The needs and preferences of general practitioners regarding their CPD learning: a Free State perspective

Abstract

Background: The Health Professions Council of South Africa (HPCSA) requires all registered Health Practitioners in South Africa to complete accredited learning opportunities, and provide proof thereof. CPD is the chosen model, which focuses on holistic development of the professional. The UFS Department of Family Medicine presents refresher courses for general practitioners, covering all relevant fields of interest.

Aim: The aim of this study was to find reasons and possible solutions for the perceived lack of interest in refresher courses by determining general practitioners’ needs and preferences for CPD training.

Methodology: A cross-sectional study design was chosen, whereby a systematic sample of 300 general practitioners registered with the HPCSA as doctors in the Free State were asked to complete a questionnaire. Needs and preferences regarding learning opportunities and factors influencing usage of these learning opportunities were assessed.

Results: The responses from 60 participants revealed that general practitioners still prefer the lecture form of presentations in large or small groups. Topics that ranked highly were Infective Diseases, Cardiology and Respiratory Diseases. Respondents indicated that general practitioners prefer not to leave their practices unattended for an extended period of time.

Conclusion: Free State general practitioners still prefer the traditional lecture-room style of learning. Their declared learning needs are in line with the regular ailments they encounter within their practices. Strategies to accommodate those who find it difficult to attend, due to time and distance concerns, should be considered.

Keywords:

• CPD
• Free State
• general practitioners
• learning opportunities
• refresher courses

Introduction

One of the medical professions that finds it the most difficult for staying in touch with current knowledge is the general practitioner. General practitioners are considered to be ‘on the edge’.¹ They are required to have some knowledge of various related medical fields and are constantly under pressure to adapt the way they approach patients and their treatment. They need to have a holistic view of the patient’s health, family matters and any other factors that may influence the patient’s welfare. Furthermore, for general practitioners, the preventive plays as important a role as the curative.

The main purpose of continuing medical education (CME) is to improve and maintain clinical knowledge and skills.² The traditional manner in CME for clinical-related knowledge transfer was a lecture given by a specialist, pharmaceutical representative or another expert on clinically related topics. Adjustments needed to be made to adapt to a changing world and greater demands.³ In South Africa, the Health Professions Act of 1974⁴ supported the development of continuing professional development (CPD) and tasked the Health Professions Council of South Africa with managing the process. Gibbs explains that CPD has become a holistic mode of training, which considers doctors to be much more than just clinicians.³

As of January 1, 2007, all registered health professionals in South Africa are required to attend and complete accredited learning opportunities with the purpose of updating and acquiring new skills and knowledge. The conversion to the CPD system was to develop the health practitioner as a complete professional, allowing for training in the medical field, ethics, personal health, practice management and medical law.⁵ Constant reflection and critical self-evaluation moves the onus from the manager to the individual for personal development in all aspects of his/her life.⁶

In South Africa, health practitioners are required to collect 30 Continuing Education Units (CEU) per year, which include five compulsory ethical discussion points. Training options include refresher courses, ward rounds, journal discussions, reviewing of journal articles, presentations, update meetings, conferences, research, media and Internet activities.⁵

The Department of Family Medicine at the University of the Free State has been presenting refresher courses for general practitioners since 1979. Through tri-annual courses, all the relevant topics are presented through triennial rotation. Courses are presented in cooperation with the topic-related specialist departments. The programme often also includes external guest speakers. Lectures are given in lecture format, with time given for group discussion.

These courses are attended by doctors from across the country. Attendance at these refresher courses has dropped since the CPD requirements. The high attendance rate of the final course of the year may indicate that physicians realise their time for CEU accumulation is coming to an end and they need to accumulate points.

A challenge for the Department of Family Medicine’s training is the small number of rural and remote general practitioners attending these development opportunities. The majority of urban practitioners have the added advantage of several CPD opportunities with various institutions. The rural physicians are often frustrated by the limited training they receive, and their training needs also differ slightly from those of their urban colleagues.^7,8

When doctors overseas were asked which learning format they preferred, general practitioners indicated live lectures and/or refresher courses as the learning format of choice.^9–11 This is despite a strong indication of general practitioners having limited time to attend such courses. Additional factors include travelling some distance, even more so for rural doctors.¹⁰

Aim

The aim of this study was to find reasons and possible solutions for the perceived lack of interest in refresher courses by determining general practitioners’ needs and preferences for CPD training.

