Paving the Way Forward for Evidence-Based Continuing Professional Development.

ABSTRACT: Continuing professional development (CPD) fosters lifelong learning and enables health care providers to keep their knowledge and skills current with rapidly evolving health care practices. Instructional methods promoting critical thinking and decision making contribute to effective CPD interventions. The delivery methods influence the uptake of content and the resulting changes in knowledge, skills, attitudes, and behavior. Educational approaches are needed to ensure that CPD meets the changing needs of health care providers. This article examines the development approach and key recommendations embedded in a CE Educator's toolkit created to evolve CPD practice and foster a learning experience that promotes self-awareness, self-reflection, competency, and behavioral change. The Knowledge-to-Action framework was used in designing the toolkit. The toolkit highlighted three intervention formats: facilitation of small group learning, case-based learning, and reflective learning. Strategies and guidelines to promote active learning principles in CPD activities within different modalities and learning contexts were included. The goal of the toolkit is to assist CPD providers to design educational activities that optimally support health care providers' self-reflection and knowledge translation into their clinical environment and contribute to practice improvement, thus achieving the outcomes of the quintuple aim.

Decision making in continuing professional development organisations during a crisis.

INTRODUCTION: Early in COVID-19, continuing professional development (CPD) providers quickly made decisions about program content, design, funding and technology. Although experiences during an earlier pandemic cautioned providers to make disaster plans, CPD was not entirely prepared for this event. We sought to better understand how CPD organisations make decisions about CPD strategy and operations during a crisis. METHODS: This is a descriptive qualitative research study of decision making in two organisations: CPD at the University of Toronto (UofT) and the US-based Society for Academic Continuing Medical Education (SACME). In March 2021, using purposive and snowball sampling, we invited faculty and staff who held leadership positions to participate in semi-structured interviews. The interview focused on the individual's role and organisation, their decision-making process and reflections on how their units had changed because of COVID-19. Transcripts were reviewed, coded and analysed using thematic analysis. We used Mazmanian et al.'s Ecological Framework as a further conceptual tool. RESULTS: We conducted eight interviews from UofT and five from SACME. We identified that decision making during the pandemic occurred over four phases of reactions and impact from COVID-19, including shutdown, pivot, transition and the 'new reality'. The decision-making ability of CPD organisations changed throughout the pandemic, ranging from having little or no independent decision-making ability early on to having considerable control over choosing appropriate pathways forward. Decision making was strongly influenced by the creativity, adaptability and flexibility of the CPD community and the need for social connection. CONCLUSIONS: This adds to literature on the changes CPD organisations faced due to COVID-19, emphasising CPD organisations' adaptability in making decisions. Applying the Ecological Framework further demonstrates the importance of time to decision-making processes and the relational aspect of CPD. To face future crises, CPD will need to embrace creative, flexible and socially connected solutions. Future scholarship could explore an organisation's ability to rapidly adapt to better prepare for future crises.

Elements and Definitions of Continuing Professional Development Leadership: A Scoping Review.

INTRODUCTION: Leaders are being asked to transform the way that continuing professional development (CPD) is delivered to focus on better, safer, and higher quality care. However, there is scarce literature on CPD leadership. We set out to study what CPD leadership means and describe the competencies required for CPD leadership. METHODS: A scoping review following Preferred Reporting Items for Systematic Reviews and Meta-analyses extension guidelines for scoping reviews guidelines was conducted. With librarian support, four databases were searched for publications related to leadership, medical education, and CPD. Publications were screened by two reviewers and three reviewers extracted data. RESULTS: Among 3886 publications, 46 were eligible for a full-text review and 13 met the final inclusion criteria. There was no agreed upon definition of CPD leadership and variable models and approaches to leadership in the literature. Contextual issues shaping CPD (eg, funding, training, and information technology) are evolving. We identified several attitudes and behaviors (eg, strategic thinking), skills (eg, collaboration), and knowledge (eg, organizational awareness) important to CPD leadership, but no established set of unique competencies. DISCUSSION: These results offer the CPD community a foundation on which competencies, models, and training programs can build. This work suggests the need to build consensus on what CPD leadership means, what CPD leaders do, and what they will need to create and sustain change. We suggest the adaptation of existing leadership frameworks to a CPD context to better guide leadership and leadership development programs.

