harnessing professionalism a reality. In 2010, it issued its Future Physician. Changing doctors in changing times4 that aimed to define the demographical and sociopolitical settings within which healthcare will be delivered over a generation and to identify the influence on doctors' roles and responsibilities of substantial population change, technological advance, economic trends and greater patient involvement. In the US, the ACP has issued new ethics guidelines, which state that physicians have a responsibility to utilise the most efficient means to effectively manage clinical problems, use resources wisely and ensure that resources are equitably available.5 It builds on certain principles of the Charter of Medical Professionalism issued in 2002 (Table 1)6 and a paper released in 2011 from the ACP Clinical Guidelines Committee that introduced the concept of value-added, cost-conscious care, where value is defined as patient-important outcomes achieved per dollar spent.7 Outcomes valued by patients relate not only to survival but also to the level of, and time to, health and recovery, disutility of care processes (e.g. diagnostic errors, ineffective care, treatment-related adverse effects), and sustainability of health or recovery and nature of illness recurrence.8 Such outcomes may have no relation to outputs (or activity levels), such as numbers of procedures or episodes of care. Importantly, this concept of value was not intended as new code for cost-cutting; instead, it defined care as being of high value if its health benefits justified its costs. High-cost interventions are good value if highly beneficial, while conversely, low-cost interventions are of no value if nonbeneficial. In determining value, harms and costs must be assessed, with costs including not only those of interventions themselves but also any downstream costs of subsequent interventions. Where several interventions are possible for a given clinical problem, studies of comparative effectiveness are required in identifying what works best for which patients under what circumstances.9 An urgent priority is to identify interventions of low value and stop doing them, and, in so doing, disinvest the healthcare system from wasteful, inappropriate care and redirect resources towards high-value care.10 The next phase might be to identify equivocal care, where potential harm and benefit are about equal; appropriate care, where potential benefits exceed potential harm; and high-value care, where care is safe, highly effective and produces a large health benefit. The ACP has taken tentative steps in this regard in identifying common clinical scenarios in which screening and diagnostic tests are of little value. To date, it has identified 37 scenarios covering a wide spectrum of physician practice.11 Recently, the ACP has joined with the American Board of Internal Medicine to launch Choosing Wisely– a campaign that has, to date, acquired a list of five questionable services from each of nine participating medical specialty societies.12 Some examples are listed in Table 2; more information is available at http://choosingwisely.org/. Helping lead the campaign is the watchdog organisation Consumer Reports that will work with other consumer-oriented groups to educate patients about the lists of wasteful services. The ACP has an online survey (http://www.annals.org) where physicians and patients can indicate if they agree with the choice of low value interventions and suggest others that should be added. Other colleges and institutions in the US and UK are undertaking similar efforts relevant to their constituencies.13,14 In time, the ACP will turn its attention to therapeutic interventions and other forms of care. At a policymaking level, it has recently released a position statement on how limited healthcare resources could be used more efficiently and effectively.15 These initiatives provide practical guidance on how physicians can enhance their professional standing and ensure value in the routine use of clinical interventions. The concept of value integrates the different notions of quality, safety, appropriateness and cost of care into one unified concept. Maximising value of healthcare requires physician engagement in improving clinical processes within the clinical microsystems of wards, clinics and procedure rooms. In addition, as physicians work within macrosystems of care (hospitals, group practices, health departments), they are also obliged, at the organisational level, to cultivate a governance and policy environment conducive to the delivery of high-value care.16 If Australasian physicians are to emulate the initiatives of the RCP and ACP, the training and continuing professional development (CPD) within the RACP must embrace a wider scope of physician practice that goes beyond biomedical and clinical domains into broader management and leadership roles. This notion is gaining traction in the curricula and assessment processes of the Physician Readiness for Expert Practice training programme that includes reflective learning exercises as part of formative assessments. The MyCPD programme awards points for participation in clinical audits and practice improvement activities. The Clinical Excellence Commission in NSW has recently established workshops for physician advanced trainees who desire greater exposure to practice improvement technologies.17 The recent review of the PQC and the advent of SPPP are further demonstrations of a greater focus on the multiple domains of exemplary professionalism. However, it is likely the RACP will need to do more over future years. The scale and complexity of healthcare innovation required in coming decades will oblige the RACP to grow the numbers of Fellows and trainees skilled and motivated in maximising value of care at both micro and macro levels. Several authorities have argued that being able to engage in healthcare reform, quality and safety improvement, evidence-informed medicine, practice-based learning, clinical systems redesign and value-added care are now essential competencies for physicians.18,19 If this is true, then these competencies need to be acquired within dedicated curricula and evaluated using formal assessment methods. Such is now the case within undergraduate and postgraduate training, and CPD programmes both overseas and locally, where experience suggests participants feel empowered to provide better quality care.20–23 Indeed, in some countries, professional training and/or licensing and revalidation processes include skills to measure and improve quality as core competencies.24–26 It is likely that the RACP will, in the near future, have to formulate a view on the merits or otherwise of physician revalidation in Australasia and what might be the core competencies to be assessed if revalidation was to be mandated by government. In marshalling resources and enthusiasm to meet these challenges, we would propose the following. First, the various College agencies directly involved in the nurturing of these ‘new’ professional competencies must be brought together under one educational governance structure within the College in order to generate a College-wide focus on maximising value in healthcare. Second, an educational agency should be tasked and resourced to produce rigorously researched training resources and assessment methods that foster these competencies across the College. Possible core elements of a value in healthcare curriculum are listed in Table 3, and we welcome suggestions from readers who may be interested in developing this curriculum. Finally, the College Board should embed a value-added, cost-conscious, systems-based healthcare perspective in all of its operations. The Specialty Societies must also play their part in assisting the College to define low-value care, develop training curricula and clinical guidelines that emphasise high-value care, and advocate for applied clinical research that reduces clinical uncertainty around what constitutes high-value care. Perhaps as a starting point, all College and specialty scientific meetings might include sessions on ‘common controversies’ or ‘idols assaulted’ that might encourage College-wide thinking about what constitutes high-value care and how our professional roles and care delivery systems may need to change in order that our patients receive it.

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