Developing a focused PDP

As doctors, we receive feedback from many sources. Some sources are formal, such as complaints, incident reviews or structured multisource feedback, others are less formal, such as individual patient outcomes, peer discussion and our own reflections on our practice. Being able to consider this feedback honestly and thoughtfully is essential to understanding our learning needs. When developing a PDP, it is natural to be drawn to our areas of interest or expertise. Of course, to stay up to date, ongoing learning in such areas is necessary but we must also pay attention to areas of our practice that we are less enthusiastic about and have perhaps not focused on previously.

It is the individual doctor's responsibility to identify their needs and consider how they will address them (GMC 2012). However, psychiatrists are helped to do this in two ways: by their CPD peer group and by the appraisal process.

• The peer group will use an informal process to help the doctor to develop a PDP that reflects their needs (rather than interests or wishes).

• At appraisal, information about the full scope of the doctor's practice and performance is formally discussed (e.g. outcome measures, complaints, incident reviews, activity levels). Using this information as a foundation, the appraiser and doctor will create a PDP. The full scope of practice – both clinical and non-clinical aspects – should be considered.

This can mean that the doctor ends up with two PDPs: one from the peer group and one from appraisal. The PDP developed in the peer group will inform the one developed in appraisal. If the processes resulting in each have been robust, the PDPs should not be too dissimilar. A significant difference in the PDPs should raise concerns that there has not been fair or honest discussion about the psychiatrist's work or needs in one or both of the processes.

It is important that CPD reflects the doctor's practice (or intended practice for the future), rather than their own personal interests. Although all doctors, whatever their experience, need to stay up to date with relevant therapeutic developments, it is inevitable that their needs will change over their career. Developing skills that are not going to be used in practice will not benefit patients.

Successfully addressing development needs

To evaluate how successful learning has been, it is necessary to be clear about what is to be achieved. The PDP must be specific and the outcomes must be to some extent measurable (Box 1).

How to best meet development needs will depend on a variety of factors. We all have preferred ways of learning – for example, by reading or through experience. In addition, different objectives will be best achieved in different ways; attending a lecture might help to meet an objective of understanding the evidence base of pharmacological treatments for treatment-resistant depression, but would be unlikely to offer a doctor much if their objective was to improve their communication skills, in which case observation and practice with a respected colleague are more likely to be effective.

The Academy of Medical Royal Colleges (2012) has created a useful template to help doctors structure their reflections when considering how new information relates to current practice and whether further actions are required (Fig. 1). Use of this template is encouraged by the Royal College of Psychiatrists (2015). There are many alternative templates that can be adjusted as needed, but all tend to cover the same areas: what the activity was, what the learning was and how it will change practice. Such notes can be used in peer-group discussions, to demonstrate value and justify the allocation of CPD credits, and within the appraisal process, to demonstrate ongoing personal development and quality improvement.

FIG 1 Example of a reflective note using the Academy of Medical Royal Colleges (2012) template.

However, completing the learning event will not in itself improve practice. The knowledge and skills acquired need to be put into practice in the psychiatrist's work.

Modifying practice after acquiring new skills or knowledge

CPD is only important inasmuch as it improves a doctor's practice; it is not an end in itself. The College's revised guidance emphases this and places the responsibility for ensuring that learning relates to practice on the peer group. CPD credits cannot be awarded to a particular activity unless the peer group are assured that the psychiatrist has considered how the activity relates to their current practice. In a relationship between peers, this requirement might not feel comfortable but it is a professional responsibility.

Collating evidence of improvement can be difficult in some circumstances and will be impossible if the initial objective is not specific. Organisations are now collecting more clinically relevant outcome measures (although this is not yet universal) and clinical audit is a useful tool for measuring performance against predetermined standards. In its guidance on revalidation, the College acknowledges the benefit of clinical audit in both identifying the need for improvement and demonstrating that it has taken place (Royal College of Psychiatrists 2014). Showing that learning has been incorporated into practice need not and should not be onerous. Considering learning in relation to clinical practice through, for example, a case-based discussion, is a useful way to gain feedback. If honestly and openly approached, such a process could identify further, previously unconsidered learning as needed. The result, therefore, is one of continued learning, reflection and change (Fig. 2).

FIG 2 The learning cycle.

Reflecting on current practice to identify development needs

We need to consider not just what we are doing but why. This often happens after significant events such as a serious incident or a complaint and this is, of course, necessary and good practice. However, if reflection is restricted to such times, consideration of our practice will be restricted and probably unfairly critical. We need to evaluate our practice on an ongoing basis, and to do that we need mechanisms to support us.

• Reflective practice groups allow teams to consider how they respond in (often) challenging situations and the feelings that patients and situations can evoke.

• CPD peer groups help the psychiatrist to explore their practice and, from formal or informal feedback, consider which areas could improve through the CPD process.

• Appraisal considers the whole of a doctor's practice and uses both hard and soft data to support discussion about the care they provide and the relationships they form with patients and colleagues.

• Case-based discussion and clinical supervision with peers will explore a relatively small area of practice in detail. Although it is not required by the GMC, the College recommends that psychiatrists undertake at least two case-based discussions each year.

• Review processes should allow doctors and clinical teams to learn from incidents and consider their development needs.

