Aust. N.Z. J. Med. (1978), 8, pp. 191-194 CONTINUING EDUCATION
An Evaluation of Five Years Experience with a Physicians Workshop D. I . Newble" From the Department of Medicine, Queen Elizabeth Hospital, Woodville, South Australia
Summary: An evaluation of five years experience with a Physicians Workshop. D. I. Newble, Aust. N.Z. J. Med., 1978, 8, pp. 191-194.
be of value to physicians in other hospitals wishing to establish similar activities.
This paper reports five years experience with a new type of continuing education programme for practising physicians. The continued development and the organisation of the programme is described. A high proportion of the hospital's physicians have regularly attended and participated. Annual questionnaire surveys have shown a high degree of satisfaction with the programme and the majority of physicians give it a high priority in their continuing educational activities. The features which appear to be responsible for the success of the programme include the variety of the format, the quality of the presentations, the active participation by all physicians and the fact that the activities are specifically aimed at the practising physician rather than physician trainees.
Development and Organisation Over the last five years the hospital has provided a weekly continuing education programme in internal medicine. The essential feature of this programme is that it is designed specifically for the trained practising physician. This contrasts with the more usual situation where hospital medical meetings are less specific and attempt to cater for physician trainees, interns and students in addition to the specialist staff. The broad goal of the Workshop was to provide a forum which met two of the three levels of educational need identified in the Ad Hoc Report on Continuing Education and Re-evaluati~n.~ Thus, the meeting aimed to meet the educational needs of general physicians and of specialist physicians in areas outside their subspecialty. No attempt has been made to provide for the more specific needs of the specialist in his subspecialty, and in recent years it has become apparent that these needs are being adequately met by the development of unit based advanced training programmes. In 1971, the Organising Committee formulated the following series of objectives for the Workshop : 1. To encourage attendance of all physicians and attached resident staff. 2. To encourage active participation of all physicians at the level of both presentation and discussion. 3. To improve the standard of presentation and chairmanship. 4. To structure the meeting to encourage active audience participation as a group learning procedure. 5. To include regular educational segments on the bases of medicine and basic medical sciences.
In 1972 the physicians at the Queen Elizabeth Hospital agreed to participate in an experimental programme of continuing education. The initial experiences with this programme, which became known as the Physicians Workshop, have been reported previously.' The concept of group workshops was discussed by Professor Don Wilson in his report on Continuing Medical Education.' He commented that this method was potentially very valuable for large hospitals and he identified the Queen Elizabeth Hospital workshop as the best example he had seen. In the light of this favourable comment, a review of the developments in the programme since 1972 and an attempt to assess whether it has met its original aims may 'Senior Lecturer in Medicine. University of Adelaide Correspondence: Dr. D. I. Newble, Department of Medicine, Queen Elizabeth Hospital, Woodville, SA 501 1 Accepted for publication: 9 November, 1977
192
NEWBLE
6. To regularly reassess the programme to allow for the incorporation of new ideas. 7. To maintain a diversified and interesting programme. The hospital's physicians unanimously accepted these objectives and supported the broad goal outlined previously. They were prepared to give priority to attendance and participation in the meeting. An organising committee was established and charged with implementing the stated objectives. Chairmen of the committee have been appointed for two years and the committee members have included the chairman and elected representatives of the hospital's Physicians Subcommittee. The committee has also had the continuous services of a physician with a particular interest in medical education who had taken responsibility for initiating new educational methods and undertook the evaluation of the programme. The committee took particular care to provide adequate variety in the programme, both in content and format, as well as to ensure that all areas of medicine were adequately covered and that all physicians and units had an opportunity to participate in presentations. It is not possible to give full details of Workshop activities but Table 1 shows a section of the programme for 1977. The basic format of a long session of 45 minutes duration and two short sessions of 20-30 minutes duration, reported previously, has been retained.' However, considerably more flexibility and variety of format has been introduced in the succeeding years. This is evident in the section illustrated. Regular TABLt I Workqhop programme 1977 -
Date Session type ~
31) 3
~
~~
Topic ~
Presenter ~~~
~
~~~~~~~~~
~
~
Methodology
ECG X-ray
Cardiology
64
Long Short Short
Case presentations Purines E M 1 Scdnnlng
General clinic Vlsltor Kadiology
13 4
Long Long
CPCC
Pathology Gastroenterology
20 4
Inflammatory bowel disease
VOL.
