ABSTRACT
At a time when the world continues to be gripped by one of the most significant pandemics in history, medical regulators are understanding, more than ever, the value of effective regulation on the provision of health care locally, nationally and across national borders. It has never been more important for regulators to work together, share experiences and information, and strive for regulatory best practice.
The COVID-19 pandemic due to the SARS-CoV 2 virus and its variants has put a new focus on the work of the International Association of Medical Regulatory Authorities (IAMRA), particularly in the area of Continued Competency. In 2016, IAMRA released a Statement on Continued Competency which was revised in 2020 and is summarised in this article.
A survey of IAMRA members has indicated that in response to the COVID-19 pandemic, 50% of respondents limited, cancelled or otherwise suspended their CPD/CME requirements; 64% recognised CPD/CME delivered outside their country; 79% will continue to accept virtual CPD/CME in the future and 57% give equal weight to virtual and in-person CPD/CME. Only 50% of respondents were familiar with the work of the International Academy for CPD Accreditation.
The COVID-19 pandemic has resulted in education providers finding new ways of offering content that is innovative, interactive, and easily accessible from the learner’s location. Many Medical Regulators have also adapted to the current environment and have embraced new systems of CPD/CME delivery.
Background: IAMRA and the Rise of Global Regulatory Collaboration
In May 1994, the Federation of State Medical Boards of the USA (FSMB), under contract with the US Department of Health and Human Services, planned and hosted the first International Conference on Medical Regulation in Washington, D.C. Participants came from Australia, Canada, Ireland, New Zealand, South Africa, the UK and the USA. Observers attended from Egypt, Israel, Mexico and Taiwan.
Designed to initiate dialogue among the attendees, the conference focused on the status of medical regulation in participating nations, examined current research on topical subjects and identified emerging research needs. The attendees concluded that regulatory issues are not unique to any one nation (a sentiment that holds true today) and decided to hold a second conference in Australia in 1996. That began a pattern of biennial conferences that continues to this day, albeit disrupted in 2020 by the COVID-19 pandemic.
In September 2000, medical regulatory authorities from Australia, Canada, Ireland, New Zealand, South Africa, Sweden, the UK and the USA formed the International Association of Medical Licencing Authorities, which was formally incorporated in 2004 in the State of Texas as the International Association of Medical Regulatory Authorities (IAMRA). The IAMRA Secretariat continues to be supported by the generosity of the FSMB.
Membership of IAMRA in the “Member” category is open to medical regulatory authorities and to national associations of medical regulatory authorities. The term “medical regulatory authority” (MRA) refers to any organisation recognised by the government of a specific country or jurisdiction as being responsible for the regulation, and/or registration/licensure of physicians whereby such practitioners are entitled to practise the profession of medicine.
Membership of IAMRA in the “Partner” category is a relatively recent addition to the organisation and open to authorities and entities that have a nexus to IAMRA: 1) as indicated by direct contribution to the quality and integrity of the practice of medicine, and therefore medical regulation, through activities such as medical education and assessment (undergraduate and postgraduate), credentialing of licenced/registered practitioners; 2) by virtue of directly regulating health care professionals other than the medical profession.
IAMRA’s vision is “that everyone around the world is treated and cared for by safe and competent doctors”. Its mission is “to promote effective medical regulation worldwide by supporting best practice, innovation, collaboration and knowledge sharing in the interest of public safety and in support of the medical profession”.Footnote1
IAMRA recognises that effective regulation makes a vital contribution to patient safety. Most MRAs have a similar objective: to protect patients by employing effective regulatory tools to manage risk, to ensure that physicians are fit to practise, and to contribute to the provision of high-quality health care. The challenge for medical regulators is to create relevant and effective systems that can respond to the rapidly changing environments in which physicians work, changes in health care and communication technologies, evolving health care delivery systems and as is increasingly apparent, the emergence of pandemics and catastrophic climate or weather events.
Given the mobility of the medical workforce, IAMRA also recognises that the impacts of medical regulation can be felt across the world; what happens in one jurisdiction has the potential to affect another, both positively and adversely. Facilitating interconnectedness and collaboration is the mechanism by which IAMRA fosters best practice and collegiality in medical regulation.
