Implementing high-value, cost-conscious care: experiences of Irish doctors and the role of education in facilitating this approach.

BACKGROUND: Adopting high-value, cost-conscious care (HVCCC) principles into medical education is growing in importance due to soaring global healthcare costs and the recognition that efficient care can enhance patient outcomes and control costs. Understanding the current opportunities and challenges doctors face concerning HVCCC in healthcare systems is crucial to tailor education to doctors' needs. Hence, this study aimed to explore medical students, junior doctors, and senior doctors' experiences with HVCCC, and to seek senior doctors' viewpoints on how education can foster HVCCC in clinical environments. METHODS: Using a mixed-methods design, our study involved a cross-sectional survey using the Maastricht HVCCC-Attitude Questionnaire (MHAQ), with a subset of consultants engaging in semi-structured interviews. Descriptive analysis provided insights into both categorical and non-categorical variables, with differences examined across roles (students, interns, junior doctors, senior doctors) via Kruskal-Wallis tests, supplemented by two-group analyses using Mann-Whitney U testing. We correlated experience with MHAQ scores using Spearman's rho, tested MHAQ's internal consistency with Cronbach's alpha, and employed thematic analysis for the qualitative data. RESULTS: We received 416 responses to the survey, and 12 senior doctors participated in the semi-structured interviews. Overall, all groups demonstrated moderately positive attitudes towards HVCCC, with more experienced doctors exhibiting more favourable views, especially about integrating costs into daily practice. In the interviews, participants agreed on the importance of instilling HVCCC values during undergraduate teaching and supplementing it with a formal curriculum in postgraduate training. This, coupled with practical knowledge gained on-the-job, was seen as a beneficial strategy for training doctors. CONCLUSIONS: This sample of medical students and hospital-based doctors display generally positive attitudes towards HVCCC, high-value care provision, and the integration of healthcare costs, suggesting receptiveness to future HVCCC training among students and doctors. Experience is a key factor in HVCCC, so early exposure to these concepts can potentially enhance practice within existing healthcare budgets.

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

CONTEXT: 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. METHODS: We undertook a scoping review following Arksey and O'Malley, including sources of evidence about doctors' attitudes to MPC in the United States, the United Kingdom, Canada, Australia, New Zealand and Ireland, and using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) as a guide. RESULTS: One hundred and twenty-five sources of evidence were included in the review. One hundred and two were peer-reviewed publications, and 23 were reports. Most were from the United Kingdom or the United States and used quantitative or mixed methods. There was agreement across jurisdictions that MPC is a good idea in theory but doubt that it achieves its objectives in practice. Attitudes to the processes of MPC, and their impact on learning and practice were mixed. The lack of connection between MPC and practice was a recurrent theme. Barriers to participation were lack of time and resources, complexity of the requirements and a lack of flexibility in addressing doctors' personal and professional circumstances. CONCLUSIONS: Overall, the picture that emerged is that doctors are supportive of the concept of MPC but have mixed views on its processes. We highlight implications for research and practice arising from these findings.

Orientation of medical trainees to a new clinical environment (the ready-steady-go model): a constructivist grounded theory study.

BACKGROUND: High-quality orientation of trainees entering a new clinical workplace is essential to support education and patient safety. However, few consultants receive extensive formal training to support new trainees and must create their own ways of integrating newcomers into their clinical team and work environment. We aim to conceptualise the strategies consultants use in the early stages of working with new trainees that will be useful for future faculty development in this area. METHODS: We used constructivist grounded theory (CGT) methodology by interviewing fifteen consultants in three medical specialties, to explore how trainees are integrated into a new clinical environment. We used CGT principles and procedures (iteration, constant comparison, and theoretical sampling) to analyse and construct a conceptual interpretation of the empirical data. RESULTS: Consultants' central concern when introduced to a new cohort of trainees was that they had the required knowledge and skills (ready), were adapted and integrated into the new workplace and clinical team (steady), and safely participating in practice (go). Consultants used two broad strategies: formal orientation and informal orientation. Both these approaches had the common goal of intensifying interaction between consultants and trainees to get trainees to a position where they were ready, adapted, integrated, and participating safely and efficiently in practice. Several disruptors were identified by participants that delayed and sometimes completely inhibited the orientation process. CONCLUSIONS: The model of orientation constructed through this research could be a valuable tool to support faculty development initiatives, the reflective learning practice of clinical supervisors, and curriculum design. The disruptors were identified as valid priorities for improving trainee orientation in postgraduate medical education. Future research should involve a longitudinal approach to explore trainee engagement with orientation upon entering a new clinical workplace.

