Editorials

MAINPRO®

Self-regulation, professionalism, and continuing professional development

Richard Handfield-Jones, MD, CCFP, FCFP

For most members of the College of Family Physicians of Canada (those who achieved certification in 1998 or before), the end of the first 5-year cycle of MAINPRO® (which stands for Maintenance of Proficiency/Maintien de la compétence professionnelle) is approaching. In this issue of Canadian Family Physician, we pre­sent important information on how to meet your requirements and so renew your Maintenance of Certification for the next 5 years. On page 931, you will find helpful and practical ways to collect MAINPRO-C credits. In this editorial, I will attempt to explain why the College has taken its particular approach to the Maintenance of Certification program.

Medicine in Canada is privileged to be a self-regulated profession. Self-regulation is granted by a society when it believes a profession to be the only group to know its field well enough to define its own standards of practice, trusts the profession to set and enforce appropriate behavioural standards for its members, and deems that self-regulation is the best way to achieve the good it derives from that profession.1 Along with the benefits enjoyed through self-regulation come certain responsibilities. One of these is to set, monitor, and be responsive to educational standards.

Standard setting in the context of self-regulation is the responsibility of organizations whose representatives are duly elected by their members.2 In Canadian medical education, this responsibility is shared by several national and provincial medical organizations including the Royal College of Physicians and Surgeons of Canada and our own College for specialty and family medicine education, respectively. The two Colleges’ roles in setting the standards for continuing medical education (CME) are a critical component of an integrated model of achieving and maintaining practice standards developed by the Federation of Medical Licensing Authorities of Canada.3

One emerging issue in setting medicine’s education standards is distinguishing between CME and continuing professional development (often abbreviated as CPD). Continuing medical education can be defined as activities leading physicians to enhance their clinical skills and knowledge. But family physicians do much more than just care for patients. Inherent in the College’s four principles of family medicine is the fact that family physicians play various roles: clinician, researcher, administrator, and many others.4 Attainment of certification is based on a physician’s understanding of and commitment to these principles; our Maintenance of Certification program should be also. Continuing professional development is more general than CME. It includes all the activities that lead physicians to enhance their knowledge and skills in all of their roles. This is an important element of professionalism: commitment to and maintenance of competence across all responsibilities.5 The College is increasingly adopting this concept for MAINPRO. MAINPRO is less about your clinical role (ie, CME), and more about questioning and enhancing everything you do (ie, continuing professional development).

Responding to your beliefs and needs

Though continuing professional development is a responsibility essential to self-regulation, it should be a positive experience. Certainly, lifelong inquisitiveness is a defining characteristic of physicians. The College believes that fulfilling its Maintenance of Certification requirements within the context of a standards-based program should be enjoyable and stimulating. Further, your continuing professional development should be under your control; you should have ownership of it. The College’s job should be to ensure that MAINPRO responds to your own continuing professional development beliefs and activities. How does it do this? Here are two examples.

First, MAINPRO is based upon standards defined according to general educational principles and values (http://www.cfpc.ca/cme/mainpro/mainpro.asp). These standards do not address the specific content of any activity. The College has no intention of developing a continuing professional development "curriculum" to dictate what our members should be learning. It is up to individual physicians to plan their own ongoing continuing professional development based on questions that arise from their day-to-day work.

Second, there are many options for the three kinds of credits (MAINPRO-M2, MAINPRO-M1, and MAINPRO-C). We tend to equate CME with attending a course or conference. But family physicians do many things that help them, either intentionally or consequentially, improve their professional competencies. The College recognizes this by allowing an array of learning activities for each kind of credit. You might be unaware that some of your current activities are eligible for credits. For example, did you know that your hospital’s Tuesday morning rounds could be accredited for MAINPRO-M1 credits? Or that sitting on your emergency room’s quality assurance committee qualifies for MAINPRO-C credits?

How do these ideas pertain to MAINPRO-C credits in particular? Of all College policies of the last decade, few have been as controversial as MAINPRO-C credits. For various reasons, the College decided in the early 1990s to abandon its former Maintenance of Certification program. We considered various alternatives. One proposal was to introduce an assessment-based system by using a recertification examination. This proposal was quickly rejected as being too regressive. Eventually, the College decided to base its new program on emerging concepts in continuing education. MAINPRO-C credits were created as a way to quantify progressive learning activities deemed to be developed according to these concepts. Despite early struggles, we strongly believe that all members can now easily collect MAINPRO-C credits. This is especially true with the recent introduction of new options.

