Where to now after a learning and educational needs analysis of Fellows of the Australasian College for Emergency Medicine?

See also pp. 51–57, pp. 58–65, pp. 156–163. A six-article series by Dent et al. in the February, this and subsequent Emergency Medicine Australasia issues describes results from a global learning and educational needs analysis of Fellows of the Australasian College for Emergency Medicine (FACEM) continuing professional development (CPD).1–6 Only one previous published emergency physician (EP) learning needs analysis was identified that specifically addressed procedures.7 The Australasian College for Emergency Medicine (ACEM), its Maintenance of Professional Standards (MOPS) committee and the authors should be congratulated on initiating and completing such an important undertaking at this critical stage of ACEM development. Part of this undertaking was to progress a professional development course for FACEMs, now known as the Advanced Complex Medical Emergencies (ACME) course, which has run successfully in a number of simulation centres. Recently, the Australian Medical Council (AMC) accredited ACEM for at least 6 years as a professional medical college. ACEM was commended for ‘The College’s MOPS program, which is well developed, available online and easy to complete, and has a high rate of compliance by fellows with program requirements'. Recommendations by the AMC were that the ACEM: (i) ‘Develop an approach to competency testing of procedural skills for fellows, using simulation where possible’; and (ii) ‘In considering the issue of retraining, develop a policy that can be used to guide retraining or remediation of fellows, should this need arise’.8 So where to now with CPD given this needs analysis, the ACME course and the AMC recommendations? Reassuringly, Dent et al.'s analysis had a high (59%) response rate which was consistent across Australasia. There was a low response rate from 2006 graduates, which is not surprising after their recent completion of a rigorous fellowship examination! Otherwise, the lowest response rates occurred in fellows who received their FACEM prior to 1995.1 Is this of concern, and could this group be most in need of CPD? What motivates a fellow to respond, and is it linked to his or her motivation to participate in, or the perceived need for, or benefit of, CPD? The study did not separate groups of FACEM by how they obtained their qualification; whether by examination, as a grandfather, or as an overseas specialist credentialing interview.1 It is important to recognize that someone, 2 years post-ACEM fellowship, could have practised for 12 years overseas as an EP. Trained EP from the USA, the UK and Canada (who are members of the Royal College of Physicians and Surgeons of Canada in the latter case) are seldom required to sit our fellowship examination, but might have significant diversity in prior CPD type and involvement. Prior CPD involvement not only depends on the country where the fellowship was awarded, but practitioner vintage in relation to the evolution of their home CPD. To date, all American Board of Emergency Medicine EP applying for our fellowship, who are 10 or more years post-ABEM fellowship, would be expected by ACEM to have recertified. The ABEM approach of mandatory recertification after 10 years is based partly on the theory of declining general and current knowledge with time, along with some historical failures of voluntary approaches by other specialty boards. There was an oral examination up to 1993 based on patient records, but this then was altered to a written process. Changes in knowledge, medical professional practice and patient outcomes are of course very different outcome measures.9 The ABEM website now outlines a process of Emergency Medicine Continuous Certification, which includes four components: (i) professional standing; (ii) life-long learning and self-assessment; (iii) assessment of cognitive expertise; and (iv) assessment of practice performance. The first three components were implemented in 2004, and component four is expected to be implemented in 2010.10 For readers not entirely familiar with the ACEM MOPS programme, ACEM credentials a range of mainly elective and self-directed CPD activities. Examples of the larger categories include accredited meetings, workshops, learning projects, practice-related CME activities, teaching, presentations at academic meeting, examining at college examinations, published articles in a refereed journal, passive and active quality improvement, retrospective peer review of cases, logging clinical practice procedural skills, MOPS online clinical interpretation and case management active peer review. Each fellow must submit online a mandatory annual return that must demonstrate a minimum of points accumulated across the annual tally, the skills maintenance section and over a 5 year cycle.8 Recent website revision should have addressed concerns raised in the series by FACEMs about online recording.5 Fellows might be audited by ACEM. At present, only the New South Wales and New Zealand (NZ) Medical Boards/Council require currency of MOPS, but other regions might follow. Should ACEM have a recertification process and/or mandatory assessments? CPD is most effective when it is self-directed and relevant to the learner,3 but assessment drives learning. Interestingly, one-third of fellows indicated no or infrequent online MOPS participation, where multiple choice question assessment related to a clinical question or scenario.3 The ACME course, although elective, is expensive for fellows. Given AMC recommendations and the statement ‘the team would encourage the college to move to a test of competence rather than simply logging completion of a particular procedure’, should the ACME course be required by all, and is this going to become inevitable? What other ways could ACEM meet the