Perceived Advantages and Disadvantages of Online Continuing Professional Development (CPD) During COVID-19: CPD Providers' Perspectives.

INTRODUCTION: COVID-19 precipitated many CPD providers to develop new technology competencies to create effective online CPD. This study aims to improve our understanding of CPD providers' comfort level, supports, perceived advantages/disadvantages, and issues in technology-enhanced CPD delivery during COVID-19. METHODS: A survey was distributed to CPD providers at the University of Toronto and members of the Society for Academic Continuing Medical Education and analyzed using descriptive statistics. RESULTS: Of the 111 respondents, 81% felt very to somewhat confident to provide online CPD, but less than half reported IT, financial, or faculty development supports. The top reported advantage to online CPD delivery was reaching a new demographic; top disadvantages included videoconferencing fatigue, social isolation, and competing priorities. There was interest in using less frequently used educational technology such as online collaboration tools, virtual patients, and augmented/virtual reality. DISCUSSION: COVID-19 precipitated an increased comfort level in using synchronous technologies to provide CPD, giving the CPD community an increased cultural acceptance and skill level to build on. As we move beyond the pandemic, it will be important to consider ongoing faculty development, particularly toward asynchronous and HyFlex delivery methods to continue expand CPD reach and negate negative online experiences such as videoconferencing fatigue, social isolation, and online distractions.

Moving beyond 'think leadership, think white male': the contents and contexts of equity, diversity and inclusion in physician leadership programmes.

The lack of both women and physicians from groups under-represented in medicine (UIM) in leadership has become a growing concern in healthcare. Despite increasing recognition that diversity in physician leadership can lead to reduced health disparities, improved population health and increased innovation and creativity in organisations, progress toward this goal is slow. One strategy for increasing the number of women and UIM physician leaders has been to create professional development opportunities that include leadership training on equity, diversity and inclusivity (EDI). However, the extent to which these concepts are explored in physician leadership programming is not known. It is also not clear whether this EDI content challenges structural barriers that perpetuate the status quo of white male leadership. To explore these issues, we conducted an environmental scan by adapting Arksey and O'Malley's scoping review methodology to centre on three questions: How is EDI currently presented in physician leadership programming? How have these programmes been evaluated in the peer-reviewed literature? How is EDI presented and discussed by the wider medical community? We scanned institutional websites for physician leadership programmes, analysed peer-reviewed literature and examined material from medical education conferences. Our findings indicate that despite an apparent increase in the discussion of EDI concepts in the medical community, current physician leadership programming is built on theories that fail to move beyond race and gender as explanatory factors for a lack of diversity in physician leadership. To address inequity, physician leadership curricula should aim to equip physicians to identify and address the structural factors that perpetuate disparities.

The Ontological Choreography of Continuing Professional Development: A Mixed-Methods Study of Continuing Professional Development Leaders and Program Directors.

INTRODUCTION: Reports have forecast significant changes ahead for Continuing Professional Development (CPD). With new models on the horizon, CPD developers will require additional knowledge and training. Our objective was to learn how CPD leaders and developers came into their roles, if they are engaged in scholarship and the challenges and opportunities in pursuing scholarship. METHODS: We conducted a mixed grounded theory study, inviting CPD leaders within our institution for interviews focused on career paths, CPD and scholarly activities, networks, and supports and challenges. We invited 405 program/conference directors from our institution to participate in a survey focused on similar themes. We used the framework of ontological choreography in our final analysis. RESULTS: We conducted 13 interviews and had a survey response rate of 28.6% (n = 116). We identified three themes: (1) the pathway to becoming an expert in CPD planning and delivery is often unplanned, unclear, and uncredentialed; (2) CPD is undervalued as a field, with inadequate time and funding allocated; and (3) engagement with scholarship is variable while identifying resources to support scholarship is difficult. DISCUSSION: Beyond the usual calls for CPD to be more appropriately recognized and valued, this article offers another way to explore why past visions of the future have not been fully realized; CPD means different things to different people; it is ontologically different even across a single network in a single faculty.

Rapid Knowledge Mobilization and Continuing Professional Development: Educational Responses to COVID-19.