Doctors' maintenance of professional competence: a qualitative study informed by the theory of planned behaviour.

BACKGROUND: Medical regulators worldwide have implemented programmes of maintenance of professional competence (MPC) to ensure that doctors, throughout their careers, are up to date and fit to practice. The introduction of MPC required doctors to adopt a range of new behaviours. Despite high enrolment rates on these programmes, it remains uncertain whether doctors engage in the process because they perceive benefits like improvements in their practice and professional development or if they solely meet the requirements to retain medical registration. In this study, we aimed to explore the relationship between doctors' beliefs, intention and behaviour regarding MPC through the lens of the Theory of Planned Behaviour (TPB) to make explicit the factors that drive meaningful engagement with the process. METHODS: We conducted a qualitative study using semi-structured interviews. From a pool of 1258 potential participants, we purposively selected doctors from multiple specialities, age groups, and locations across Ireland. We used thematic analysis, and the TPB informed the analytic coding process. RESULTS: Forty-one doctors participated in the study. The data analysis revealed doctors' intention and behaviour and the factors that shape their engagement with MPC. We found that attitudes and beliefs about the benefits and impact of MPC mediated the nature of doctors' engagement with the process. Some participants perceived positive changes in practice and other gains from participating in MPC, which facilitated committed engagement with the process. Others believed MPC was unfair, unnecessary, and lacking any benefit, which negatively influenced their intention and behaviour, and that was demonstrated by formalistic engagement with the process. Although participants with positive and negative attitudes shared perceptions about barriers to participation, such perceptions did not over-ride strongly positive beliefs about the benefits of MPC. While the requirements of the regulator strongly motivated doctors to participate in MPC, beliefs about patient expectations appear to have had less impact on intention and behaviour. CONCLUSIONS: The findings of this study broaden our understanding of the determinants of doctors' intention and behaviour regarding MPC, which offers a basis for designing targeted interventions. While the barriers to engagement with MPC resonate with previous research findings, our findings challenge critical assumptions about enhancing doctors' engagement with the process. Overall, our results suggest that focused policy initiatives aimed at strengthening the factors that underpin the intention and behaviour related to committed engagement with MPC are warranted.

A national stakeholder consensus study of challenges and priorities for clinical learning environments in postgraduate medical education.

BACKGROUND: High quality clinical learning environments (CLE) are critical to postgraduate medical education (PGME). The understaffed and overcrowded environments in which many residents work present a significant challenge to learning. The purpose of this study was to develop a national expert group consensus amongst stakeholders in PGME to; (i) identify important barriers and facilitators of learning in CLEs and (ii) indicate priority areas for improvement. Our objective was to provide information to focus efforts to provide high quality CLEs. METHODS: Group Concept Mapping (GCM) is an integrated mixed methods approach to generating expert group consensus. A multi-disciplinary group of experts were invited to participate in the GCM process via an online platform. Multi-dimensional scaling and hierarchical cluster analysis were used to analyse participant inputs in regard to barriers, facilitators and priorities. RESULTS: Participants identified facilitators and barriers in ten domains within clinical learning environments. Domains rated most important were those which related to residents' connection to and engagement with more senior doctors. Organisation and conditions of work and Time to learn with senior doctors during patient care were rated as the most difficult areas in which to make improvements. CONCLUSIONS: High quality PGME requires that residents engage and connect with senior doctors during patient care, and that they are valued and supported both as learners and service providers. Academic medicine and health service managers must work together to protect these elements of CLEs, which not only shape learning, but impact quality of care and patient safety.

