Doctors' attitudes to maintenance of professional competence: A scoping review

Recent decades have seen the international implementation of programmes aimed at assuring the continuing competence of doctors. Maintenance of Professional Competence (MPC) programmes aim to encourage doctors' lifelong learning and ensure high‐quality, safe patient care; however, programme requirements can be perceived as bureaucratic and irrelevant to practice, leading to disengagement. Doctors' attitudes and beliefs about MPC are critical to translating regulatory requirements into committed and effective lifelong learning. We aimed to summarise knowledge about doctors' attitudes to MPC to inform the development of MPC programmes and identify under‐researched areas.


| INTRODUCTION
The principle that doctors should engage with lifelong learning throughout their working lives is one that few would challenge.
Consensus on how to ensure that this happens has been more elusive.
The once accepted view that 'keeping up to date' was a personal matter for doctors to attend to without the need for external review had been rejected in recent decades. 1,2 Growing emphasis on patient safety and quality of care, challenges to professional self-regulation 3,4 and high-profile cases of malpractice 5 have led to the implementation of programmes to assure the continuing competence of doctors. 6,7 Various terms are used to describe these programmes: revalidation, recertification, relicensing, maintenance of competence, maintenance of certification and maintenance of licensure. 8,9 In this paper, we will use the term Maintenance of Professional Competence (MPC).
MPC programmes vary internationally but, in general, involve educational and/or assessment elements such as participation in knowledge self-assessments, examinations, quality improvement projects, appraisal, peer and patient feedback and continuing professional development (CPD). [9][10][11][12] The intended outcomes of these activities are manifold. Their overarching objective is to improve the quality of patient care. Other objectives include building public trust, encouraging commitment to lifelong learning and enhancing professional development. 9,13 Some MPC activities, such as interactive CPD, appraisal, review of patient complaints and multisource feedback, have been shown to impact doctors' knowledge, skills, attitudes and behaviours. 10 Participation in MPC increases engagement with clinical governance and quality improvement 14 and is associated with better processes and outcomes of patient care. [15][16][17] Nonetheless, questions remain as to whether MPC achieves its intended outcomes. 10,18 This has led to much debate about whether and how MPC programmes should be implemented. In many jurisdictions, participation is a legal requirement for all doctors 10 ; in others, for example, the United States, it is linked to specialty certification rather than medical licensure and is therefore technically voluntary, although the requirements of US insurers and employers render participation effectively mandatory. An emphasis on learning through CPD and practice-based activities is common to most programmes, but there are clear differences in relation to assessment. The United States is unique in using knowledge testing for summative purposes, with significant focus on identifying under-performance, whereas other programmes use only formative assessment and focus on development. 10,19 Ideally, learning for the benefit of patients should be at the heart of MPC, and as committed lifelong learners, doctors should feel motivated and engaged to participate. Yet apparent compliance with the requirements of MPC has been reported as masking deep-rooted cynicism about the process. 20 There is evidence that participation in MPC can lead to feelings of anger and frustration and consequent disengagement. 1,21 Theories concerned with motivation, learning and behaviour 22,23 suggest that negative emotions, experiences and beliefs directly affect motivation and engagement with learning.
Recent research has shown that doctors' beliefs about the benefits of MPC mediated the nature of their engagement with the process. 24 There is evidence that many doctors engage with MPC as a tick-box exercise, 20 creating an impression of compliance without learning or behaviour change. 25,26 MPC can also have unintended consequences.
For example, the introduction of MPC in the United Kingdom increased the risk of hospital consultants leaving practice without any evidence that these doctors were underperforming. 27 Governments, regulatory bodies and other health care organisations have invested heavily in creating MPC programmes on the assumption that they will ensure that doctors engage with career-long learning and leading to better patient care. But although rules and regulations create a framework for MPC, only learners can produce a practice of lifelong learning. Doctors' attitudes and beliefs about MPC are thus critical to translating regulatory requirements to a committed practice of lifelong learning for the benefit of patients.
We undertook a scoping review of the literature looking at doctors' attitudes to MPC. Our aim was to summarise current knowledge with a view to informing the development of MPC programmes and identifying under-researched aspects of the topic for further inquiry.
Our research team included representation from a range of stakeholders in MPC within our own jurisdiction: the regulator, the postgraduate training bodies who administer the programme, the health service and patients.

| METHODS
We chose a scoping review methodology 28,29 because our research questions were exploratory, and early searches revealed the breadth and heterogeneity of the literature. 30,31 Scoping methodology affords the inclusion of various types of literature and methodological approaches, making it useful for reporting on the depth and breadth of literature on a topic. 28,29,32 The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) 33 was used, and the checklist is provided in Appendix S1.