8,NO. 2
sessions on clinical methodology were devoted to updating clinical skills and were, at times conducted in appropriate sites away from the lecture theatre. Regular clinico-pathological correlation clinics have been conducted by the Pathology Department. On other occasions the whole of the time was given over to a symposium or to a major review of a specific topic commissioned from a staff member. The organising committee has'also attempted to introduce topics of wider concern to physicians than internal medicine or medical science. Recent sessions or symposia on postgraduate medical education, peer review, homicide, sports medicine, the physician and the Aboriginal, hypnotherapy and biofeedback give some indication of the variety achieved. Particular success has been achieved with short sessions consisting of films of interesting or unusual clinical signs (mini-clinic) and clinical problems presented as multiple choice questions (physicians quiz). Reports from physicians who have attended national or international conferences were often sought. At the end of each year the final Workshop was devoted to a quiz in which questions were included from many topics covered during the year's programme. Results
The success of the programme must be judged on the degree to which it achieved its stated objectives. The first of these was attendance which can also be taken as a good index of satisfaction with the programme and of the stated expectation that physicians would reorder their priorities to allow them to attend the meetings. The attendance figures over the five year period, shown in Table 2, indicate that approximately 70 "g of physicians have attended over half of all meetings and 40-60'4 have attended over three quarters of all meetings. Average attendance has been 60-70 0,;. There has been no tendency for these attendance levels to drop. TABLE 2 Workshop attendance ( ",>)
Long Short Shorl
QUlL
Obesity
Dept of Medicine Cardiology Endocrinology
27 4
Long Long
Venereal diseases Cerebral lymphoma
VDCC Vlsltor
Over XI",, meetings
70
44
81
75
72
45 -
Symposium
Biofeedback
Psychiatry
Over 7 5 " , , meetings
60
28
55
42
43
Marrow transplants
1972 ~~~~~~
1973
1974
1975 .
~~~~~~
~~~~~
1976 ~~~~
APRIL
1978
The second major objective was active participation. The structure and format of the Workshop has ensured that some participation is unavoidable. Every physician was asked to personally present a session at least once a year either on a subject of his own choice or on a topic commissioned by the committee. Active participation by an audience is always hard to achieve but is believed to be essential for effectivelearning. Rigid enforcement of adequate discussion time following didactic presentations and effective chairmanship are vital. Efforts to enhance participation by altering the format of sessions have been variably successful. Surprisingly, small group discussion has not been universally successful but carefully conducted quiz sessions, unknown case presentations, clinical methodology sessions and the miniclinics have been both successful and enjoyed by participants. The programme has been formally assessed by using a yearly feedback questionnaire. On each occasion a response rate of over 90% has been achieved. Questions have been directed to ascertain the degree of satisfaction with the workshop as a whole and with individual sessions. Feedback has been sought on the innovations and suggestions for change have been solicited. Table 3 shows that a high degree of satisfaction has been retained. The gradual fall in the proportion of satisfied to undecided responses from 1972-1975 may be noted and it is clear that moves to improve the programme in 1976 have been successful. In 1972, 94";, agreed or strongly agreed that the Workshop was valuable and in 1976 the figure was 797" with 13"i undecided. It was the hope of the organising committee that the programme would fulfil a substantial continuing educational need, particularly in updating knowledge over a wide area. Table 4 shows that a high proportion of physicians
1972 ~
Satistied Undecided Diasatistied
193
EVALUATION OF THE PHYSICIANS WORKSHOP
1973
1974 .