Methodology

To determine the needs and preferences of general practitioners, a ‘snapshot’ of the general practitioner population in the FS is a suitable measure. A representative group needed to be selected with no pre-determined bias other than their profession. For this purpose, a cross-sectional study design was chosen.¹²

For the Free State province, there were 1 039 general practitioners listed on the HPCSA’s register in 2010. A systematic sample of 300 participants from the target population was selected.¹³ The smaller sample was selected to improve manageability in an attempt to improve the response rate, which is usually low in posted questionnaires. Numbers were generated by the biostatistician’s randomisation software and the researcher used the numbers to identify the 300 participants numerically from the list of general practitioners registered with the HPCSA as having their permit address in the Free State Province.

A questionnaire was used to gather quantitative data; this was followed by comments made in the qualitative-style, open-ended questions. The questionnaire included three main sections, set in accordance with the objectives: Profile of the participant; Needs and preferences of general practitioners; and Refresher course usage. Each section included short-answer questions, but Section 2 also incorporated four-point Likert-scale questions. To test the validity of the questionnaire, a pilot study was done with five refresher course attendees meeting the inclusion criteria. No problems could be identified and the pilot study results were included in the main study.

The study received approval from the Ethics Committee of the Faculty of Health Sciences at the University of the Free State. Participants completed an informed consent form and they were assured that all information would be kept confidential.

In November 2011, the first author posted questionnaires to the postal addresses of the 300 randomly chosen general practitioners. As a mechanism of response, participants were given a choice of posting, faxing, emailing or completing the questionnaire on an online form (SurveyMonkey®). After a period of limited response, the researcher attempted to contact the participants with persistent reminders via telephone, SMS, e-mail and/or fax. The researchers agreed to conclude the data gathering by November 2012, with a total of 60 responses and 20 unclaimed questionnaires received. This amounts to a disappointing response rate of 21%. Interesting to note is that although the majority (40%) of these preferred to return their responses by regular mail, almost one-third (28%) made use of the online questionnaire.

The information was captured electronically and the researchers were assisted by the Department of Biostatistics, UFS, with analysis of the data. Results were summarised by percentages and frequencies.

Results

Demography

Slightly more than half of the responding general practitioners (53%) were male, and the median age was 45 with the majority (47%) being in the 40–59 (Middle Adulthood¹⁴) group. A large group of respondents (58%) completed their basic medical degree at the University of the Free State. The results showed that 51% had completed some form of additional postgraduate qualification. Regarding employment, general practitioners in private practice formed the majority group of 60%; 17% were government employed, while the remaining respondents were either purely academically employed (7%), in a research capacity (5%), with a private hospital (3%) or no longer employed in the medical field (3%).

Only one participant indicated that he/she has no Internet access available at home or at work.

Only 15% indicated being from a rural area. Of the respondents who answered the question (55%) on whether other facilities/medical personnel are accessible when they are not, everyone indicated availability of some form of medical assistance, with the majority (36%) indicating both a hospital and other physicians in the immediate area. These numbers may be skewed due to the low number of responses from rural doctors.

Regarding the types of ailments commonly encountered at their practices, respiratory ailments formed the largest grouping (27%), followed by circulatory ailments (20%) and infectious diseases (12%). Respiratory ailments included upper respiratory infections, bronchitis, sinusitis, pneumonia, pharyngitis and flu. Circulatory ailments were grouped from general circulatory diseases, hypertension and stroke. Infectious and parasitic diseases included HIV, tuberculosis, malaria and general infections.

Needs and preferences

Participants were asked to specify their preferences from the type of learning opportunities available. Figure 1 displays the percentages of respondents choosing 3 or 4 on the four-point scale. A few participants did not rate each choice, which may point to ‘no interest’ or misinterpretation of the question.

Figure 1: Learning opportunities preferences (n = 57).

Most participants preferred refresher (65%) or short courses (56%), with CME on computer (47%) and journals (47%) not lagging far behind. There seems to be little interest in teleconferencing (9%) and supervised in-service training (7%).

Although the number of rural respondents was low, the researchers investigated separately the results of the rural participants regarding learning opportunities. Refresher courses (56%) and short lectures (56%) remained high, but specialist visits increased to 44%. Comparing more current technological training methods with the age groups, only the above-60 age group showed very little interest in computer-based training.

To determine the educational design participants prefer, large group (60%) and small group (56%) rated highly as did journal reading (44%) and interactive learning on computer/Internet (42%), which is in line with the learning opportunities preferences in Figure 1, but practical sessions (63%) showed that an important learning aspect is being missed.

For each of the 21 training needs listed, Figure 2 indicates what percentage of respondents chose the option as one of the top 5 or choices 6 to 10.

Figure 2: Top 10 choices for training needs (n = 57).

From the few additional comments received, the main problems identified were a lack of time and suggestions for a more condensed programme covering multiple topics.