INTRODUCTION: The field of Continuing Professional Development (CPD) has a role to play in supporting health care professionals as they respond to the COVID-19 pandemic. However, the evolving science of COVID-19, the need for quick action, and the disruption of conventional knowledge networks pose challenges to existing CPD practices. To meet these emergent and rapidly evolving needs, what is required is an approach to CPD that draws insights from the domain of knowledge mobilization (KMb). METHODS: This short report describes a research protocol for exploring rapid KMb responses to COVID-19 at one Canadian academic teaching hospital. The proposed research will proceed as a case study using a mixed methods design collecting quantitative (surveys and Web site use metrics) and qualitative data (interviews) from individuals involved in developing, using, and supporting the KMb resources. Analysis will proceed in two phases: descriptive analysis of data to share insights and integrative analysis of data to build theory. RESULTS: Results from this study will inform the immediate KMb and CPD contribution to the COVID-19 response. DISCUSSION: Findings from this study will also make a broader contribution to the field of CPD, theoretically informing intersections between KMb and CPD and therefore contributing to an integrated science of CPD.

Evaluation of a pilot rural mentorship programme for and by pre-clerkship medical students.

INTRODUCTION: While medical school interventions can help address rural physician shortages, many urban Canadian medical students lack exposure to rural medicine. The Rural Mentorship Programme (RMP) is a 4-month pilot initiative designed by medical students to bridge this gap by pairing preclerkship medical students at an urban medical school with rural physician mentors to provide exposure to rural careers. METHODS: A realist-influenced methodology evaluated perceived benefits and challenges of RMP, assessed how RMP influenced mentee perceptions and intentions towards rural careers, and investigated factors leading to success. Quantitative and qualitative data were collected through evaluative pre-, post-, and 4-month post intervention surveys, mentor interviews and a mentee focus group. Likert scales assessed satisfaction, attainment of objectives and mentee changes in perceptions and intentions. RESULTS: 18/23 mentees and 11/15 mentors completed at least 1 survey; 5 mentees joined the focus group and 3 mentors were interviewed. Most mentees were of non-rural backgrounds and initially neutral about pursuing rural practice. RMP helped mentees better understand rural careers. They especially valued the mandatory community clinical visit and forming relationships with mentors. Mentors enjoyed teaching, reflecting on their careers and demonstrating the merits of rural practice. Transportation and scheduling were major programme challenges. CONCLUSIONS: This pilot suggests that structured mentorship programmes can improve understanding of, and provide exposure to, careers in rural medicine for urban medical students. Results will inform future programme development.

Résumé Introduction: Alors que les interventions des écoles de médecine peuvent contrer la pénurie de médecins en régions rurales, beaucoup d'étudiants en médecine des régions urbaines du Canada ne sont pas exposés à la médecine rurale. Le Rural Mentorship Programme (RMP) est une initiative pilote de 4 mois conçue par des étudiants en médecine pour combler cette lacune en appariant des étudiants d'une école de médecine urbaine n'ayant pas encore fait leur stage clinique à des médecins-mentors des régions rurales pour exposer les étudiants à une carrière en milieu rural. Méthodes: Une méthode influencée par la réalité a évalué les bienfaits et les difficultés perçus du RMP, a évalué comment le RMP influait sur les perceptions et intentions des mentorés envers une carrière en région rurale et s'est penchée sur les facteurs de réussite. Des données quantitatives et qualitatives ont été recueillies par enquêtes évaluatives avant, après et 4 mois après l'intervention, par entrevues avec les mentors et par un groupe cible composé de mentorés. Des échelles de Likert ont évalué la satisfaction, l'atteinte des objectifs et la variation des perceptions et intentions des mentorés. Résultats: Dans l'ensemble, 18 mentorés sur 23 et 11 mentors sur 15 ont répondu à au moins 1 enquête; 5 mentorés SE sont joints au groupe cible et 3 mentors ont été interviewés. La plupart des mentorés étaient d'origine non rurale et étaient initialement neutres à l'idée d'une pratique rurale. Le RMP a aidé les mentorés à mieux comprendre la carrière en milieu rural. Ils ont surtout apprécié la visite clinique obligatoire en communauté et la relation qu'ils ont formée avec leur mentor. Les mentors ont valorisé enseigner, réfléchir sur leur carrière et démontrer les mérites de la pratique rurale. Le transport et les horaires étaient les grands défis du programme. Conclusions: Ce projet pilote laisse croire que les programmes de mentorat structurés améliorent la compréhension des étudiants en médecine des régions urbaines à l'idée d'une carrière en médecine rurale et exposent ces étudiants à la médecine rurale. Les résultats éclaireront l'élaboration de futurs programmes. Mots-clés: Mentorat; étudiant en médecine; médecine rurale; éducation médicale de premier cycle; évaluation du programme; groupes d'intérêts d'étudiants en médecine.