Integrating information over time

So what really distinguishes learning activities approved for MAINPRO-C credits? In most continuing education systems (and this applies to nonmedical programs also), the emphasis of approval, or accreditation, is on determining the quality of the information presented in individual learning activities. This usually includes an assessment of the planning process, attempts made to understand participants’ learning needs, the venue and style of the presentation, and the evaluation process. We use this traditional activity-Centred approach in reviewing activities for MAINPRO-M1 credits. And it is the essential model for other large-scale CME accreditation systems in both Canada and the United States. This method views CME as a series of discrete events occurring at moments in time during a practice career (Figure 1).

Figure 1. Continuing medical education activities as discrete events: The traditional activity-Centred method views continuing medical education as a series of discrete events occurring at moments in time during a practice career.

For MAINPRO-C credits, the College has taken a new and innovative approach. Here, we focus on the process of information integration rather than on just information acquisition. The actual continuing professional development activity itself becomes secondary to the overall process of information management. We encourage our members to consider how they identify the need to acquire certain information, critically appraise its value relative to their practice, decide to alter their practice, and ultimately assess the effect of the process. This approach is based on an increasingly accepted model of practice-integrated reflective learning first described by Donald Schön.6 It is at the heart of the College’s program called Pearls™, and of many educational initiatives in other organizations.

The process of integrating information into work over time is illustrated in Figure 2. This figure can be labeled differently to illustrate specific kinds of continuing professional development, such as CME activities for clinical practice or faculty development activities for academic work.

Figure 2. Integrating information into work over time: This figure can be labeled differently to illustrate various specific kinds of continuing professional development, such as continuing medical education activities for clinical practice or faculty development activities for academic work.

The practical result is that MAINPRO-C credits can now be applied to any kind of learning for any of your roles. The only requirement is to document the process. To make this easier, the College has developed a series of credit submission forms. Some of these forms have been tailored to specific kinds of activities. One is generic and can be applied to any aspect of your day-to-day professional activities.

Broad and flexible

No structured standards-based program will be fully accepted by everyone affected by it. But we have attempted, in the last few years, to make MAINPRO as broad and flexible as possible. In the spirit of self-regulation, moreover, these policies are defined and established by those who best understand your needs. The members of the National Committee on CME and the College’s Board of Directors are all practising family physicians.

As accountability and public interest (both of which are inherent and necessary in professionalism and self-regulation) increase over time, the medical profession will have to be able to demonstrate that its members are practising according to accepted standards.7 Ultimately, this will be ensured through ongoing self-assessment, peer assessment, and learning, all integrated into the fabric of daily practice. Though some might view this as an intrusion into the independent nature of practice, it can happen in a positive and beneficial way if managed proactively by the profession itself through its educational, regulatory, and other representative organizations. The College believes that its Maintenance of Certification program in general, and the innovative ways of documenting practice-integrated learning through the use of MAINPRO-C credits in particular, are important and positive contributions we can make to this process.

For more information on how you can use the opportunities mentioned here, look in the Resources section (page 931) and in Vital Signs (page 1024) in this issue of Canadian Family Physician. All the details about MAINPRO can be found on the College’s website (http://www.cfpc.ca/cme/mainpro/mainpro.asp). And remember that the College is always ready to answer your questions about its policies or how MAINPRO applies to you.

Dr Handfield-Jones is Director of Continuing Medical Education for the College of Family Physicians of Canada in Mississauga, Ont.

Correspondence to: Dr Richard Handfield-Jones, College of Family Physicians of Canada, 2630 Skymark Ave, Mississauga, ON L4W 5A4

References

1. Canadian Medical Association. Professionalism in medicine. Ottawa, Ont: Canadian Medical Association; 2001.
2. Pellegrino ED, Relman AS. Professional medical associations: ethical and practical guidelines. JAMA 1999;282:984-6.
3. Federation of Medical Licensing Authorities of Canada. Position paper on the Canadian model for monitoring and enhancement of physician performance. Ottawa, Ont: Federation of Medical Licensing Authorities of Canada; January 1996.
4. College of Family Physicians of Canada. Standards for accreditation of residency training programs. Mississauga, Ont: College of Family Physicians of Canada; 2000. Available from: http://www.cfpc.ca/education/redbook/rbmain.asp. Accessed 2002 March 26.
5. Sullivan WM. Medicine under threat: professionalism and professional identity. Can Med Assoc J 2000;162(5):673-5.
6. Schön DA. The reflective practitioner. New York, NY: Basic Books; 1983.
7. Wynia MK, Latham SR, Kao AC, Berg JW, Emanuel LL. Medical professionalism in society. N Engl J Med 1999;341:1612-6.