Foundations of Continuing Education

Self-Assessment in CPD: Lessons Fromthe UK Undergraduate and PostgraduateEducation Domains

TIM DORNAN, MA, DM, FRCP, PHD

UK continuing education is moving from credit-earning, taught continuing medical education (CME) to a continuingprofessional development (CPD) system that explicitly links education to change in practice, managed and mon-itored through mandatory peer appraisal. Alongside multisource feedback and consideration of issues of poorperformance, satisfactory personal development planning will be required for relicensure and recertification. Thatsystem gives self-assessment, in the guise of reflection, a central place in personal development. This article usesinstances of directed self-assessment drawn from undergraduate and early postgraduate medical education toconsider how a positive system of self-assessment and professional self-regulation could be operationalized. Itexplores why medical students made avid use of an e-technology that presents the intended outcomes of theirproblem-based curriculum in a way that helps them seek out appropriate clinical opportunities and identify whatthey learned from them. It contrasts the experience of early postgraduate learners who, presented with a similare-technology, found it hard to see links between their official curriculum and their day-by-day learning experiences,at least partly because the intended outcomes it offered were remote from what they were actually learning. Anyextrapolation to CPD must be very tentative, but I advocate continued exploration of how best to use e-technologyto support and structure (ie, direct) self-assessment. Direction could originate from consensus statements andother well-defined external standards when learners lack mastery of a domain. When learners must respond toinstitutional demands, direction could be provided by corporate goals. In areas of mastery, I propose learnersthemselves should define personal standards. In areas of difficulty, external assessment would take the place ofself-assessment.

Key Words: continuing medical education, continuing professional development, self-assessment, licensure, cer-tification, technology-enhanced learning

Introduction and Historical Context

Continuing medical education ~CME! entered the UK med-ical lexicon a decade ago, when it was already well estab-lished in the United States, Canada, Australia, and other partsof the world. Until then, practitioners in all disciplines ex-cept general practice ~who were financially rewarded fortaking up postgraduate education opportunities! had man-aged their own continuing education without any formal ob-ligation or reward. The introduction of CME was driven bya wish among leaders to show the medical profession wasregulating itself and practitioners were keeping up to date.

Despite strong evidence that taught CME was ineffective atchanging physicians’ behavior,1 UK professional bodiesadopted a regulatory system that credited doctors for beingtaught rather than a system that set out to improve publichealth by developing them and their practices.

Perspectives have broadened since then. The term con-tinuing professional development ~CPD! has been adoptedin preference to CME to “encompass subjects not just di-rectly related to patient care but also the wider range ofprofessional activities that are required for a doctor to prac-tice medicine.” 2 The Academy of Medical Royal Collegeshas linked “support to specific changes in practice” to itsdefinition of CPD.3 The development of more valid sum-mative measures of the safety of a doctor’s practice has freedCPD from a quasi-summative role and allowed its focus tobecome more explicitly formative. Nevertheless, a summa-tive requirement for quality assurable “bums on seats” CMEhas dominated the first decade of UK CPD. General prac-tice, a special case by virtue of its place as an innovator inpostgraduate education, the special contractual status of gen-eral practitioners, and the rather different role of its RoyalCollege, has been an exception in using a portfolio to linkpersonal development planning with organizational need.4

Dr. Dornan: Professor of Medicine, University of Manchester, Manchester,England.

Correspondence: Tim Dornan, Hope Hospital, University of ManchesterMedical School, Stott Lane, Salford, England M6 8HD; e-mail:tim.dornan@manchester.ac.uk.

© 2008 The Alliance for Continuing Medical Education, the Society forAcademic Continuing Medical Education, and the Council on CME,Association for Hospital Medical Education. • Published online in WileyInterScience ~www.interscience.wiley.com!. DOI: 10.10020chp.153

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS, 28(1):32–37, 2008

Most UK health care is delivered by the government-operated National Health Service ~NHS!, which has madeannual appraisal mandatory This peer-supported, primarilyformative process ~discussed in more detail later! has estab-lished a rather different tone for the second decade of CPD,which can now move more in the direction of enhancingindividual performance. That move increases the demandfor self-assessment, as acknowledged by at least one majorregulator of CPD,2 but what does self-assessment mean inthe current UK context? The paragraphs that follow de-scribe the state of the art, consider the potential role of self-assessment in a two-pronged system of summative regulationand formative quality development, and conclude by extrap-olating recent evidence from undergraduate and early post-graduate education to the future of CPD.