~
I976
1975
~
~
72 I2
57
SO
IS
I6
28
21 29
~
36 4s
73 I2
Ih
IS
TABLE 4 The Workshop rates a high priority in my continuing education activities (",) Strongly agree
1974 1975 1976
7 17
38
Agree
59 52 38
Undecided
Strongly disagree
17
0 0
17
0
19 . A
A major advantage is exposure to information from other specialties 1973 197b
37 68
50 32
3 0
3 0
gave the Workshop a high priority in their continuing education activities and felt that their exposure to information from other specialties was a major advantage. It is this input that is less likely to be obtained from other sources and it may be the major motivating factor for participation in programmes such as the Workshop. The feedback questionnaire also sought information on the perceived value of individual presentations, session types and new or innovative educational methods. Physicians have been asked to rate these on a scale of one (poor) to six (excellent). Mean scores can be calculated but it is sometimes difficult to make clear judgements due to the wide standard deviations around the mean. As in any educational endeavour, individuals prefer different methods of learning and ratings may reflect this preference rather than the quality of the offering. However, ratings have been of value, particularly in assessing the response to innovative sessions. For example, series on the bases of medicine have consistently rated well over the five year period (range 4.2-5.2) as have clinical methodology sessions (4.2-4.8). Small group sessions (3.5) and clinico-pathological correlation clinics (3.4-4.0) have been less popular. The recently introduced miniclinics (4.8) and physicians quiz (4.6) have been well received. It must be added that a popularity rating does not necessarily correlate with the real educational value of the session but the committee is of the opinion that enjoyment is an important motivational factor and a pre-
194
NEWBLE
requisite for effective learning. It would therefore look for ways of improving the impact of a low rating session but would not discard it if it felt it could still be of value. An example of this would be small group sessions. These were discontinued in early years because of the poor response but it was felt that the unpopularity was more related to the topics chosen for discussion rather than to the method itself. Discussion
The physician has an unenviable task in attempting to retain his competence once he becomes a member of the College. This problem is particularly acute in the area of medical and scientific knowledge. It has been estimated that the half-life of medical knowledge is less than ten years and the increasing diversification into specialist and subspecialist practice makes it even more difficult to prevent this obsole ~ c e n c e .There ~ is, therefore, a growing need for methods which will help keep the physician in contact with changes in his own and other disciplines and also with changes in the needs of the community. Only a minority will have sufficient motivation to retain their competence at the highest level without assistance. The College has made major initiatives in this area with alterations in scientific meetings, with the establishment of an Advisory Committee on Continuing Education and, most importantly, with the appointment of a full time Director of Continuing Education to head the new Continuing Education Centre. The initiatives of such a central organisation will need to be complemented by initiatives at a local hospital level as well as by the more effective use of individual study and selfassessment. The development of the Physicians Workshop provides a model which could prove suitable for implementation in other hospitals. It has received favourable comment from several leading overseas medical educators and may be unique in its objectives and success. The
VOL.
8, NO. 2
maintenance of a high level of attendance and participation over a five year period can be regarded as a distinct success. The essential ingredients of this success were thought to be the design of a programme specifically for practising physicians, the agreement of all physicians to attend and support the aims of the programme, the quality of presentations, the variety of format, particularly with regard to ensuring active participation, and the flexibility of the planning. At a time when the concepts of quality assurance and peer review, either by self-regulation or by external control, are frequently discussed it is important to assess the value of current continuing educational activities. It might have been noted that the objectives of the Workshop did not include a reference to improving patient care, the ultimate criterion on which to judge the success of continuing education in assuring quality of patient care. It has, however, usually been assumed that an updating of knowledge and skills is a prerequisite to the maintenance of standards. A successful Workshop, such as the one described, does provide an opportunity for the development of more formal peer review activities, activities which could then be clearly related to an attractive educational programme and consequently less threatening to individual physicians.
Acknowledgements
The author wishes to thank all members of the organising committee and the physicians of the Queen Elizabeth Hospital who have participated in the Workshop and have regularly completed the assessment questionnaires.
References I . NEWBLE, D. I., KERRGRANT, A., SAGE,R. E. and BURSTON, R. A. (1973):An experiment in continuingeducation for physicians,Aust. N.Z. J. Med. 3,512. 2. WILSON,D. (1 976): Report to the Royal Australasian College of Physicianson continuing medical education. 3. HUNTER, .I. D., GOULSTON, K. and NEWBLE, D. I. (1973):Report oncontinuing education and re-evaluation of physicians, Royal Australasian College of Physicians. 4. CARMICHAEL, H. (1970): In Congress in Medical Education, Council on Medical Education, AMA, Chicago.