Reimagining Bias: Making Strange With Disclosure.

ABSTRACT: Academic presentations in health professions continuing professional development (CPD) often begin with a declaration of real or potential conflicts utilizing a three-slide template or a similar standardized display. These declarations are required in some constituencies. The three-slide template and similar protocols exist to assure learners that the content that follows has been screened, is notionally bias free, and without financial or other influence that might negatively affect health provider behavior. We suggest that there is a potential problem with this type of process that typically focusses in on a narrow definition of conflict of interest. There is the possibility that it does little to confront the issue that bias is a much larger concept and that many forms of bias beyond financial conflict of interest can have devastating effects on patient care and the health of communities. In this article, we hope to open a dialogue around this issue by "making the familiar strange," by asking education organizers and providers to question these standard disclosures. We argue that other forms of bias, arising from the perspectives of the presenter, can also potentially change provider behavior. Implicit biases, for example, affect relationships with patients and can lead to negative health outcomes. We propose that CPD reimagine the process of disclosure of conflicts of interest. We seek to expand reflection on, and disclosure of, perspectives and biases that could affect CPD learners as one dimension of harnessing the power of education to decrease structural inequities.

A retrospective quantitative implementation evaluation of Safer Opioid Prescribing, a Canadian continuing education program.

BACKGROUND: Continuing health professions education (CHPE) is an important policy intervention for the opioid epidemic. Besides effectiveness or impact, health policy implementation should be studied to understand how an intervention was delivered within complex environments. Implementation outcomes can be used to help interpret CHPE effects and impacts, help answer questions of "how" and "why" programs work, and inform transferability. We evaluated Safer Opioid Prescribing (SOP), a national CHPE program, using implementation outcomes of reach, dose, fidelity, and participant responsiveness. METHODS: We conducted a retrospective quantitative implementation evaluation of the 2014-2017 cohorts of SOP. To measure reach and dose, we examined participation and completion data. We used Ontario physician demographic data, including regulatory status with respect to controlled substances, to examine relevant trends. To measure fidelity and participant responsiveness, we analyzed participant-provided evaluations of bias, active learning, and relevance to practice. We used descriptive statistics and measures of association for both continuous and categorical variables. We used logistic regression to determine predictors of workshop participation and analysis of covariance to examine variation in satisfaction across different-sized sessions. RESULTS: Reach: In total, there were 472 unique participants, 84.0% of whom were family physicians. Among Ontario physician participants, 90.0% were family physicians with characteristics representative of province-wide demographics. Dose: Webinar completion rate was 86.2% with no differences in completion based on rurality, gender, or controlled substance prescribing status with medical regulatory authorities. Fidelity and participant responsiveness: Nearly all participants rated the three webinars and workshop as balanced, and each element of SOP was also rated as highly relevant to clinical practice. CONCLUSIONS: This evaluation demonstrates that Safer Opioid Prescribing was implemented as intended. Over a short period and without any external funding, the program reached more than 1% of the Ontario physician workforce. This suggests that the program may be a good model for using virtual CHPE to reach a critical mass of prescribers. This study represents a methodological advance of adapting evaluation methods from health policy and complex interventions for continuing health professions education. Future studies will assess effectiveness and impact on opioid prescribing and utilization within evaluation models of complex interventions.

Tackling the void: the importance of addressing absences in the field of health professions education research.

Many processes and practices in the field of health professions education have been based more on tradition and assumption than on evidence and theory. As the field matures, researchers are increasingly seeking evidence to support various teaching and assessment methods. However, there is a tendency to focus on a limited set of topics, leaving other areas under-examined and limiting our understanding of the field. By explicitly examining areas that are undescribed, i.e. absences in the literature, researchers and scholars have the potential to enrich our practice and our field's understanding of what counts as legitimate research. Using the theoretical framework of Bourdieu's concept of field, we conducted an instrumental case study of three published research projects that each had a finding of absence. We examined each case individually, and then analyzed across cases. Our dataset included published papers, peer-review feedback, and reflective notes. Each of the cases interrogated a different form of absence: absence of content, absence of research, and absence of evidence. While the typology suggests that each absence was different, there were similarities across cases in terms of challenges in 'proving' the reality of the absence and some disbelief or discomfort with accepting the findings as rigorous and/or legitimate. Absence research has potential to add to our theoretical and methodological approaches to the field. This type of research is potentially an exciting and productive new way for scholars to shed light on aspects of health professions education that have received limited attention to date.