The State of the Art

The description that follows is drawn from succinct andinformative recent publications by the Royal College ofPhysicians of London.2,5 The European Union of MedicalSpecialties laid down, in its Basel Declaration, aims ofCPD, which acknowledged the maintenance of safety anddevelopment of quality.6 The organizational hub of UK CPDis a Directors of CPD Group, which has representativesfrom each of the UK Medical Royal Colleges and theirFaculties and the General Medical Council ~GMC!. It re-ports to the Academy of Medical Royal Colleges, whichestablished a set of 10 guiding principles concerning theimplementation, quality assurance, and probity of CPD, butnot its fundamental purpose.3 The way in which the sys-tem operates is illustrated in the next section.

Illustration—CPD for UK Physicians2

The Federation of Royal Colleges of Physicians, represent-ing the Royal Colleges of London, Edinburgh, and Glasgow,has a CPD system centered on an online diary holding in-formation about approved events and allowing participantsto record participation in those and other developmental ac-tivities. It is a credit system, 1 credit representing 1 hour ofeducational activity. Events taking place outside a practitio-ner’s employing organization, designated external, are indi-vidually approved according to a defined set of qualitycriteria. Use of terms like teaching methods and target au-dience to frame those criteria implicitly defines such eventsas lectures, although the word facilitator is also present. In-ternal events also attract credits, maintenance of the qualityof which is delegated to a practitioner’s employing organi-zation. Credits are also awarded for activities such as read-ing journals and participating in distance learning activities.A minimum of 250 credits must be earned over a 5-yearrolling cycle, of which at least 125 must be external, theremainder for internal or personal activities. Although par-ticipants must enter free text in a single box entitled Feed-back and reflection in order to earn credits, the link between

those entries and the process of personal development plan-ning is not made explicit by the e-technology. The expec-tation that educational activities will be planned and linkedto performance in the workplace is acknowledged in cov-ering guidance notes, but creation of that link is left to theappraisal process. Satisfactory participation in the federa-tion’s CPD scheme leads to a physician’s being “in goodstanding with the College.” That curiously British phrasetacitly acknowledges CPD’s lack of teeth in the wider pol-itics of UK medicine—not being in good standing does notdirectly lead to withdrawal of licensure to practice or spe-cialist certification, though it will probably contribute to suchcensures in future times.

CPD Nationally

The various schemes provided by members of the Academyof Royal Colleges are broadly similar to the one described,using hours of activity as their currency. Some specificallyreward training, secondment to workplaces other than a prac-titioner’s own, improvement of the quality of practice, andrisk management, though most UK practitioners could sat-isfy the CPD requirement of the body with whom they areregistered by passive activities unlinked to the context or goalsof their clinical practice,2 thereby accomplishing the goal ofappraisal and revalidation.7

Appraisal and Revalidation

Whereas CPD was introduced by Royal Colleges, manda-tory appraisal was introduced by government, which has anear monopoly over health care provision. Annual appraisalbecame mandatory 5 years ago, combining a formative, pro-active role in doctors’ development with the summative roleof identifying and handling poor performers. Importantly,appraisal is delegated to individual employing0contractingorganizations so a doctor’s development is considered intheir corporate as well as their individual context. Proof ofsatisfactory participation in a recognized CPD scheme isrequired evidence at appraisal.

As the need for a system of revalidation came to be rec-ognized, the GMC, which licenses doctors and certifies spe-cialists, proposed a framework marrying the processes ofappraisal and revalidation. CPD credits were to be part of theevidence supporting the summative decision that alloweda doctor to continue in practice. However, high-profile casesof doctors’ incompetent or murderous be-havior called intoquestion both the authority of the GMC and the rigor of theproposed system.8 A resolution is emerging in the form oflocal appraisal that combines multisource feedback, consid-eration of instances of poor performance, and personal de-velopment planning, including educational activities.9,10 So,the judgemental and developmental elements of regulationand CPD will result in a development plan “that outlines theobjectives, learning needs, and actions required of the ap-praisee to achieve the improvements identified throughout

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the appraisal.” 5 While the term self-assessment is usedsparingly in today’s vernacular of UK CPD, the term reflec-tion is used liberally. The following section examines thenature and potential role of self-assessment through a theo-retical lens.