Membership in IAMRA has grown steadily, such that today IAMRA has 118 members from every world region. IAMRA’s biennial educational conferences are valued by members as opportunities to learn from, and connect with, other MRAs. IAMRA conferences are often the primary source of continuing professional development (or continuing medical education) for many physicians who participate in some capacity, in medical regulation. The COVID-19 pandemic resulted in the postponement of the 13th International Conference in Johannesburg in September 2020. However, IAMRA has worked hard to maintain connections with and between its members during this challenging period.
IAMRA does not promote a particular model of medical regulation or dictate how MRAs should operate, recognising that regulatory models are influenced by the structure of the health care system, the legal framework in which regulatory authorities operate and the resources available. Within IAMRA’s membership, many different models of regulation and degrees of independence and autonomy are represented. In view of this, one of IAMRA’s objectives is to provide resources to assist members as they navigate the challenges and competing priorities of regulating the medical profession in their own jurisdiction. Statements on key regulatory issues are a cornerstone of IAMRA’s resource development. Recent statements have addressed Regulation in Disaster Situations, Independence in Medical Regulation, Physician Health and Wellbeing, Prescribing Drugs of Dependence, and Research and Accreditation in Medical Education.
IAMRA’s Interest in Continued Competency
In 2014, one of IAMRA’s strategic goals was to, “identify the principles of continued competency”, in recognition of the shifting regulatory landscape in this area.
Traditionally, physicians were not required to demonstrate their knowledge and skills after their initial training and licensure. Licensure or registration, once granted, was usually life-long. In many developed countries, this is no longer the case, with the right to practise linked either to some means of demonstrating competence or to participation in activity designed to support ongoing learning. Increasingly, medical schools strive to produce graduates who have acquired an appropriate appreciation of, and foundation for career-long learning, and many medical regulators are developing systems that build on this foundation.
Career-long learning is more important than at any time in the past: medical practice is rapidly evolving and growing more complex. The benefits of medicine have never been greater, but the risks of harm from poor practice cannot be underestimated. Unless physicians keep up to date with advances in clinical knowledge, technology and working within complex, safety-critical systems, they risk compromising the care and well-being of their patients.
While many physicians attend to these responsibilities without the involvement or intervention of the regulatory authority, the experience of many regulators is that they may benefit from encouragement to keep up to date. In fact, many regulators are making evidence of continuing medical education a requirement for ongoing licensure. There is also growing recognition that physicians can more effectively engage in continuing professional development opportunities when their choice of educational activities is informed by the context in which they practise and the conditions experienced by the patients they treat, as well as any gaps in their medical knowledge or other competencies. As such, there is a growing need for not only a wide array of educational options but also, guidance for choosing those options that will be most meaningful for improvement in practice.
From the 1970s, regulatory authorities began to introduce systems to address these issues. At their most basic, these systems simply encourage physicians to participate in Continuing Medical Education (CME) or Continuing Professional Development (CPD) without reference to the quality or relevance of this activity to their practice and with limited or no consequences for physicians who fail to comply. At the other end of the spectrum are more complex systems that require physicians to demonstrate their skills and knowledge throughout their careers, with a direct link to their continuing licensure. Such systems include those that require physicians to pass high stakes assessments at various points in their careers as part of their specialisation and those linked to regular objective checks on professional reflection and performance.
In addition to offering various resources for medical regulators, including convening biennial international conferences, IAMRA develops consensus statements based on collaborative input from multiple international regulatory agencies that help regulators navigate a wide variety of key issues. Statements have been published on issues ranging from physician health and well-being, to the accreditation of medical education.Footnote2
In 2016, IAMRA members endorsed a statement in support of Continued Competency, recognising that a key role of medical regulation is to set competency standards and require physicians to keep up to date throughout their careers. The statement was revised in 2020 and released on 20 October 2020 as a Management Committee Statement, pending endorsement by IAMRA’s membership at the Members General Assembly in October 2021.
The recommendations of the statement and the impact of the COVID-19 pandemic on regulatory approaches to Continued Competency are considered below.
Summary of IAMRA’s Statement on Continued Competency
IAMRA acknowledges that medical regulatory authorities employ a diverse range of measures to make sure that physicians remain competent throughout their careers. Accordingly, the statement does not promote a particular model for implementing a Continued Competency system, but instead sets out goals, benefits and guiding principles. In doing so, it is recognised that regulators should take into account the structure of their health care system, their regulatory model and the resources available. Continued Competency systems may or may not have a direct link to licence renewal.
