Considerations for continuing professional development in the post-pandemic era: national experiences from psychiatry
In 2020, the COVID-19 pandemic had a transformative impact on medical education, including continuing professional development (CPD). Academic health centres (AHCs) needed to rapidly innovate to meet the educational needs of both trainees and practicing physicians. Demand for educational content related to COVID-19, combined with physical distancing limits, had a profound impact on CPD. Beyond intra-institution collaboration, there was a need for communicating experiences in effective CPD practices between AHCs. For psychiatric CPD in Canada, the pre-existing Council of Psychiatric Continuing Education (COPCE) provided a ready means for collaboration. COVID-19’s impact led to an increased interest in sharing of expertise on CPD programming in face of the pandemic’s challenges. We sought to understand the changes in delivery and programming and to identify recommendations for CPD in the post-pandemic era. 

COPCE members (LH, RR, HM, HMc) organized an environmental scan informed by Kern’s six-step approach. We created an online 31-item survey using Opinio ( ), a survey creation software hosted on Dalhousie University servers. We developed questions iteratively over several meetings through discussions, drawing upon professional experience of multiple authors as CPD educators, then edited for relevance, clarity, thematic flow, and survey length. We distributed the survey to COPCE members at the May 2021 biannual meeting. Note that three co-authors (LH, RR, HMc) completed the survey as CPD leads for their respective schools. We calculated descriptive statistics for Likert-scale question responses and used thematic analysis for the free-text responses. We categorized our findings based on interactions between technology, learners, and teachers, aligning with the Passive-Interactive-Creative-Replace-Amplify-Transform (PICRAT) model. In the fall of 2021, we emailed all 17 Canadian medical schools through their COPCE representatives, CPD Directors, or Psychiatry Department Heads to complete the survey. We sent three email reminders. This project was reviewed and determined by the University of Toronto research ethics board to be a quality improvement study and thus exempt from ethics review. 

Summary of our findings Nine individuals responded (52.9% response rate) with a wide geographical distribution. Seven respondents were CPD Directors, one was a CPD Coordinator, and one a former Grand Rounds Coordinator. Eight were psychiatrists, one was a PhD. Responsibilities comprised program planning, continuing education for faculty, mentoring, and chairing CPD committees. Six of nine schools reported having paused CPD offerings for one to three months at the beginning of the pandemic. Six respondents reported they had used grand rounds to present clinical information about COVID-19, including sessions pertaining to physician wellness. PIC: learners’ interaction with technology As a result of a universal shift to virtual delivery during COVID-19, two schools reported challenges in participant engagement due to a change from Interactive to Passive engagement ( ), where one respondent commented, “Our small department used to have rich discussion when in person. Now this has reduced.” Nonetheless, the Interactive domain was observed in most of the respondents (seven of nine), who felt that audience participation and engagement was effectively maintained ( ). Although five of nine departments did not provide training in online technology to CPD, presenters were Creative in using online emojis, reaction icons, and polls. Creativity was also seen in the attempts to balance engagement with new security challenges with virtual delivery (e.g., speaker harassment by unexpected attendees). Six of nine institutions reported using prior registrations and screening of attendees, and eight utilized active monitoring of chats. Muting the audience and disabling cameras were strategies for managing larger audiences, while inviting attendees to turn on their cameras in smaller-group sessions, or when asking questions in larger virtual venues was seen as ways to promote engagement. RAT: technology’s impact on teachers Replacement was seen universally, with Zoom being the most used online platform in place of in-person sessions; while only four departments were using Zoom in some capacity pre-pandemic, eight of nine were using it by fall 2021. Three of nine reported that administrative and technological changes in under- and post-graduate medical education (UGME/PGME), such as conversion to online activities, had also influenced CPD delivery. Amplification was also observed, with eight respondents perceiving an increase in attendance at virtual CPD events ( ). Seven reported no new or re-allocated funds received for CPD initiatives; however, eight respondents stated the cost of CPD delivery during COVID-19 had decreased. Transformation through technology was identified by many as the next step in post-pandemic CPD. Five responses expressed interests in hybrid models; one respondent expressed a desire to “return to in-person CPD when possible, but hopefully in a hybrid manner where both in person and online can be done simultaneously.” Another stated their department will “hopefully transition to hybrid events” and “provide more asynchronous content, since the need is rising among our audience.” 