Self-Assessment

Preceding paragraphs have teased out the UK CME-CPD-appraisal-revalidation complex into summative and de-velopmental components. There is convincing publishedevidence that people do not make reliable summative as-sessments of their own competence. Those with the lowestcompetence tend to be least reliable, tending to overestimatetheir competence.11–13 So it seems wise to entrust summa-tive judgments of competence to multisource feedback, evi-dence of workplace performance, and critical incident reviewrather than self-assessment. But could self-assessment havea place in the developmental component of CPD?

To answer that question, I draw on Eva and Regehr’s useof five theoretical perspectives to “move beyond . . . ‘guessyour grade’ studies of self-assessment.” 14 From the first oftheir perspectives, professionals’ sense of self-efficacy in re-lation to a particular task is in dynamic equilibrium withtheir success at performing the task, moderated by a rangeof contextual and social influences. Those influences makeself-assessment unreliable but can be manipulated to en-hance the likelihood of task success by boosting expecta-tion. From the cognitive and metacognitive perspective,professionals do not have direct introspective access to theirown cognitions and have to rely on cues that are variablyavailable and potentially misleading, so again summativeself-assessment is predictably unreliable, but manipulable.From the social cognition perspective, professionals get toknow themselves by observing how others react to them, soself-assessment is socially mediated. Likewise, expertise de-velopment theories emphasize the importance of social in-teraction, in that professionals’ potential performance isenhanced by being given feedback and pushed beyond theircurrent ability. Finally, from the reflective learning perspec-tive, Eva and Regehr highlight how important it is that learn-ers are able to reflect in action—to know when they do notknow and seek external help. They tentatively synthesize a“route to self-improvement,” comprising feedback from ex-ternal sources that boosts professionals’ sense of efficacy,gives them insight into their cognitions and social inter-actions, and enhances skill. According to their formulation,the one part of assessment that depends wholly on self is anability to recognize challenge and reflect in practice to as-sure patient safety. Expressed in those terms, self-assessmenthas not just a place but an essential place in reflective pro-fessional development, but it must surely be a supported,rather than solitary process. While support may include in-animate sources like practice guidelines and information flowsderived from audit, social interaction is likely to be an im-portant source of support. Even the capacity to reflect in

practice would surely benefit from social interaction. Build-ing on those theoretical arguments, Sargent and colleagueshave coined the term directed self-assessment to refer toself-assessment activities informed by external resources suchas preceptors and practice guidelines and influenced by prac-tice context.15 They hypothesize, for future research, thatdirected self-assessment could have a place in a positiveculture of self-assessment and professional self-regulation,a proposal I return to at the end of this article. In the nextsection, I report applications of self-assessment to the firstand second stages of the UK medical education con-tinuum and then consider whether and how the experiencecould be applied to the final stage, CPD.

Self-Assessment Initiatives in the UnitedKingdom

Example 1: Undergraduate Medical Education

Since the University of Manchester moved from discipline-based, didactic education to problem-based medical educa-tion ~PBME!, students have clamored for clearer guidanceabout their syllabus. PBME sets out to engender epistemiccuriosity and make learning an open-ended, lifelong processso some degree of uncomfortable uncertainty is a necessaryconsequence. However, Manchester’s experience was thatcoupling PBME with an integrated curriculum structure,which ~as mandated by the GMC! no longer used clinicaldisciplines as the organizing principle of learning, caused adegree of uncertainty that undermined clerkship learning.16

Within a design-based research methodology, we provided aframework for self-assessment during clerkship learning anddeveloped an e-technology to support it.17 The added degreeof direction helped students become “self-motivated.” 18 Inthe words of one focus group respondent, the framework“helps a lot because it gives you the minimum threshold ofguidance which . . . is . . . required for self-directed learn-ing.” This process, which is supported by social interactionwith teachers, is thus an exemplar of directed self-assessment.