For the purpose of the statement, “Continued Competency” includes, but is not limited to, systems named “Revalidation”, “Maintenance of Licensure”, Maintenance of Competence’ as well as Continuous Quality Improvement, CME/CPD points systems and peer assessment.
“Continued Competency” is more than a system of quality assurance; it recognises the value of continuous quality improvement and encourages physicians’ commitment to career-long learning (education) and integration of new knowledge into practice.
In IAMRA’s statement, the goals, benefits and underpinning principles of a Continued Competency system are stated as followsFootnote3
Goals
A well-constructed Continued Competency system should aim to ensure that all licensed physicians are fit to practise and meet established professional and care standards.
The primary goals of a system should be to ensure a culture of continuous quality improvement for all licensed physicians through self-reflection, peer interaction and feedback mechanisms (including feedback from patients), and foster their intrinsic motivation to improve, thereby affirming their inherent professionalism. The system should build an expectation that learning and quality improvement are ongoing and integrated into practice, not only a point-in-time administrative requirement. A system can also add structure to physicians’ learning efforts, making these more efficient, effective, and relevant to their day-to-day practice. In some jurisdictions, this occurs through the structured collection of feedback from peers and patients, coupled with facilitated discussion about how to use this feedback to identify learning opportunities. In others, physicians are supported in their creation of a learning plan that incorporates specific educational goals based on practice data, followed by ongoing monitoring of progress at achieving these goals.
A secondary goal may be to enable regulators to mitigate risks to patient safety by identifying physicians who may benefit from focused assessment and practice improvement efforts. It can also enable earlier intervention when a physician’s knowledge, skills or behaviour are starting to raise concerns or are not being appropriately maintained or enhanced.
Benefits
The benefits of a Continued Competency system are felt by:
physicians; a well-managed and constructed Continued Competency system can encourage self-reflection and foster their intrinsic motivation to improve, thereby affirming their inherent professionalism. It can also add structure to physicians’ learning efforts, making these more efficient, effective, and meaningful;
patients, by increasing their confidence in the medical profession and providing opportunities to be active participants in supporting improvements in clinical practice by providing feedback on care received, their needs and expectations;
those that employ or contract with physicians by providing assurance that their physicians are participating in a robust and effective quality improvement system;
those providing learning programmes, by assisting them in the development of targeted, relevant programmes;
regulators, by improving confidence in their regulatory function.
Principles underpinning a Continued Competency System
Regulators, in consultation with the profession and stakeholders in the broader community, are encouraged to develop a system that is:
Inclusive -bringing all licenced physicians in to an effectively governed competency framework;
Evidence-informed
using data for continuous improvement;
expecting learning programmes to employ a variety of interactive learning techniques including peer interaction and reflective practice, and address accepted and relevant competencies, including but not limited to; medical knowledge, working in partnership with patients and other health care professionals, patient care, interpersonal and communication skills, professionalism, practice-based learning and improvement, and health advocacyFootnote4;
Feasible
commensurate with the human and other resources available to the regulator and the health system in which physicians operate;
does not impose a disproportionate administrative or financial burden on physicians and builds on existing processes and systems while avoiding conflicts of interest;
does not create access barriers for patients;
Location-appropriate
culturally appropriate;
commensurate with the learning resources available to physicians in the wider healthcare system;
offers options for meeting requirements, builds on and integrates with existing learning systems including, where appropriate, recognising education credits across international borders;
Mandatory – underpinned by law to ensure that participation and regulatory outcomes are enforceable;
Accredited – where robust, independent accreditation is available and affordable.
In addition to the guidance provided above, the Statement on Continued Competency concludes with the following:
‘IAMRA supports and encourages medical regulators to develop and implement Continued Competency systems that are designed to improve the quality of medical practice by promoting, encouraging or requiring career-long learning and continuous quality improvement for all practising physicians. The model adopted should, as far as possible, be in accordance with the guidance in this statement.’
The Impact of the COVID-19 Pandemic
The principles set out in IAMRA’s statement include that a Continued Competency system must be feasible and location appropriate, both of which proved to have considerable relevance in the circumstances of the COVID-19 pandemic. In the context of a health system under stress, rampant spread of the virus and widespread lockdowns, many jurisdictions found it was neither feasible nor appropriate to expect or require the usual Continued Competency systems to operate.