Nine individuals responded (52.9% response rate) with a wide geographical distribution. Seven respondents were CPD Directors, one was a CPD Coordinator, and one a former Grand Rounds Coordinator. Eight were psychiatrists, one was a PhD. Responsibilities comprised program planning, continuing education for faculty, mentoring, and chairing CPD committees. Six of nine schools reported having paused CPD offerings for one to three months at the beginning of the pandemic. Six respondents reported they had used grand rounds to present clinical information about COVID-19, including sessions pertaining to physician wellness. 

As a result of a universal shift to virtual delivery during COVID-19, two schools reported challenges in participant engagement due to a change from Interactive to Passive engagement ( ), where one respondent commented, “Our small department used to have rich discussion when in person. Now this has reduced.” Nonetheless, the Interactive domain was observed in most of the respondents (seven of nine), who felt that audience participation and engagement was effectively maintained ( ). Although five of nine departments did not provide training in online technology to CPD, presenters were Creative in using online emojis, reaction icons, and polls. Creativity was also seen in the attempts to balance engagement with new security challenges with virtual delivery (e.g., speaker harassment by unexpected attendees). Six of nine institutions reported using prior registrations and screening of attendees, and eight utilized active monitoring of chats. Muting the audience and disabling cameras were strategies for managing larger audiences, while inviting attendees to turn on their cameras in smaller-group sessions, or when asking questions in larger virtual venues was seen as ways to promote engagement. 

Replacement was seen universally, with Zoom being the most used online platform in place of in-person sessions; while only four departments were using Zoom in some capacity pre-pandemic, eight of nine were using it by fall 2021. Three of nine reported that administrative and technological changes in under- and post-graduate medical education (UGME/PGME), such as conversion to online activities, had also influenced CPD delivery. Amplification was also observed, with eight respondents perceiving an increase in attendance at virtual CPD events ( ). Seven reported no new or re-allocated funds received for CPD initiatives; however, eight respondents stated the cost of CPD delivery during COVID-19 had decreased. Transformation through technology was identified by many as the next step in post-pandemic CPD. Five responses expressed interests in hybrid models; one respondent expressed a desire to “return to in-person CPD when possible, but hopefully in a hybrid manner where both in person and online can be done simultaneously.” Another stated their department will “hopefully transition to hybrid events” and “provide more asynchronous content, since the need is rising among our audience.” 

Our study revealed a shift in the mode of delivery of CPD programs, as was reported in most of the world of medical education. Based on the PICRAT model, as recommended by the AMEE Guide No. 161, considerations must be made when using online learning in place of face-to-face education. Most of the observed changes relate not only to a simple Passive Replacement of conventional in-person sessions, but also at the Interactive, Creative, Amplification, and Transformation levels. We identified that CPD in the post-pandemic era should strive for a balance between an improved virtual attendance with online security and rich communication supported by in-person programming. We summarize our practical recommendations to CPD leaders post-pandemic in . Virtual options will allow for greater participation with lower cost Our findings of perceived increase in attendance and reduced costs are similar to those at other centres, where there was increased audience participation in regularly scheduled activities, such as grand rounds and conferences. - The increased accessibility of virtual delivery offers the opportunity for a larger audience both within and beyond the institution. However, having more participants present may not mean they are fully engaged. While seven respondents reported positive views on engagement, it is notable that two expressed concerns. CPD planners should be mindful of using strategies to maintain the rich interactions typically supported by face-to-face CPD programming while leveraging the increased virtual attendance ( , Rec. 1). More resources are needed for hybrid conferences A recent review by Cheng et al. found that the virtual format provides many advantages for continuing medical education, such as convenience, larger collaboration opportunities, and favourable learning formats. However, it is partially inhibited by technological barriers, poor design, cost and time restraints. Many respondents commented that a hybrid model of CPD was likely to be implemented in their departments post-pandemic. Hybrid models have been used successfully in numerous educational settings. - Future CPD programming will require technological, financial, and human resources, as well as adequate planning, to mitigate the barriers of hybrid delivery. ( , Rec. 2). A nation-wide community of practice for CPD leaders may be beneficial While the pause in CPD in several schools suggest there may have been competing priorities, the inclusion of COVID-19-related clinical topics (including wellness) demonstrates the role CPD can play in providing up-to-date information in a rapidly evolving situation. Sklar et al. emphasized the value of CPD in promoting an institution-wide learning culture. In addition to the educational infrastructure provided by departmental CPD programs, it is beneficial to have a national network of CPD directors, such as COPCE for the field of Psychiatry. The CPD directors at COPCE meet twice annually to explore, share, and guide practices. As COVID-19 catalyzed a renewed interest in optimizing CPD programming, this survey was promptly commissioned, designed, and disseminated in a timely manner, and attained a high response rate facilitated by the pre-established network. A national organization can be a platform for sharing lessons learned from individual CPD departments and bringing together faculties to promote innovations and disseminate helpful practices. ( , Rec. 3) Strengths and limitations Strengths of this study include the timely collection of data from across Canada facilitated by a national organization with a mandate in psychiatry CPD. While not every medical school responded, and our findings are specific to Psychiatry in Canada, they likely reflect similar barriers and facilitators encountered in other fields in relation to the universal pivot to virtual CPD. Limitations of this study include the small sample size and respondents’ perceived attendance rather than empirical data; a follow-up study with more objective data collection may strengthen our conclusions. Moreover, since COPCE is a small network, some of the CPD leaders that designed the study were also participants of the survey. 

