Shared responsibility for continuing professional development translates into short-term trade-offs

In Denmark, the continuing professional development (CPD) of consultants is the shared responsibility of employers, represented by heads of department (HOD) and consultants [1]. This policy encourages self-governance rather than requiring points to practice or regular re-certifications as may be the case in other healthcare systems [2, 3]. Among the few formal agreements to guide the governance of shared responsibility in Denmark is that consultants have a right to spend a minimum of ten paid working days a year on CPD [4].

Surveys indicate that a considerable proportion of consultants spend less than ten days annually on CPD. To understand what may affect the translation of the right to CPD into practice and to inform possible policy adjustments at the department level, it is conducive to understand how shared responsibility for CPD is managed.

The overall aim of this study was to explore how CPD is practiced when consultants and HOD share responsibility. The research questions were: What are consultants’ wishes and conditions for CPD, and what patterns emerge in their trade-offs between wishes and conditions?

METHODS

We designed an interview study building on what we already know from surveys of consultants’ CPD activities. Five specialties were purposively selected: anaesthesia, oncology, orthopaedic surgery, paediatrics and clinical microbiology to ensure representation across specialties and ensure variation in terms of economic support from the pharmaceutical industry. No clinical microbiologists responded to our invitation.

We invited HOD for an interview. Furthermore, we asked them to identify a newly appointed and a more senior consultant for an interview.

We prepared one interview guide for the HOD and another for consultants (Figure 1). All interviewees consented to participate in the study. The first five interviews were conducted by BB and DO, and the remaining by BB. The interviews lasted 23-61 minutes. The Research Ethical Committee of the Capital Region of Copenhagen waived review (Journal-no.: H-18065537).

Data analysis

Interview data were first analysed in terms of the individual consultants’ descriptions of their wishes and options regarding CPD. This analysis showed how their choices were often the result of a series of carefully considered “trade-offs” between various elements that were given value in the context of a particular set of economic, organisational and normative structures. Here, we apply the term trade-off to describe the situated process of weighing elements in CPD activities, i.e. topic, funding, time and forms of learning, that may turn into pros and cons in consultants’ descriptions of their activities. Trade-offs between these elements became the empirical focus of this analysis, and generalisations are made at the level of these elements. Critical theory was chosen as an overall analytical inspiration for its ability to illuminate the nexus between individual choices and structural conditions [5-7]. Our choice of theory reflects our assumption that patterns in the uptake of CPD are not shaped by individuals’ plans or motives alone, nor by institutional structures, but emerge in their interplay.

Trial registration: not relevant.

RESULTS

We conducted 26 individual semi-structured interviews in 2019 in four specialties and nine departments in the Capital Region of Copenhagen. Interviewees comprised ten HOD and 16 consultants.

Some elements were recurring in the consultants’ considerations, i.e. topic, funding, time and the relation between learning methods and learning gains. These elements are presented below as separate entities with indications of how consultants made trade-offs, which tie into the actual practicing of shared responsibility for CPD activities at the department level as described at the end of the section. In Table 1, selected consultants’ trade-offs are illustrated.

Trade-offs regarding topics for continuing professional development

From interviews with both consultants and HOD, it appeared that they almost exclusively prioritised learning in relation to the role as a medical expert over roles as a manager, a collaborator or a communicator. This pertained to consultants across specialties and levels of experience. A variety of courses within these areas are available in the region and are offered free of charge. Even so, these areas are rarely prioritised. Many consultants did consider these topics important, but they considered that keeping up with developments in their medical specialisation was more important.

Despite high degrees of specialisation, the consultants were able to find learning opportunities, and many enjoyed forming part of international networks. In some specialties, extended courses to sub-specialise are available at the Danish, Scandinavian or European level. These courses are considered very attractive, although they require a considerable amount of time and often imply quite large out-of-pocket expenses without any guarantee that the new skills will lead to a specialist function.

Trade-offs regarding sources of funding for continuing professional development

Practices relating to funding of CPD activities were among the most variable elements among departments. Some HOD spent their CPD budget on annual one-day seminars for all employees including nurses. Others allocated an annual sum as a grant to be applied for by individual consultants wishing to attend a course or congress. A few HOD were able to fully fund consultants’ participation in congresses and courses.

Departmental budgets may cover all or parts of CPD costs. Furthermore, the HOD can grant time off with or without salary. Departmental CPD budgets are annual. This complicates long-term planning.  Recently, access to funding from the pharmaceutical industry has become considerably harder to come by and become more controversial than was previously the case.

Several consultants were engaged in an individually designed, longer-term plan with partial financial support, but it remained unclear to which extent all consultants were aware of this option and how systematically the option was being made available. A recurring concern among HOD is how to allocate limited funds in a fair and transparent manner. Many consultants pay part of their CPD-related expenses themselves or take time off without pay to participate in CPD activities. Some saw this practice as the extension of a long-held tradition and considered this condition an established fact, whereas others considered this to be exploitation by the employer.

Trade-offs regarding time to learn, work and time off

As mentioned, HOD can offer time for CPD activities with or without salary up to a certain level. Both consultants and HOD experience that this possibility has decreased considerably over the past five to eight years due to what is occasionally referred to as ”production pressure”. Several interviewees expressed concern about this trend as they genuinely felt responsible for their patients, but were worried that the pressure would undermine the quality and safety of treatment in the longer term. During the same time period, congresses have increasingly been moved to weekends in order to avoid taking time away from patients, thus encroaching on consultants’ time off.