Continuing Professional Development Needs Amongst University of Toronto's Department of Radiation Oncology Faculty.

Continuing professional development (CPD) and lifelong learning are core tenets of most healthcare disciplines. Where undergraduate coursework lays the foundation for entry into practice, CPD courses and offerings are designed to aid clinicians in maintaining these competencies. CPD offerings need to be frequently revised and updated to ensure their continued utility. The purpose of this qualitative study was to better understand the CPD needs of members of the University of Toronto's Department of Radiation Oncology (UTDRO) and determine how these needs could be generalized to other CPD programs. Given that UTDRO consists of members of various health disciplines (radiation therapist, medical physicists, radiation oncologists, etc.), eleven semi-structured interviews were conducted with various health professionals from UTDRO. Inductive thematic analysis using qualitative data processing with NVivo® was undertaken. The data was coded, sorted into categories, and subsequently reviewed for emergent themes. Participants noted that a general lack of awareness and lack of access made participation in CPD programs difficult. Members also noted that topics were often impractical, irrelevant, or not inclusive of different professions. Some participants did not feel motivated to engage in CPD offerings due to a general lack of time and lack of incentive. To address the deficiencies of CPD programs, a formal needs assessment that engages stakeholders from different centers and health professions is required. Needs assessments of CPD programs should include analyzing elements related to access, how to utilize technology-enhanced learning (TEL), determine barriers to participation, and understand how to better engage members.

Dismantling the master's house: new ways of knowing for equity and social justice in health professions education.

Health professions education (HPE) is built on a structural foundation of modernity based on Eurocentric epistemologies. This foundation privileges certain forms of evidence and ways of knowing and is implicated in how dominant models of HPE curricula and healthcare practice position concepts of knowledge, equity, and social justice. This invited perspectives paper frames this contemporary HPE as the "Master's House", utilizing a term referenced from the writings of Audre Lorde. It examines the theoretical underpinnings of the "Master's House" through the frame of Quijano's concept of the Colonial Matrix of Power (employing examples of coloniality, race, and sex/gender). It concludes by exploring possibilities for how these Eurocentric structures may be dismantled, with reflection and discussion on the implications and opportunities of this work in praxis.

Microlearning to improve CPD learning objectives.

BACKGROUND: Despite active involvement in teaching, clinical educators facilitating the continuing professional development (CPD) of their fellow specialists may not have formal training in medical education. Although required to write focused, measurable, topic-relevant, attainable and time-bound learning objectives to clearly inform learners on their learning intentions, CPD educators often receive no training on how to develop them. Microlearning is an online learning format occurring without real-time or interpersonal interaction, aiming to deliver easily accessible small units of focused information that are readily applicable for professionals. We hypothesised that Portuguese ophthalmologist educators lecturing to their fellow specialists would benefit from a microlearning experience (MLE) to improve the quality of their learning objectives. METHODS: We created an MLE about writing effective learning objectives. In phase 1, 25 clinical educators, scheduled to lecture at an ophthalmology conference in Portugal, were invited to watch the MLE, write and classify their learning objectives according to Bloom's modified taxonomy, and complete an evaluation survey. In phase 2, 86 clinical educators were invited to view the MLE and complete the survey. RESULTS: In phase 1, 20% of participants completed the exercise and survey. They categorised their objectives high on Bloom's taxonomy, considered the MLE useful and stated their intent to apply the principles learned in practice. In phase 2, 29% of participants provided feedback. All agreed that the intervention was clear and useful and 87% expressed an intent to use this information in their educational practice. CONCLUSIONS: The majority of participants found the MLE clear and useful. Further studies are necessary to measure the impact of the MLEs used by clinical educators.

Measuring Advanced/Extended Practice Roles in Arthritis and Musculoskeletal Care in Canada.