| Protocol and registration
The protocol for this scoping review was published in 2019. 34

| Eligibility criteria
Included sources of evidence had to relate to MPC in doctors. All specialties and scopes of practice were included. Following initial searches, we limited our review to doctors in the United Kingdom, the United States, Canada, Australia, New Zealand and Ireland, based on a lack of published information relating to MPC programmes in other countries.
We included sources that provided empirical data about doctors' attitudes to MPC as a whole, pilots of MPC or elements of the MPC process (eg, quality improvement, multisource feedback and assessment). Sources focusing on specific elements were only included if an explicit link was made between the element and MPC.
There were no limits in respect of the date of publication or research methods used. Peer-reviewed original research papers, commentaries and letters containing empirical data, and governmental or organisational reports and consultation documents containing empirical data relevant to the focus of the review were included. We excluded non-peer-reviewed commentaries, reviews and letters and grey literature other than the reports and consultation documents referred to earlier. We limited the included studies to those in the English language.

| Literature search strategy
We employed a three-step approach to identify relevant studies. We

| Data charting process and data items
A data extraction tool was developed in Microsoft Excel, including author(s), title, publication, year, country, study design, population description, sample size and findings. All researchers used the tool to retrieve relevant information; we met to assess whether our approach to data extraction was consistent with the research questions and purpose and refined the data extraction tool accordingly. Crosschecking was undertaken to identify any inaccuracies or oversights.
Discrepancies were resolved amongst the core team with the involvement of the broader research team when necessary.

| Critical appraisal of individual sources of evidence
We did not formally appraise the quality of individual sources of evidence, consistent with established scoping review methods. 28,33

| Synthesis of results
The synthesis of results involved a descriptive numerical summary analysis and a qualitative thematic analysis of the findings presented in included sources of evidence. Thematic analysis similar to approaches used in qualitative research 37 is recommended by Levac et al. 28 and involved identifying themes and gaps in the literature.
Qualitative analysis software (NVivo) was used to facilitate this process. 38 The results are reported through a combination of tables, figures and thematic summaries.

| Description of studies
The PRISMA flow diagram in Figure 1 outlines the process that led to the selection of 125 sources of evidence for inclusion in the review.
One hundred and two were published in peer-reviewed journals, and  Doctors with a role in implementing MPC were more likely to have a favourable view about the process than the doctors on whom the process was imposed. 53,71,74,76,78,94,97,109 Time and experience with the process also appeared to impact doctors' attitudes positively, and resistance to MPC gradually reduced over time. 43,52,53,62,78,99,[110][111][112][113] Having support from colleagues and the workplace to participate in MPC also influenced doctors' attitudes positively. 21,60,78,[114][115][116] A few studies reported that doctors felt that participating in MPC diminished their professional status and returned them to a student/testing mindset. 46,53 Authorities' ineffective resolution of systemic difficulties identified by the doctor in the course of MPC was another reason for the lack of trust in the integrity of the process. 20,26,71 Doctors were of the view that MPC has the potential to result in or already has led to unintended consequences; for example, that doctors would leave their practice and careers or retire early. 60

| Implications for practice
Patients are the primary consideration in requiring doctors to maintain their professional competence. Doctors are stakeholders in MPC, but their dissatisfaction with its processes do not override the need to ensure safe, high-quality patient care. Nonetheless, attending to issues raised by doctors does offer an opportunity to improve MPC programmes, so that they engage and motivate doctors while yielding the desired outcomes for regulators and patients. Doctors in the studies we reviewed agreed that MPC programmes are necessary; however, optimal structure and content of MPC remains controversial. Programmes vary widely, from their underpinning philosophy to their operational detail. There has been a trend towards implementation of mandatory MPC programmes in developed countries. 10,19 Amongst the jurisdictions included in our review, four of five have implemented mandatory MPC in the past decade. In the United States, participation is mandatory for those who hold timelimited specialty certification and wish to maintain it. There is evidence that voluntary participation amongst US doctors with unlimited certification is lower than amongst those for whom it is mandated. 164 Similarly, participation in annual appraisal increased in the United Kingdom when it became part of the mandatory revalidation process. 54 Our finding that participation was driven predominantly by regulatory requirements means it is unlikely that voluntary programmes could meet the objective of providing accountability to patients and the public for the profession as a whole.
There is growing evidence the participation in MPC is associated with better processes and outcomes for patient care. [15][16][17][165][166][167][168][169] The perception, held by many doctors, of a lack of impact on practice as reported in our review must be interpreted in the light that learners are not always the best judges of what has been learned. [170][171][172] Further research into the impact of MPC, moving beyond association to causation, would help to convince doctors of its value as well as reassuring regulators and the public that MPC is achieving its goals. An MPC programme can be understood as a complex intervention, one with multiple interacting elements set in a dynamic environment. 175 Such interventions have essential core components alongside more peripheral adaptable elements. 176 A possible explanation for the mixed views reported in relation to elements of MPC programmes is that they work well in some contexts but not in others, meaning that there is no single 'best' model. 10 Implementing a complex intervention requires tailoring the intervention to local contexts while maintaining the essential core required to generate the outcomes. 176 In health, co-production is described as a way of working with patients to improve health and creating user-led, people-centred health care services. 177 In the context of MPC, co-production would require regulators to work closely with doctors in the local contexts in which they deliver care to design meaningful learning activities to maximise benefit to their patients. 178,179 In the interest of fairness and equity, there must be consistency in broad terms in programme requirements; however, this does not equate to the 'sameness' of a one-size-fits-all approach. The advantages of co-production are greater ownership of MPC processes by doctors, greater relevance to their practice and thus greater benefit to their patients, early and ongoing identification of barriers or problems with the processes, responsive changes to address these and greater motivation for doctors to engage in MPC effectively.
Co-production offers a way to ensure that MPC is meaningful and effective 179 that promises benefits for patients. There are also significant challenges associated with co-production. It requires resources and time, and the new forms of knowledge it generates may not align well with the evidence demanded by regulators. 177 A key point of difference between programmes is the emphasis they place on engaging doctors in learning activities versus assessing their knowledge and competence. 10 The forms of evidence used to make summative decisions are shaped by these philosophical differences. Many European programmes require participation in learning and practice improvement activities without testing knowledge or competence. 10,19 Collection of evidence relating to performance in practice may be required to support reflective learning, but the evidence itself is not used for summative purposes. In such systems, it is failure to participate satisfactorily over a period of time that can lead to penalties. Our suggestion for co-production sits more comfortably within this sort of development focused approach. By contrast, the US system stands out for its strong focus on summative assessment.
Having developed from a high-stakes knowledge test taken every 10 years, with the addition of more formative elements latterly, it retains a greater focus on identifying poor performance through testing than is seen in other programmes. 10,180 This tension between the formative and summative objectives of MPC programmes is prominent in the UK literature. When annual appraisal, a formative process, was subsumed into the summative process of revalidation, doctors perceived a tension between what had been a supportive and development focused activity and the possibility of punitive action for poor performance. 42,[76][77][78] In practice, fitness-to-practice concerns arising in the context of appraisal are addressed outside the revalidation process. It is non-engagement rather than poor performance that results in a loss of licence to practice within the revalidation process. 181 The number of doctors referred to the General Medical Council for fitness to practice issues has not increased since revalidation was implemented, 182 and, perhaps relatedly, concerns about the formative/summative tension have lessened over time. 11,52,53,62,79 Whether programmes lean more towards development or assessment, they are constructed on assumptions that participation in formative activities will translate into better, safer patient care and/or that testing knowledge and competence in all doctors is the best way to identify a small proportion who underperform. Both assumptions require stronger evidence to fully justify the cost and scale of the programmes they underpin.