An Evaluation of Five Years Experience with a Physicians Workshop D. I . Newble" From the Department of Medicine, Queen Elizabeth Hospital, Woodville, South Australia
Summary: An evaluation of five years experience with a Physicians Workshop. D. I. Newble, Aust. N.Z. J. Med., 1978, 8, pp. 191-194.
be of value to physicians in other hospitals wishing to establish similar activities.
This paper reports five years experience with a new type of continuing education programme for practising physicians. The continued development and the organisation of the programme is described. A high proportion of the hospital's physicians have regularly attended and participated. Annual questionnaire surveys have shown a high degree of satisfaction with the programme and the majority of physicians give it a high priority in their continuing educational activities. The features which appear to be responsible for the success of the programme include the variety of the format, the quality of the presentations, the active participation by all physicians and the fact that the activities are specifically aimed at the practising physician rather than physician trainees.
Development and Organisation Over the last five years the hospital has provided a weekly continuing education programme in internal medicine. The essential feature of this programme is that it is designed specifically for the trained practising physician. This contrasts with the more usual situation where hospital medical meetings are less specific and attempt to cater for physician trainees, interns and students in addition to the specialist staff. The broad goal of the Workshop was to provide a forum which met two of the three levels of educational need identified in the Ad Hoc Report on Continuing Education and Re-evaluati~n.~ Thus, the meeting aimed to meet the educational needs of general physicians and of specialist physicians in areas outside their subspecialty. No attempt has been made to provide for the more specific needs of the specialist in his subspecialty, and in recent years it has become apparent that these needs are being adequately met by the development of unit based advanced training programmes. In 1971, the Organising Committee formulated the following series of objectives for the Workshop : 1. To encourage attendance of all physicians and attached resident staff. 2. To encourage active participation of all physicians at the level of both presentation and discussion. 3. To improve the standard of presentation and chairmanship. 4. To structure the meeting to encourage active audience participation as a group learning procedure. 5. To include regular educational segments on the bases of medicine and basic medical sciences.
In 1972 the physicians at the Queen Elizabeth Hospital agreed to participate in an experimental programme of continuing education. The initial experiences with this programme, which became known as the Physicians Workshop, have been reported previously.' The concept of group workshops was discussed by Professor Don Wilson in his report on Continuing Medical Education.' He commented that this method was potentially very valuable for large hospitals and he identified the Queen Elizabeth Hospital workshop as the best example he had seen. In the light of this favourable comment, a review of the developments in the programme since 1972 and an attempt to assess whether it has met its original aims may 'Senior Lecturer in Medicine. University of Adelaide Correspondence: Dr. D. I. Newble, Department of Medicine, Queen Elizabeth Hospital, Woodville, SA 501 1 Accepted for publication: 9 November, 1977
192
NEWBLE
6. To regularly reassess the programme to allow for the incorporation of new ideas. 7. To maintain a diversified and interesting programme. The hospital's physicians unanimously accepted these objectives and supported the broad goal outlined previously. They were prepared to give priority to attendance and participation in the meeting. An organising committee was established and charged with implementing the stated objectives. Chairmen of the committee have been appointed for two years and the committee members have included the chairman and elected representatives of the hospital's Physicians Subcommittee. The committee has also had the continuous services of a physician with a particular interest in medical education who had taken responsibility for initiating new educational methods and undertook the evaluation of the programme. The committee took particular care to provide adequate variety in the programme, both in content and format, as well as to ensure that all areas of medicine were adequately covered and that all physicians and units had an opportunity to participate in presentations. It is not possible to give full details of Workshop activities but Table 1 shows a section of the programme for 1977. The basic format of a long session of 45 minutes duration and two short sessions of 20-30 minutes duration, reported previously, has been retained.' However, considerably more flexibility and variety of format has been introduced in the succeeding years. This is evident in the section illustrated. Regular TABLt I Workqhop programme 1977 -
Date Session type ~
31) 3
~
~~
Topic ~
Presenter ~~~
~
~~~~~~~~~
~
~
Methodology
ECG X-ray
Cardiology
64
Long Short Short
Case presentations Purines E M 1 Scdnnlng
General clinic Vlsltor Kadiology
13 4
Long Long
CPCC
Pathology Gastroenterology
20 4
Inflammatory bowel disease
VOL.