• The cycle of clinical audit requires considering the findings (comparing practice with established or agreed standards) to develop an action plan for improvement.

Alongside these are many less formal discussions about what they do that clinicians have with colleagues during day-to-day practice.

If they are committed to improvement and learning, any of the above mechanisms will provide the psychiatrist with a rich view of their practice and therefore suggest what their development needs are.

Reflecting on new learning to change practice

Even if new knowledge has been acquired, without changes to practice patients will not experience any benefit. Reflection is the process that bridges the gap between theory and practice. However, changing practice is not necessarily simple. Most psychiatrists work within teams and interact closely with others. Changing an individual's practice might, therefore, not be possible without changing a wider system. It is thus essential, when setting objectives, that not only the needs of the doctor but the needs of the teams and services in which they work are considered.

As when setting development objectives, considering how new learning will affect practice requires space and honest consideration of our own behaviour. Through regular meetings the peer group will allow space for the doctor to consider both their needs and later, through reflection and appropriate challenge, whether they have met their learning objectives.

In practice, some reflection will need to take place in other arenas (such as incident reviews or clinical audit meetings) or by the doctor alone. Achieving meaningful reflection might require practice. As shown in Fig. 1, the Academy of Royal Colleges’ template provides a useful framework for reflection.

The doctor

The GMC (2012) simply states that ‘you are responsible for identifying your CPD needs, planning how these needs should be addressed and undertaking CPD that will support your professional development and practice’. To identify relevant CPD, the doctor needs to consider the available information about their practice and reflect on areas for improvement. This must cover the entirety of practice, both clinical and non-clinical. Without this open and honest reflection, the effect of any subsequent learning will be limited. The doctor is also responsible for reflecting how new learning should be considered alongside current practice and, as far as they are able, for changing practice as appropriate. In both these areas, although the individual doctor is responsible, they should be supported to do this effectively.

To be in good standing with the College for CPD, all clinically active psychiatrists are required to undertake, on average, 30 h of clinical CPD and thus ensure a high standard of care is experienced uniformly by patients.

The CPD peer group

A doctor's peers are a useful asset in identifying development needs and how and when these needs should be met. The College relies on the effective functioning of a peer group when considering whether someone is in good standing for CPD (Box 3). The peer group should ‘support the individual in developing and completing a relevant [PDP] that leads to an improvement in that person's skills or competence and therefore an improvement in care provided to patients’ (Royal College of Psychiatrists 2015: p. 4). In addition, the peer group is responsible for accrediting learning as CPD activity. A learning activity can only be allocated CPD credits if:

• it is relevant to the psychiatrist's scope of practice (or intended practice)

• it is of sufficient quality

• learning has been understood and, through reflection, considered alongside current practice.

The peer group is not fulfilling its duty to the psychiatrist if it does not robustly consider these points.

Rather than answer a set of MCQs at the end of this article, I invite you to complete the reflective template in Fig. 3 so that it can be considered for CPD credits by your CPD peer group.

FIG 3 Reflective template for completion and consideration for CPD credits by your peer group after reading this article.

Appraisal

The appraisal process is at the core of revalidation and, thus, the assurance we give to the public that doctors are safe practitioners. It examines the full scope of the doctor's practice and encourages reflection. CPD is one way in which a doctor can demonstrate that they are up to date in their practice and developing the skills required in their work.

During appraisal, information about the doctor's practice is considered and the doctor is required to reflect on it, with a view to developing a PDP. A good appraiser will support reflection in a way that promotes learning and a formative approach. They will also seek to understand how quality or improvement has been demonstrated.

The following information should be used to develop a PDP within the appraisal:

• information from and reflection on complaints and other forms of patient feedback

• information from and reflection on incidents relating to the doctor or the service in which they work

• multisource feedback

• clinical activity information

• clinical outcome information (in the form of patient reported outcome measures (PROMs), patient reported experience measures (PREMs), clinician reported outcome measures (CROMs), etc.)

• reflections on incidents or feedback in other services (but of relevance to the doctor's practice)

• the PDP agreed with the CPD peer group.

Good appraisal, therefore, will start the cycle by developing a PDP that reflects the doctor's scope of practice and development needs within it and challenges the doctor to reflect on their development and demonstrate ongoing improvement in practice.

Employers

Employers have a responsibility to ensure that their workforce is up to date and working to appropriate standards. CPD is one mechanism for achieving this. The health service is facing unprecedented financial challenges, but effective CPD does not come without sufficient resources. This is not simply an adequate study leave budget (learning is not necessarily met through taught courses), but also allowing doctors the time to reflect on their development needs and the meaning of new knowledge in relation to their own practice, and also to evaluate the impact of any change.

As already mentioned, psychiatrists rarely work in isolation. If the ambition of CPD is to improve patient care, learning in teams is an important option, at least for some people. Therefore, it will be necessary for a whole team, not just a single doctor, to find time for reflection.

Finally, honest and open reflection has been described as a key element to effective CPD. This includes being able to reflect on our actions when things go wrong. Learning from serious incidents is essential to developing safe doctors and safe services and is understandably what the public demands of us. Employers have a major role in providing an environment that is supportive of this approach.