| Implications for research
Most of the sources of evidence included in this review relied on survey data. Although some have thousands of respondents, the depth of their findings has been limited by the methodologies employed.
Many have focused on evaluating operational aspects of MPC. They have provided a snapshot of attitudes but have not elucidated the reasoning behind them. This lack of depth in the field is compounded by a lack of theoretical underpinning, with less than 10% of sources of evidence referring to a specific theory.
Use of appropriate theory can greatly enhance the quality of research, sharpening research questions, shaping the data collected and adding depth, meaning and transferability to findings. 183,184 Although There is scope for further well-funded, high-quality research in this area, specifically research that uses theory, links MPC to engagement with learning and uses implementation sciences approaches.

Research in jurisdictions beyond the United Kingdom and the United
States would also add to the field. The varied programmes in place internationally create an opportunity for greater exploration of the influence of context on attitudes and engagement as well as efficacy.

| Strengths and limitations
This review is part of a programme of research undertaken by researchers, knowledge users and other stakeholders in MPC in Ireland, including patient representation. The focus of the review and our discussion of its findings was influenced by this group, bolstering its direct relevance to those who design, deliver, participate in and benefit from MPC. We have followed a recognised methodology and reported our findings using the PRISMA-ScR framework.
By limiting our review to the United Kingdom, the United States, Canada, Australia, New Zealand and Ireland and to English-language papers, we may have excluded useful data from elsewhere. We deviated from our published protocol by not including the final and optional step of expert consultation, which might have identified some additional sources of evidence. This decision was made in the context of the SARS CO-V pandemic and the desire to publish the research without undue delay.

| CONCLUSION
Participation in MPC is associated with better processes and outcomes of patient care. Doctors are supportive of the concept of MPC but have mixed views on its processes. Moves to reduce bureaucracy currently afoot will be welcome. Implementation science offers a way to motivate doctors and optimise the benefits to patients through local adaptation of learning activities in partnership with doctors.
There remain substantial philosophical and operational differences between MPC programmes internationally, with a need for more evidence to support the assumptions underpinning these extensive and expensive programmes. There is scope for well-funded, high-quality research utilising theory to move the field forward. Board, Ireland. The funding body was not involved in the design of the review, analysis or interpretation nor in drafting the manuscript.

CONFLICT OF INTEREST
None.

AUTHOR CONTRIBUTIONS
AW carried out the search, data screening and extraction; drafted the manuscript and prepared and approved the final version for publication. EG carried out the search, data screening and extraction; revised the manuscript and approved the final version for publication. IK carried out the search and data screening; revised the manuscript and approved the final version for publication. DB conceptualised the study, carried out the data screening, drafted the manuscript, provided feedback on revisions and approved the final version for publication. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

ETHICS STATEMENT
No ethical approval, as no human subjects were involved in this scoping review.