It has become normal practice for Manchester medicalstudents to map their learning to the intended objectives oftheir outcome-based curriculum and use their own previousentries in the system to define their future learning needs.The system directs them toward learning experiences thatfill gaps in their learning and helps them progressively coverthe content of the curriculum.19,20 This highly structured in-stance of directed self-assessment provides some proof ofconcept, albeit at a stage of clinical education when learnersdepend on a curriculum and support from teachers to pre-scribe learning need. Partial direction of students’ learningenhances their motivation to learn. To date, clinicians havenot been very engaged in using the technology to supportstudents’ clerkship learning, but the current thrust of ourwork is to enhance social interaction around the curriculumobjectives by making the technology supportive of teachersas well as students.

Dornan

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Example 2: The Novel UK Foundation Programme

UK postgraduate medical education started to undergo whole-sale restructuring in August 2005. Formerly, medical grad-uates had a mandatory year of preregistration house officer~PRHO! training, 2–3 years of general professional ~seniorhouse officer @SHO#! training, and a period of specialist reg-istrar training, whose length varied by specialty but was typ-ically 3–4 years. The first 2 years have been replaced by aFoundation Programme, during which trainees on 4-monthwork-based educational placements must attain a definedset of competencies.21 They then progress to specialist train-ing ~equivalent to residency!, which progresses from gen-eral specialist to higher specialist training over a 4- to 6-yearperiod.

In reality, the educational content of the first foundationyear is little different from that of the PRHO year exceptthat trainees are assessed summatively by means of mini-CEXs,22 Direct Observation of Practical Procedures, Case-Based Discussions, and Multisource Feedback and rotatethrough more specialties. Goals set by trainees at the start ofeach placement, the results of those assessments, and per-sonal reflections are held in a portfolio that also records theoutcome of appraisals. Failure to provide satisfactory evi-dence at appraisal debars trainees from progressing to in-dependent practice. Our group has successfully developedand implemented the same e-technology used by undergrad-uate students to support foundation training.23

Since robust long-term evidence is still lacking, the out-come can only be judged from trainees’ informal reactionsto workplace assessment, which are strongly positive whentheir supervisors willingly give formative feedback. Unfor-tunately, placing responsibility on trainees to persuade re-luctant and sometimes ill-trained supervisors to assess themhas too often marred the experience. In contrast, trainees’experiences of being given a 70-page-long training syllabusand expected to self-assess by mapping workplace assess-ments and reflective portfolio entries to it have been lesspositive.21 The curriculum stresses the importance of life-long learning in statements like “Doctors should be contin-ually learning from clinical practice—failure to recognisethis calls into question an individual’s commitment to life-

long learning and continuing professional development.” Else-where, it speaks of the learner’s using the curriculum “tomeasure progress against externally defined standards” and“developing the skills and habits of continuous assessmentof their everyday performance at work.” The foundation doc-tor, according to the curriculum, should “reflect on each de-cision, each management plan, and each action taken . . . indiscussion with their supervisors.” A portfolio, which re-duces the 70-page syllabus to 50 words, presented as sevenheadings with white space between them for reflective en-tries, is provided to help them do so. So, there is a disjointbetween the two different presentations of the official cur-riculum and learners’ curriculum in action.24 TABLE 1 showsthat a sample of Manchester trainees, surveyed soon afterthe introduction of foundation training, rated the officialcurriculum, portfolio, and formal off-the-job education muchless educational than their informal work-based experiencesand tacit learning.25 Manchester trainees have not beenalone in criticizing the foundation curriculum on educa-tional grounds,26 and the unsuccessful introduction of anational residency selection scheme in 2007 has resonatedin a way that will surely lead to further changes in founda-tion training.27

This rather negative experience of directed self-assessmentposes many questions. Is it too early in the process of changeto judge success? Were trainees and supervisors adequatelytrained? Is the curriculum appropriate and is it ade-quately represented in the portfolio? Is it appropriate to mapinformal learning to external standards? Are the paper andelectronic systems provided to support learning up to thejob? I believe the devil is in either the detail of the imple-mentation or the principles of outcome-based education ratherthan the fundamental principles of directed self-assessment,which I apply to CPD in the next paragraph.