Refresher course usage

Some 38% of participants indicated that they had attended refresher courses at the Department of Family Medicine, UFS, in the previous three years; 21% had attended courses presented by other academic institutions in the previous three years. The main stated factors deterring participants from making use of refresher courses are listed in Table 1.

Table 1: Factors influencing usage of UFS Department of Family Medicine Refresher Course opportunities (n = 60).

Influencing factor		Percentage (%)
Cannot afford time away from practice/hospital		70
Difficult to find locums		37
Distance away from practice/hospital and home		32
Course too long		18
Would prefer lectures after hours		17
Lack of finances/sponsors		13
Would prefer a different educational method		12
Lectures do not meet my needs		7
Other	Was not aware of courses/not informed	7
	Patient/academic responsibilities	2
	Difficult for locum to miss work (financially)	2

In an open-ended question on how the department could improve their learning opportunities, only 10% indicated they were satisfied with the courses, whereas 11% asked for better and earlier communication of these opportunities.

Discussion

From these results, general practitioners indicated a preference for refresher courses and short lectures. Even with modern technology offering a range of private, student-driven and easily accessible CPD training formats, the responding doctors from the Free State tend to prefer a course or lecture attended by a number of peers. This is in line with findings from studies abroad.^9–11

Practical sessions as an educational design should receive consideration, despite previous experiences where general practitioners showed a lack of interest in practical training. This design option needs to be further researched.

Supervised in-service training received a very low rating as a learning option. Further research is suggested on how this training could be made more attractive to prospective learners, considering the worldwide movement of learning towards the workplace.

The reported ailments most commonly encountered at the participants’ practices (respiratory ailments, circulatory ailments and infectious diseases) were also the three subjects that received the most interest (infective diseases, cardiology and respiratory). This may indicate that general practitioners have a clear understanding of their learning needs, in order to serve the community.

General practitioners struggle to attend courses due to their responsibilities at their practices, and finding locums has become increasingly difficult. The distance and being away from work/home for a period of time were other factors that weighed considerably on general practitioners’ choice to attend refresher courses.

Limitations and recommendations

Due to the low response rate representativeness cannot be claimed, but the respondents’ results do indicate trends that could be used to make recommendations. Similar studies varied in their response rates, ranging from 5% to 59%, but the struggle to acquire sufficient feedback is apparent.^9–11

In retrospect, an additional question should have been added inquiring how CEU points were accumulated if not via courses.

Lecture-format courses are still the preferred teaching method, which include refresher and short courses. Departments of Family Medicine should also consider including more practical sessions. Other formats to explore would be self-driven learning via computer and Internet-based courses/lectures. Rural doctors have an additional preference for specialist visits. Organising more such visits to the districts could also be considered.

General practitioners realise what their learning needs are. Courses should thus be planned and the amount attention focused on these topic areas should be determined by these needs.

Shorter courses with more widely covered topics are recommended. Presenting courses in more of the districts could also solve the travel and distance from home concerns.

CPD is intended to fall within the Adult Learning theory, where learning is self-directed and the motivation for seeking knowledge is based on the professional’s needs within his/her profession.³ Whether this is achieved with professionals being forced to chase the required points, especially those with limited time, should be researched in a subsequent study. Most advocates of the CPD system will claim that formal lectures are a poor way of gaining knowledge transfer. Doctors are now forced to accumulate CEU points and seem to prefer an ineffective manner of knowledge transfer. However, the system puts pressure on them to accumulate points, which may result in the accumulation of available points in areas that are not of primary interest to them.

A concern that should be kept in mind is the moderate levels of knowledge transfer that take place during the traditional lecture/conference format, which makes it one of the less preferred methods from an educational point of view, especially when not combined with other forms of learning.¹⁵ This issue was not measured in this study, but should be examined thoroughly in future projects.

Conclusion

Refresher courses should continue to be presented in lecture format, although more practical sessions should be considered. It seems that peer interaction could be an important factor that drives general practitioners to persist with large-group lecture format training. Doctors have shown in this study that they know their own needs, and that of the community they serve. General practitioners identify their learning needs according to the type of ailments they encounter most often.

Departments of Family Medicine should consider strategies to accommodate those who find it difficult to attend due to time and distance concerns.

Authors’ contribution

J.Bo. conducted the study as per requirement of M.HPE degree; J.Be. was the main study leader who was involved from project planning to final report; W.J.S. was co-study leader who assisted with planning and interpretation; G.J. assisted with protocol planning, questionnaire design, data analysis and manuscript preparation.

Competing interests

All authors declare that no competing interests exist in this study.

Acknowledgements

Mr FC van Rooyen, Department of Biostatistics, UFS, is thanked for assistance with statistical analysis, and personnel at the Department of Family Medicine, UFS, for their support during the project.