OBJECTIVE: Our objective was to characterize Canadian workforce attributes of extended role practitioners (ERPs) in arthritis care. METHODS: We used an exploratory, mixed-methods study that was based on the Canadian Rheumatology Association's Stand Up and Be Counted Rheumatologist Workforce Survey (2015). An anonymous online survey was deployed to groups of non-physician health care professionals across Canada who potentially had post-licensure training in arthritis care. Demographic and practice information were elicited. Qualitative responses were analyzed using grounded theory techniques. RESULTS: Of 141 respondents, 91 identified as practicing in extended role capacities. The mean age of ERP respondents was 48.7; 87% were female, and 41% of ERPs planned to retire within 5 to 10 years. Respondents were largely physical or occupational therapists by profession and practiced in urban/academic (46%), community (39%), and rural settings (13%). Differences in practice patterns were noted between ERPs (64.5%) and non-ERPs (34.5%), with more ERPs working in extended role capacities while retaining activities reflective of their professional backgrounds. Most respondents (95%) agreed that formal training is necessary to work as an ERP, but only half perceived they had sufficient training opportunities. Barriers to pursuing training were varied, including personal barriers, geographic barriers, patient-care needs, and financial/remuneration concerns. CONCLUSION: To our knowledge, no previous studies have assessed the workforce capacity or the perceived need for the training of ERPs working in arthritis and musculoskeletal care. Measurement is important because in these health disciplines, practitioners' scopes of practice evolve, and ERPs integrate into the Canadian health care system. ERPs have emerged to augment provision of arthritis care, but funding for continuing professional development opportunities and for role implementation remains tenuous.

Family physicians and health advocacy: Is it really a difficult fit?

OBJECTIVE: To examine whether family medicine residents and faculty members appreciate the full spectrum of health advocacy as described in articles published in Canadian Family Physician in 2016 and to identify the perceived challenges and enablers of advocating across the entire spectrum. DESIGN: Analysis of a subset of data from a qualitative study using semistructured interviews and focus groups. SETTING: University of Toronto in Ontario. PARTICIPANTS: A total of 9 family medicine faculty members and 6 family medicine residents. METHODS: A subset of transcripts from a 2015 qualitative study that explored family medicine and psychiatry residents' and faculty members' understanding of the CanMEDS-Family Medicine health advocate role were reviewed, guided by interpretive descriptive methodology. MAIN FINDINGS: Results indicated that family medicine physicians and residents were able to identify the full spectrum of advocacy described in the Canadian Family Physician articles and that they valued the role. Further, there was widespread agreement that being a health advocate was linked with their identities as health professionals. The time it takes to be a health advocate was seen as a barrier to being effective in the role, and the work was seen as extremely challenging owing to system constraints. Participants also described a gap in training relating to advocacy at the system level as a challenge. CONCLUSION: Team-based care was seen as one of the most important enablers for becoming involved in the full spectrum of advocacy, as was time for personal reflection.

Understanding health advocacy in family medicine and psychiatry curricula and practice: A qualitative study.

BACKGROUND: We explored understanding and experiences of health advocacy among psychiatry and family medicine residents and faculty and the implications for clinical care and teaching through the lens of relationship-centred care. METHODS: This qualitative study was conducted in the psychiatry and family medicine departments at a large urban university. We interviewed 19 faculty members and conducted two focus groups with 18 residents. Semi-structured questions explored the relational meaning of health advocacy, how residents and faculty learned about the role and ethical considerations involved in incorporating advocacy work into clinical practice within a relationship-centred care framework. RESULTS: Four themes emerged from the interviews and focus groups: 1) health advocacy as an extension of the relationship to self; 2) health advocacy and professional boundaries in the physician-patient relationship; 3) health advocacy within a team-based approach; and 4) health advocacy and the physician-community/organization relationship. Participants described implications for practice of the challenges of health advocacy, including perceived institutional risks, professional boundaries and the appropriation of patient voice. CONCLUSIONS: Our study provides insights into the relational complexities of the health advocate role in residency curriculum and clinical practice. All participants described health advocacy as a broad spectrum of actions that are guided by relationships among patients, health care professionals and communities. Our analysis revealed that some challenges that participants identified with a health advocacy role could be addressed by anchoring the role within a specific theoretical framework. This would better enable us to create a culture of advocacy in the training and development of physicians.