In June 2021, IAMRA conducted an informal survey of its members to gauge the impact of changes to Continued Competency systems as a result of the COVID-19 pandemic; specifically the role of virtual activities as a means to facilitate Continuing Professional Development (CPD)/Continuing Medical Education (CME) delivery in circumstances where there is limited access to in-person events. Fourteen members completed the survey.
Results
93% of respondents stated that the accreditation and/or certification of CPD/CME activities that are acceptable for registration and licensure renewal, is regulated.
CPD/CME requirements ranged from 18 to 50 hours per year, although most programmes span 2, 3 or even 5 years.
50% of respondents reported that CPD/CME requirements were cancelled, limited, or otherwise suspended for a period of time as a result of the pandemic.
64% of respondents said that CPD/CME that is delivered electronically/online from outside of their country, is recognised by the regulator, while 21% said that such activities are not recognised.
79% of respondents stated that virtual CPD/CME will continue to be accepted in the future; the remainder did not know if this would be the case.
57% of respondents stated that virtual CPD/CME will count for the same number of hours/credits as in-person activities, while 14% said that it will not and 29% were unsure. One respondent noted that the credit assigned to virtual CPD/CME depends on whether there is interaction between speakers and participants.
50% of respondents are familiar with the work of the International Academy for CPD Accreditation and 50% are not.
In addition, members were asked to list at least one benefit and one challenge in allowing virtual CPD/CME to meet requirements for registration/licensure renewal.
Benefits were perceived to include:
More flexibility for licensees to complete requirements
More availability of activities, both locally and internationally
Opportunities for physicians meet their educational goals in meaningful ways
The convenience/ease of attendance; accessibility and geographic flexibility
Easy delivery of activities with reduced cost
Cost and time saving for attendees
Capacity is not limited
The identified challenges and disadvantage were:
Ensuring active participation in the activity
Limited interaction with peers
Limited ability for questions/answers
Online learning experience may not achieve the same outcome as in-person activities
Equipment expense and availability in rural areas
Network/internet instability or lack of access
IAMRA views participation in ongoing education as more than a perfunctory activity aimed at fulfiling regulatory requirements. Rather, regulatory systems should encourage the selection of the most relevant and pedagogically appropriate educational opportunities available. The digitisation of educational content can vastly increase the number of relevant learning opportunities and make it much more likely that specific learning needs can be met.
Although the response to this survey was modest, possibly reflecting the pressure under which MRAs are currently operating, IAMRA is aware that many of its members have adapted their Continued Competency programmes as a consequence of the COVID-19 pandemic and have embraced virtual events as constituting acceptable CPD/CME. IAMRA itself has embraced virtual learning by presenting an extensive programme of webinars for its members and staged a successful virtual conference in October 2021.
The COVID-19 pandemic has resulted in education provider finding new ways of offering content that is innovative, interactive, and easily accessible from the learner’s location. It has also bred far greater familiarity with online learning modalities among physicians who are now much more willing to seek out digital education as learning needs arise.
It is noteworthy that only half of the survey respondents were familiar with the work of the International Academy for CPD Accreditation. Given the inclusion of principles in IAMRA’s statement related to the recognition of education credits across international borders and the importance of accreditation to ensure that educational activities meet specific quality standards, it would appear that many MRA’s would benefit from education in this area. The International Academy’s work towards developing substantive equivalency among CPD/CME accreditation systems would greatly benefit the regulatory endeavour around the world.
It is vital for medical regulators to learn from their collective experience of the last two years and seek sustainable and adaptable ways to manage their regulatory responsibilities in a world where local or global phenomena will continue to challenge existing systems. We believe that IAMRA’s statement on Continued Competency is timely and offers relevant and important guiding principles that enable flexibility and adaptability while maintaining the integrity and standards of the system.
IAMRA is committed to assisting medical regulatory authorities in any way it can and will continue to facilitate collaborative learning and the interconnectedness of medical regulatory authorities around the world.
Disclosure Statement
No potential conflict of interest was reported by the author(s).
Notes
1 Access at https://www.iamra.com/vision
3 https://www.iamra.com/resources/Documents/Mgmt%20Cmte%20Statement%20on%20Continued%20Competency.pdf:
Adapted from Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialities (ABMS) core competencies and Royal College of Physicians and Surgeons of Canada CanMEDS Framework.