8,NO. 2
sessions on clinical methodology were devoted to updating clinical skills and were, at times conducted in appropriate sites away from the lecture theatre. Regular clinico-pathological correlation clinics have been conducted by the Pathology Department. On other occasions the whole of the time was given over to a symposium or to a major review of a specific topic commissioned from a staff member. The organising committee has'also attempted to introduce topics of wider concern to physicians than internal medicine or medical science. Recent sessions or symposia on postgraduate medical education, peer review, homicide, sports medicine, the physician and the Aboriginal, hypnotherapy and biofeedback give some indication of the variety achieved. Particular success has been achieved with short sessions consisting of films of interesting or unusual clinical signs (mini-clinic) and clinical problems presented as multiple choice questions (physicians quiz). Reports from physicians who have attended national or international conferences were often sought. At the end of each year the final Workshop was devoted to a quiz in which questions were included from many topics covered during the year's programme. Results
The success of the programme must be judged on the degree to which it achieved its stated objectives. The first of these was attendance which can also be taken as a good index of satisfaction with the programme and of the stated expectation that physicians would reorder their priorities to allow them to attend the meetings. The attendance figures over the five year period, shown in Table 2, indicate that approximately 70 "g of physicians have attended over half of all meetings and 40-60'4 have attended over three quarters of all meetings. Average attendance has been 60-70 0,;. There has been no tendency for these attendance levels to drop. TABLE 2 Workshop attendance ( ",>)
Long Short Shorl
QUlL
Obesity
Dept of Medicine Cardiology Endocrinology
27 4
Long Long
Venereal diseases Cerebral lymphoma
VDCC Vlsltor
Over XI",, meetings
70
44
81
75
72
45 -
Symposium
Biofeedback
Psychiatry
Over 7 5 " , , meetings
60
28
55
42
43
Marrow transplants
1972 ~~~~~~
1973
1974
1975 .
~~~~~~
~~~~~
1976 ~~~~
APRIL
1978
The second major objective was active participation. The structure and format of the Workshop has ensured that some participation is unavoidable. Every physician was asked to personally present a session at least once a year either on a subject of his own choice or on a topic commissioned by the committee. Active participation by an audience is always hard to achieve but is believed to be essential for effectivelearning. Rigid enforcement of adequate discussion time following didactic presentations and effective chairmanship are vital. Efforts to enhance participation by altering the format of sessions have been variably successful. Surprisingly, small group discussion has not been universally successful but carefully conducted quiz sessions, unknown case presentations, clinical methodology sessions and the miniclinics have been both successful and enjoyed by participants. The programme has been formally assessed by using a yearly feedback questionnaire. On each occasion a response rate of over 90% has been achieved. Questions have been directed to ascertain the degree of satisfaction with the workshop as a whole and with individual sessions. Feedback has been sought on the innovations and suggestions for change have been solicited. Table 3 shows that a high degree of satisfaction has been retained. The gradual fall in the proportion of satisfied to undecided responses from 1972-1975 may be noted and it is clear that moves to improve the programme in 1976 have been successful. In 1972, 94";, agreed or strongly agreed that the Workshop was valuable and in 1976 the figure was 797" with 13"i undecided. It was the hope of the organising committee that the programme would fulfil a substantial continuing educational need, particularly in updating knowledge over a wide area. Table 4 shows that a high proportion of physicians
1972 ~
Satistied Undecided Diasatistied
193
EVALUATION OF THE PHYSICIANS WORKSHOP
1973
1974 .