Our findings of perceived increase in attendance and reduced costs are similar to those at other centres, where there was increased audience participation in regularly scheduled activities, such as grand rounds and conferences. - The increased accessibility of virtual delivery offers the opportunity for a larger audience both within and beyond the institution. However, having more participants present may not mean they are fully engaged. While seven respondents reported positive views on engagement, it is notable that two expressed concerns. CPD planners should be mindful of using strategies to maintain the rich interactions typically supported by face-to-face CPD programming while leveraging the increased virtual attendance ( , Rec. 1). 

A recent review by Cheng et al. found that the virtual format provides many advantages for continuing medical education, such as convenience, larger collaboration opportunities, and favourable learning formats. However, it is partially inhibited by technological barriers, poor design, cost and time restraints. Many respondents commented that a hybrid model of CPD was likely to be implemented in their departments post-pandemic. Hybrid models have been used successfully in numerous educational settings. - Future CPD programming will require technological, financial, and human resources, as well as adequate planning, to mitigate the barriers of hybrid delivery. ( , Rec. 2). 

While the pause in CPD in several schools suggest there may have been competing priorities, the inclusion of COVID-19-related clinical topics (including wellness) demonstrates the role CPD can play in providing up-to-date information in a rapidly evolving situation. Sklar et al. emphasized the value of CPD in promoting an institution-wide learning culture. In addition to the educational infrastructure provided by departmental CPD programs, it is beneficial to have a national network of CPD directors, such as COPCE for the field of Psychiatry. The CPD directors at COPCE meet twice annually to explore, share, and guide practices. As COVID-19 catalyzed a renewed interest in optimizing CPD programming, this survey was promptly commissioned, designed, and disseminated in a timely manner, and attained a high response rate facilitated by the pre-established network. A national organization can be a platform for sharing lessons learned from individual CPD departments and bringing together faculties to promote innovations and disseminate helpful practices. ( , Rec. 3) 

Strengths of this study include the timely collection of data from across Canada facilitated by a national organization with a mandate in psychiatry CPD. While not every medical school responded, and our findings are specific to Psychiatry in Canada, they likely reflect similar barriers and facilitators encountered in other fields in relation to the universal pivot to virtual CPD. Limitations of this study include the small sample size and respondents’ perceived attendance rather than empirical data; a follow-up study with more objective data collection may strengthen our conclusions. Moreover, since COPCE is a small network, some of the CPD leaders that designed the study were also participants of the survey. 

The pandemic has substantially affected the mode of delivery, content, program continuity, attendance, and costs of CPD programming in Psychiatry. This study has shown that despite an improved attendance, a virtual CPD offering should also consider online security and rich interactions that were upheld in in-person events. A hybrid model may best leverage the advantages of both virtual and in-person modalities. As the landscape of CPD has changed post-pandemic, sharing of information through a national community of practice has the potential to support CPD in Canada. 