Experience of enhanced near-peer support for new medical graduates of an Irish university: a phenomenological study.

CONTEXT: Factors contributing to the stressful transition from student to doctor include issues with preparedness for practice, adjusting to new status and responsibility, and variable support. Existing transitional interventions provide inconsistent participation, responsibility and legitimacy in the clinical environment. Enhanced support by near peers for new doctors may ease the transition. Irish medical graduates of 2020 commenced work early, creating an unprecedented period of overlap between new graduates and the cohort 1 year ahead. OBJECTIVE: To explore the experience of commencing practice for these new doctors with this increased near-peer support. DESIGN: We used interpretive phenomenological analysis as our methodological approach, informed by the cognitive apprenticeship model, to explore the experience of enhanced near-peer support at the transition to practice. Participants recorded audio diaries from their commencement of work, and a semistructured interview was conducted with each, after 3 months, concerning their experience of their overlap with the previous year's interns. SETTING: University College Cork, one of six medical schools in Ireland. PARTICIPANTS: Nine newly qualified medical doctors. MAIN OUTCOME MEASURES: An exploration of their experience of transition to clinical practice, in the context of this enhanced near-peer support, will inform strategies to ease the transition from student to doctor. RESULTS: Participants felt reassured by having a near-peer in the same role and safe to seek their support. This empowered them to gradually assume increasing responsibility and to challenge themselves to further their learning. Participants perceived that commencing work before the annual change-over of other grades of doctor-in-training enhanced their professional identities and improved patient safety. CONCLUSIONS: Enhanced near-peer support for new doctors offers a potential solution to the stressful transition to practice. Participants were legitimate members of the community of practice, with the status and responsibility of first-year doctors. Furthermore, this study reinforces the benefit of asynchronous job change-over for doctors-in-training.

Maintenance of professional competence in Ireland: a national survey of doctors' attitudes and experiences.

OBJECTIVES: Programmes to ensure doctors' maintenance of professional competence (MPC) have been established in many countries. Since 2011, doctors in Ireland have been legally required to participate in MPC. A significant minority has been slow to engage with MPC, mirroring the contested nature of such programmes internationally. This study aimed to describe doctors' attitudes and experiences of MPC in Ireland with a view to enhancing engagement. PARTICIPANTS: All registered medical practitioners in Ireland required to undertake MPC in 2018 were surveyed using a 33-item cross-sectional mixed-methods survey designed to elicit attitudes, experiences and suggestions for improvement. RESULTS: There were 5368 responses (response rate 42%). Attitudes to MPC were generally positive, but the time, effort and expense involved outweighed the benefit for half of doctors. Thirty-eight per cent agreed that MPC is a tick-box exercise. Heavy workload, travel, requirement to record continuing professional development activities and demands placed on personal time were difficulties cited. Additional support, as well as higher quality, more varied educational activities, were among suggested improvements. Thirteen per cent lacked confidence that they could meet requirements, citing employment status as the primary issue. MPC was particularly challenging for those working less than full-time, in locum or non-clinical roles, and taking maternity or sick leave. Seventy-seven per cent stated a definite intention to comply with MPC requirements. Being male, or having a basic medical qualification from outside Ireland, was associated with less firm intention to comply. CONCLUSIONS: Doctors need to be convinced of the benefits of MPC to them and their patients. A combination of clear communication and improved relevance to practice would help. Addition of a facilitated element, for example, appraisal, and varied ways to meet requirements, would support participation. MPC should be adequately resourced, including provision of high-quality free educational activities. Systems should be established to continually evaluate doctors' perspectives.