~
I976
1975
~
~
72 I2
57
SO
IS
I6
28
21 29
~
36 4s
73 I2
Ih
IS
TABLE 4 The Workshop rates a high priority in my continuing education activities (",) Strongly agree
1974 1975 1976
7 17
38
Agree
59 52 38
Undecided
Strongly disagree
17
0 0
17
0
19 . A
A major advantage is exposure to information from other specialties 1973 197b
37 68
50 32
3 0
3 0
gave the Workshop a high priority in their continuing education activities and felt that their exposure to information from other specialties was a major advantage. It is this input that is less likely to be obtained from other sources and it may be the major motivating factor for participation in programmes such as the Workshop. The feedback questionnaire also sought information on the perceived value of individual presentations, session types and new or innovative educational methods. Physicians have been asked to rate these on a scale of one (poor) to six (excellent). Mean scores can be calculated but it is sometimes difficult to make clear judgements due to the wide standard deviations around the mean. As in any educational endeavour, individuals prefer different methods of learning and ratings may reflect this preference rather than the quality of the offering. However, ratings have been of value, particularly in assessing the response to innovative sessions. For example, series on the bases of medicine have consistently rated well over the five year period (range 4.2-5.2) as have clinical methodology sessions (4.2-4.8). Small group sessions (3.5) and clinico-pathological correlation clinics (3.4-4.0) have been less popular. The recently introduced miniclinics (4.8) and physicians quiz (4.6) have been well received. It must be added that a popularity rating does not necessarily correlate with the real educational value of the session but the committee is of the opinion that enjoyment is an important motivational factor and a pre-
194
NEWBLE
requisite for effective learning. It would therefore look for ways of improving the impact of a low rating session but would not discard it if it felt it could still be of value. An example of this would be small group sessions. These were discontinued in early years because of the poor response but it was felt that the unpopularity was more related to the topics chosen for discussion rather than to the method itself. Discussion
The physician has an unenviable task in attempting to retain his competence once he becomes a member of the College. This problem is particularly acute in the area of medical and scientific knowledge. It has been estimated that the half-life of medical knowledge is less than ten years and the increasing diversification into specialist and subspecialist practice makes it even more difficult to prevent this obsole ~ c e n c e .There ~ is, therefore, a growing need for methods which will help keep the physician in contact with changes in his own and other disciplines and also with changes in the needs of the community. Only a minority will have sufficient motivation to retain their competence at the highest level without assistance. The College has made major initiatives in this area with alterations in scientific meetings, with the establishment of an Advisory Committee on Continuing Education and, most importantly, with the appointment of a full time Director of Continuing Education to head the new Continuing Education Centre. The initiatives of such a central organisation will need to be complemented by initiatives at a local hospital level as well as by the more effective use of individual study and selfassessment. The development of the Physicians Workshop provides a model which could prove suitable for implementation in other hospitals. It has received favourable comment from several leading overseas medical educators and may be unique in its objectives and success. The
VOL.
8, NO. 2
maintenance of a high level of attendance and participation over a five year period can be regarded as a distinct success. The essential ingredients of this success were thought to be the design of a programme specifically for practising physicians, the agreement of all physicians to attend and support the aims of the programme, the quality of presentations, the variety of format, particularly with regard to ensuring active participation, and the flexibility of the planning. At a time when the concepts of quality assurance and peer review, either by self-regulation or by external control, are frequently discussed it is important to assess the value of current continuing educational activities. It might have been noted that the objectives of the Workshop did not include a reference to improving patient care, the ultimate criterion on which to judge the success of continuing education in assuring quality of patient care. It has, however, usually been assumed that an updating of knowledge and skills is a prerequisite to the maintenance of standards. A successful Workshop, such as the one described, does provide an opportunity for the development of more formal peer review activities, activities which could then be clearly related to an attractive educational programme and consequently less threatening to individual physicians.
Acknowledgements
The author wishes to thank all members of the organising committee and the physicians of the Queen Elizabeth Hospital who have participated in the Workshop and have regularly completed the assessment questionnaires.
References I . NEWBLE, D. I., KERRGRANT, A., SAGE,R. E. and BURSTON, R. A. (1973):An experiment in continuingeducation for physicians,Aust. N.Z. J. Med. 3,512. 2. WILSON,D. (1 976): Report to the Royal Australasian College of Physicianson continuing medical education. 3. HUNTER, .I. D., GOULSTON, K. and NEWBLE, D. I. (1973):Report oncontinuing education and re-evaluation of physicians, Royal Australasian College of Physicians. 4. CARMICHAEL, H. (1970): In Congress in Medical Education, Council on Medical Education, AMA, Chicago.