Implications for UK CPD

The opening section showed that guess your grades self-assessment is unsuitable to weed out the small number ofmurderous and rankly incompetent doctors who threaten pa-tient safety so summative assessment as a prerequisite for

TABLE 1. Percentage Agreement With Statements Presented to 49 Trainees 3 Months After Starting Foundation Training

Informal Work-Based Learning Formal Foundation Education

“My clinical learning is well supported” 80%

“My clinical learning is well supervised” 57%

“I find it easy to relate what I actually experience in my job to the stated objectivesof foundation training”

55%

“Keeping a record of my on the job learning helps me learn” 49%

“I find it easy to maintain a learning portfolio” 27%

“I regularly look at the foundation curriculum” 14%

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revalidation and recertification is in the United Kingdom tostay. As a result, CPD can now concentrate on being a for-mative, developmental process for the majority rather thana protection against the few. It is hard to see how develop-ment can be possible without self-assessment. Eva and Re-gehr’s analysis14 leads us toward a transactional construct ofself-assessment, allied to theories of self-efficacy, metacog-nition, social cognition, expertise development, and reflec-tive learning. The various theories of learning they review,together with the UK appraisal system, intersect at a singlepoint—external support, particularly social support, as a pre-requisite for self-assessment.

Directed self-assessment by Manchester medical stu-dents is successful because they have ready access to a per-sonal portfolio that is framed in such a way as to guide theirlearning and give personal meaning to workplace experi-ences. Although we have not yet documented it, there isstrong informal evidence that the process would be evenmore successful if teachers were more engaged in the pro-cess, triangulated students’ self-assessments, and sup-plemented them with formative assessments. Directedself-assessment, operationalized by giving foundation train-ees the same technology, has been less successful, perhapsbecause the official curriculum is too far removed from theirwork-based learning to give personal meaning to learners’experiences. I hypothesize that a better formulated founda-tion curriculum coupled with mentoring would be neededfor directed self-assessment to achieve its potential in thefoundation years.

In a study of e-Portfolio-supported CPD, the CanadianPC Diary software helped UK endocrinologists formulatepersonal learning goals and manage their subsequent learn-ing.28 There was enough support for the principle anduptake of the technology to warrant wider use, providedtechnical and institutional support was available. Mentor-ing, perhaps through peer interaction, would probably makethat approach to directed self-assessment work better. Butwhere should the direction originate? To keep up with pro-fessional expectations in domains of which they do not havemastery, physicians need well-defined external standards~such as consensus statements!. In domains where they mustrespond to institutional demands, corporate goals must betheir standards. In areas of mastery, their standards mustbe personally defined. And in areas of difficulty, they wouldprobably find external assessment—as opposed to self-assessment—of value. A clear implication is that clinicaldirectors, who provide peer leadership within individual clin-ical divisions, will need to take on the daunting task of link-ing the planning of CPD to workplace performance.

Comparing one’s performance against a range of arbitersof effective professional performance with the support ofpeers and0or a mentor is a far cry from the quasi-summative,credit-based systems deployed in the first decade ofUK CME; however, it seems reasonable at least to hypoth-esize that it would support and enhance effective profes-sional performance.

Acknowledgment

The author would like to thank Jan Illing and Joan Sargentfor helpful criticism of the manuscript.

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Lessons for Practice

• United Kingdom continuing education ismoving from a system that primarily re-warded being taught to one that is moreexplicitly linked to change in practice.

• Inclusion of satisfactory personal develop-ment as evidence to support relicensure andrecertification calls for clarity in the place ofself-assessment.

• The term directed self-assessment refersto self-assessment activities informed by ex-ternal resources such as preceptors andpractice guidelines and influenced by prac-tice context.

• Research from Manchester has shownhow an e-technology can present under-graduate medical students with theintended learning outcomes of theirproblem-based curriculum in a way thatsupports self-assessment.

• Early evaluation of a similar e-technologyin the United Kingdom’s new early post-graduate Foundation Programme suggeststhat the intended learning outcomes, asstated in the official curriculum, are ratherremote from learners’ actual work-basedlearning and not fully supportive of self-assessment.

• External guidelines for directed self-assessment in CPD might be as follows:• When learners lack mastery of a domain:

consensus statements and other well-defined external standards

• When learners must respond to institu-tional demands: corporate goals

• In domains of mastery: personal stan-dards defined by learners themselves

• When a learner’s practice is in question:external, rather than self-assessment

Dornan

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