Doctors' attitudes to, beliefs about, and experiences of the regulation of professional competence: a scoping review protocol.

BACKGROUND: Historically, individual doctors were responsible for maintaining their own professional competence. More recently, changing patient expectations, debate about the appropriateness of professional self-regulation, and high-profile cases of malpractice have led to a move towards formal regulation of professional competence (RPC). Such programmes require doctors to demonstrate that they are fit to practice, through a variety of means. Participation in RPC is now part of many doctors' professional lives, yet it remains a highly contested area. Cost, limited evidence of impact, and lack of relevance to practice are amongst the criticisms cited. Doctors' attitudes towards RPC, their beliefs about its objectives and effectiveness, and their experiences of trying to meet its requirements can impact engagement with the process. We aim to conduct a scoping review to map the empirical literature in this area, to summarise the key findings, and to identify gaps for future research. METHODS: We will conduct our review following the six phases outlined by Arksey and O'Malley, and Levac. We will search seven electronic databases: Academic Search Complete, Business Source Complete, CINAHL, PsycINFO, PubMed, Social Sciences Full Text, and SocINDEX for relevant publications, and the websites of medical regulatory and educational organisations for documents. We will undertake backward and forward citation tracking of selected studies and will consult with international experts regarding key publications. Two researchers will independently screen papers for inclusion and extract data using a piloted data extraction tool. Data will be collated to provide a descriptive summary of the literature. A thematic analysis of the key findings will be presented as a narrative summary of the literature. DISCUSSION: We believe that this review will be of value to those tasked with the design and implementation of RPC programmes, helping them to maximise doctors' commitment and engagement, and to researchers, pointing to areas that would benefit from further enquiry. This research is timely; internationally existing programmes are evolving, new programmes are being initiated, and many jurisdictions do not yet have programmes in place. There is an opportunity for learning across different programmes and from the experiences of established programmes. Our review will support that learning. SYSTEMATIC REVIEW REGISTRATION: PROSPERO does not register scoping reviews.

Protocol for a realist review of workplace learning in postgraduate medical education and training.

BACKGROUND: Postgraduate medical education and training (PGMET) is a complex social process which happens predominantly during the delivery of patient care. The clinical learning environment (CLE), the context for PGMET, shapes the development of the doctors who learn and work within it, ultimately impacting the quality and safety of patient care. Clinical workplaces are complex, dynamic systems in which learning emerges from non-linear interactions within a network of related factors and activities. Those tasked with the design and delivery of postgraduate medical education and training need to understand the relationship between the processes of medical workplace learning and these contextual elements in order to optimise conditions for learning. We propose to conduct a realist synthesis of the literature to address the overarching questions; how, why and in what circumstances do doctors learn in clinical environments? This review is part of a funded projected with the overall aim of producing guidelines and recommendations for the design of high quality clinical learning environments for postgraduate medical education and training. METHODS: We have chosen realist synthesis as a methodology because of its suitability for researching complexity and producing answers useful to policymakers and practitioners. This realist synthesis will follow the steps and procedures outlined by Wong et al. in the RAMESES Publication Standards for Realist Synthesis and the Realist Synthesis RAMESES Training Materials. The core research team is a multi-disciplinary group of researchers, clinicians and health professions educators. The wider research group includes experts in organisational behaviour and human resources management as well as the key stakeholders; doctors in training, patient representatives and providers of PGMET. DISCUSSION: This study will draw from the published literature and programme, and substantive, theories of workplace learning, to describe context, mechanism and outcome configurations for PGMET. This information will be useful to policymakers and practitioners in PGMET, who will be able to apply our findings within their own contexts. Improving the quality of clinical learning environments can improve the performance, humanism and wellbeing of learners and improve the quality and safety of patient care. SYSTEMATIC REVIEW REGISTRATION: The review is not registered with the PROSPERO International Prospective Register of Systematic Reviews as the review objectives relate solely to education outcomes.