AMC's request? The main take-home points and conclusions to me from Dent et al.'s series are the following: CPD activities can be time consuming and costly, but in the main it appears that service, staffing and time constraints are greater barriers than cost.5 Most useful CPD occurs in the workplace, and informally from colleagues.3 Few FACEM receive feedback on their performance.3 Most FACEM want feedback on their performance.3 A wide range of CPD topics are desired, but certain topics seem most needed. Some are more generic across medical professions, and some more specific to emergency medicine.2–4 More simulation-based training opportunities are desired.3 Although cost has not been found to be a barrier, it is a relevant consideration when any component is mandated. There are inequities between regional CME allowances, with NZ fellows in particular being at a disadvantage. In NZ, ‘professional expenses’ are reimbursable by the hospital, as no tax deductions exist in this regard. Compulsory MOPS activities could be considered a professional expense in NZ, and negotiated to be paid, in addition to an elective CME allowance. At a recent Medical Council of NZ competency workshop, the CPD programme for the NZ Faculty of the Royal Australian and New Zealand College of Obstetrics and Gynaecology (RANZCOG) was described and discussed. An interesting programme had been developed, whereby RANZCOG fellows periodically visit the practice of another specialist to make a competency and CPD evaluation. This process involved direct observation of clinical practice, and a 360 degree interview process. The evaluator met with colleagues from within the speciality, other specialities, management and nursing, and then a confidential report was given solely to the fellow for his or her reflection. In contrast, our fellows advise that although they seldom receive feedback, they receive their most useful CPD in the workplace. Should ACEM follow in a similar direction as the RANZCOG, and would this be feasible? ACEM has been limited as an educational provider. The college's large size and relative paucity of office staff numbers have dictated terms to now. The annual Scientific Conference and Winter Symposium have long provided CPD. The Director of Emergency Medicine Training (DEMT) course is a more recent development. The ACEM Council have voted in principle to move to being more of an educational provider. The Board of Censors is undergoing restructuring and could be replaced by a Board of Education. The present Council portfolio of MOPS might move to within this Board, to address the clear continuum of educational needs between trainees and fellows. Given this background and constraints, it is important to set priorities and to not re-invent the wheel. The MOPS committee is progressing down the right track. Within the FACEM group, there are many differing roles, educational needs and priorities. CPD should be kept as flexible as possible by encouraging adult learning, assessing the learner's needs, avoiding large mandatory components that will not prove useful to some individuals, and avoiding the need for periodic recertification by a continuous, valid and efficacious process. Thought needs to be given to the evidential outcomes of improved professional practice and patient care. There are many existing generic and more specific courses that would suit FACEM needs as outlined in this series, such as managerial, teaching, research and US skills. Perhaps ACEM can better communicate to fellows those CPD opportunities that already exist by conference, course or other professional medical college activity? In regards to educational activities involving teaching skills, the DEMT course has been run successfully at College headquarters since 2005, with ACEM covering DEMT's costs. Numbers are declining as the majority of DEMT have now attended the course. In the future, vacancies could be opened to the general fellowship for a fee. The course covers feedback, performance appraisal and trainee guidance leading up to College examinations, and the College's regulation 4.10 process. A future DEMT refresher course could address specific teaching, or teaching-on-the-run skills. When topics are emergency medicine-specific, or where emergency medicine perspective and applicability are highly relevant, and no course currently exists, ACEM will need to consider developing specific courses and/or online activities. Access block and patient flow, although a whole-of-hospital issue, may be good examples.2 Perhaps the real value is in developing ACEM credentialing to ensure there is departmental FACEM performance feedback, and a system for identifying and assisting the CPD needs of individual FACEM within each ED. This might be less labour-intensive and possibly just as effective as an ‘external reviewer’ who evaluates individual fellows. Any process must be done in the correct manner, and emphasize supporting fellows, reflecting on and improving their practice. If negative issues are highlighted, programmes such as the ACME course could be initiated. This could partly address the AMC recommendation with regard to remediation and retraining. Finally, although there is a clear learning continuum from training to post fellowship, I would like to emphasize that Dent et al.'s analysis was of ACEM fellows only. Although certain conclusions about the ACEM training programme could be drawn, caution is required. There will always be a training end-point and a learning curve after this during consultant practice. The AMC recommends ACEM undertake a gap analysis of their training programme.8 It will be interesting to see how the questions and challenges raised from this series, and the AMC report, will be addressed by ACEM in the future. Wayne Hazell is the immediate past Censor-in-Chief of ACEM.

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.