Putting the professional in Continuing Professional Development

Proposed changes to the mandatory continuing professional development registration standard have caused concern amongst the profession. What is the rationale for these changes?

The Dental Board of Australia is presently consulting on the Continuing Professional Development (CPD) registration standard as part of their cycle of reviewing policies (alongside a number of other health profession boards). This registration standard first came into effect in 2010, and then was reviewed and revised in 2015, so it is more than overdue to be reviewed again. There is also a legislative requirement for the Dental Board to have a registration standard for continuing professional development as a condition for registration.

Many younger practitioners may be unaware that continuing professional development was not always mandatory in Australia. Prior to national registration coming into effect in 2010, states (and territories) had their own registration boards that regulated the practice of dentistry independently of each other. The Dental Practice Board of Victoria was the first jurisdiction to introduce mandatory CPD in 2005, and this was eventually taken up by the Dental Board of Australia when the individual state and territory boards transitioned to a national scheme.

The introduction of mandatory CPD in Victoria in 2005 was contentious, with many practitioners concerned about the imposition of mandatory requirements that they felt should sit in the domain of being a professional responsibility. At the same time, the practice of dentistry had been evolving (which seems quaint when we see the changes that have occurred since then), and there was evidence that a substantial proportion of the profession did not engage in any meaningful continuing education activities to keep up to date with these changes.

A 1994 survey of CPD practices of Victorian dentists reported that 47% of dentists attended fewer than 20 hours of CPD courses over a 12-month period, 18% did not attend any continuing education courses in the preceding year and 13% did not attend continuing education courses at all.

In 2005, in anticipation of the changes coming into Victoria, I conducted research looking at participation in CPD by Victorian dental practitioners in the previous year. Nearly 90 per cent of respondents had attended a CPD course in 2004 with an average of 24 hours for dentists, 37 hours for dental specialists and 12-17 hours for dental therapists and hygienists. But 31% of dentists did less than 10 hours, and 57% did less than 20 hours.

Around that time a study in Western Australia covering 2001-2006 found 20-37% of the dentists attended at least one continuing education course a year from 2001-2006 at the major provider of continuing education in the state.

We then went back and checked what practitioners were doing in 2007, a few years after mandatory CPD was implemented. Dentists reported attending an average of 30.9 hours of certifiable clinical CPD whilst specialists attended an average of 33.2 hours of certifiable clinical CPD over a 12-month period. Practitioners also reported attending certified and non-certified non-clinical CPD as well. Nearly three quarters of respondents reported changing their practice as a result of CPD activities, whilst one quarter attended CPD mainly to meet the mandatory requirements. Still 10% of dentists had done no clinical CPD in the 12-month period.

So at least one of the concerns has always been about the small but significant proportion of practitioners who do not appear to meaningfully engage in formal measures to keep up-to-date.

I don’t think many people would argue against the principle of lifelong learning. Dentistry changes rapidly, with new materials, technologies, clinical techniques, infection control standards, patient expectations and even ethical consideration. Where some of the tension around the mandatory aspect sits has to do with whether this actually improves the quality of treatment provided, and ultimately does it lead to better patient outcomes.

A recent systematic scoping review found that CPD programs incorporating practical skill development, protocol-based implementation, organizational support, and ongoing reinforcement can enhance patient care. Studies that demonstrated positive patient outcomes tended to focus on reaction, learning, behaviour change, and results.

Another systematic review that examined evidence for continuing professional development standards for regulated health practitioners in Australia found that CPD is most effective when it is interactive, uses a variety of methods and is delivered in a sequence involving multiple exposures over a period of time that is focused on outcomes considered important by practitioners. It also found that there is not an optimal number of CPD hours but there is evidence that complex skills may require more frequent CPD.

One concern is that whilst mandatory CPD might have ensured that the proportion of practitioners who had historically not engaged in this process of lifelong learning are now at least undertaking ongoing education, there is a risk that it has become a performative ‘tick box’ exercise.

There is also a genuine concern about the commercialisation of CPD. When the Victorian scheme first started in 2005, CPD providers had to be accredited by the Board. Whilst it restricted who could provide CPD, it also meant there has some oversight of providers and course content. The national scheme does not have the same guardrails, which means that anyone can provide CPD – and often they do. CPD has become an industry, and the commercialised nature is likely to have unintended consequences. High course costs (plus the additional travel and accommodation fees, particularly for practitioners in regional and rural areas where there are fewer opportunities for local learning) and the opportunity cost of time away from work has created a ‘return on investment’ mindset about CPD. Courses are no longer just about improving clinically or learning new techniques. There is an undercurrent of ‘how can this new thing increase revenue.’

Whether it is overt or not, commercially driven CPD shapes treatment trends, normalises intervention focussed care and accelerates the uptake of more expensive procedures. Ask yourself when was the last time you attended a course based on prevention of disease rather than treatment?

What are the major changes being proposed by the Board?

The Dental Board is a bit of an anomaly amongst the various health professions. Eight national boards require 20 hours of CPD per year, three require between 25 and 30 hours per year and two (including the Dental Board) require 60 hours over a three-year period.

Some professions - chiropractors, optometrists, osteopaths and podiatrists - require completion of first aid/cardiopulmonary resuscitation (CPR) and/or management of anaphylaxis, but the Dental Board does not.

The proposed changes would:

• align CPD requirements across participating professions, including adopting a principles-based approach and a minimum of 20 hours of CPD activities per year

• require 5 of the 20 CPD hours be interactive (face to face or virtual with other practitioners)

• require additional CPD hours for practitioners with additional technical or profession-specific skills (e.g. endorsement for scheduled medicines), and

• remove mandatory minimum training requirements on first aid, CPR and/or management of anaphylaxis (for those professions that currently require this).

Interactive CPD is defined as CPD activities that involve a two-way flow of information with other practitioners, which could include case discussions with colleagues, attending online training or face-to-face hands-on training. The evidence suggests that CPD is more effective when it is interactive, and this move appears to be designed to prevent people from accruing 20 hours through watching online videos or reading journal articles. I think that this has been misinterpreted by many as requiring the attendance at face-to-face hands-on courses.

The draft revised standard would also require practitioners to reflect on and plan their learning goals and CPD activities by maintaining a portfolio that records their learning goals, activities and a reflection on how the activities are expected to improve or have improved their practice. This is a positive step that requires practitioners to focus on self-reflection and ensure that their CPD activities are meaningful in the context of the way that they practice dentistry.

The draft revised CPD standard also encourages practitioners to complete CPD on cultural safety but does not establish a requirement, as there is separate work being led by Aboriginal and Torres Strait Islander Peoples to identify specific requirements for CPD on cultural safety.

Given the level of feeling amongst the profession on this issue, I encourage everyone to consider making a submission, which you can do here.