These changes have occurred alongside shifts in work-life balance. Consultants refer to the work they do off their ward as taking up ”interest time”. It seems to have been an established assumption that one cannot stay updated in a field or advance one’s career without spending interest time after working hours. Some consultants do not distinguish very clearly between time off and interest time, whereas others, often with young families, find it harder to make trade-offs involving time. Relevant to observations about phases in personal and professional lives is also that some consultants nearing their pension seemed to be more engaged in how to transfer their experience to their younger colleagues than in planning their own CPD.

Trade-offs regarding forms of continuing professional development

Traditionally, CPD activities have been understood as congresses or courses. Many consultants expressed their appreciation for the opportunity to get updated within their fields of expertise and to refresh personal relations by engaging in professional networks.

Both consultants and HOD had a broad understanding of learning opportunities. They included in the concept both national and international exchange stays; the development of national or international guidelines; supervision of residents; and exchanges with colleagues within or across specialties. Some also mentioned weekly departmental seminars, but it seems that the quality of learning opportunities is not regularly evaluated and adjusted. E-learning is up for debate in terms of whether time spent at home on e-learning should count as working hours.

Even though many consultants consider the learning they achieve through these individualised forms of learning more valuable than participation in  congresses and courses, a back-draw is that they may need to invest a considerable amount of interest-time in identifying and organising them.

Particularly the new consultants found that they learned simply from going to work, but some called for more structured feedback. In addition, they expressed a wish for a long-term approach to the planning of their CPD activities. Departments differed considerably with respect to the degree to which and the means allocated to accommodating long-term planning of CPD activities. Some of the new consultants established mentoring relationships with same-level or more senior colleagues where transfer of experience is pivotal.

Shared responsibility in practice

Most consultants and HOD acknowledge and work towards achieving the optimal combination of individual wishes and departmental needs for development of competence. Practices differ, however, in terms of how much dialogue there is about wishes and needs. Some consultants apply once a year for a grant from the department for a particular activity, which the HOD then approves. In this form, CPD is managed as a purely administrative task. Some HOD substantively engage in consultants’ longer-term development plans and keep track of how many days individual consultants spend. Few HOD made explicit their long-term development plans for the department, which consultants would then be able to consider. Still, since many consultants funded their CPD activities partly or completely out of their own pockets, and often spent time off on them, they ultimately consider that these decisions are their own.

In some departments, no regular career development meetings are held between the HOD and consultants, whereas others experiment with delegating career development meetings to section heads. Thus, funding decisions may either remain with the HOD or be administered at the section head level.

DISCUSSION

Taking trade-offs as expressions of the nexus between individual wishes and structural conditions, we have explored which elements consultants included in their wishes, considerations and practices regarding CPD activities. This provided insight into the ways that shared responsibility was managed on a day-to-day basis.

 ”Production pressure” is not the only factor that limits consultants’ time spent on formal CPD activities; the high level of complexity in the funding CPD activities and encroachments on time of fare are also relevant and may not be recognised by employers. When these elements are drawn into trade-offs, they may signify deeper shifts in what employers can expect and ideas of what it takes to be an updated and professional physician. Some referred to this shift as physicians acquiring an employee mentality, meaning that they tend to pay more attention to working hours than to professional or academic excellence (see Table 1, item 4). It is important, however, to acknowledge that working conditions and funding flows have also changed considerably over the years, leaving less space for individual flexibility. Our findings align with a recent review of CPD activities [8].

It is interesting to note how the ”ten-day rule” works both for and against learning. The agreement makes learning countable, which is good for monitoring, but our interview data suggest that a considerable amount of very valued learning occurs in a variety of ways at work, during visits and exchange stays. An excessive focus on adhering to the ten-day rule may limit the development of other forms of learning and their inclusion into individual development plans.

Consultants often consider the ten days their own. Even though they are often ready to coordinate with department priorities, they do often pay out-of-pocket for activities and spend time off on them. With the recent union agreement to ensure a greater alignment between individual consultants’ learning activities and departments’ strategic development, the individual autonomy of consultants will be challenged. Consultants need to be convinced of the benefit of CPD activities [9].

The potential for planning via career development meetings seems underutilised. Shared responsibility for CPD activities is not only managed very differently across departments, it also varies considerably to which extent CPD is considered in conjunction with longer-term strategic department developments. Aligning the CPD activities of individual consultants, who might not need or require a one-size fits all package, with strategic planning at the department level is difficult within the current budgeting practice of the wider hospital organisation.

CONCLUSIONS

We identified four recurring elements in consultants’ trade-offs: topics, funding, time and learning gains. Trade-offs within and between these elements are strongly influenced by lack of departmental priorities, shifts in funding mechanisms, availability of support to tailor-make CPD activities, feeling responsible for patients and for “production”, shifts in perceptions of interest-time and phases in the physicians’ career and personal life.

The flexibility associated with sharing responsibility for CPD may be an advantage, but it is often not utilised to its full potential. With short-term budgets, very uneven management practices regarding longer-term strategy development in departments and untapped opportunities to structure learning, and do so in more diverse ways, a considerable risk exists that CPD activities remain coincidental or even a waste of time and funds.

Correspondence Birgitte Bruun. E-mail: birgitte.bruun@regionh.dk

Accepted 21 December 2022

Conflicts of interest none. Disclosure forms provided by the authors are available with the article at ugeskriftet.dk/dmj

Cite this as Dan Med J 2023;70(3):A07220431