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Perceived need and barriers to continuing professional development among doctors Divine Ikenwilo ∗ , Diane Skåtun Health Economics Research Unit, University of Aberdeen Scotland, United Kingdom
a r t i c l e
i n f o
Article history: Received 29 January 2014 Received in revised form 1 April 2014 Accepted 9 April 2014
Keywords: Scotland National Health Service Continuing professional development Revalidation Consultant Specialty and associate specialist
a b s t r a c t There is growing need for continuing professional development (CPD) among doctors, especially following the recent introduction of compulsory revalidation for all doctors in the United Kingdom (UK). We use unique datasets from two national surveys of non-training grade doctors working in the National Health Service in Scotland to evaluate doctors’ perceptions of need and barriers to CPD. We test for differences over time and also examine differences between doctor grades and for other characteristics such as gender, age, contract type and specialty. Doctors expressed the greatest need for CPD in clinical training, management, and information technology. In terms of perceived barriers to CPD, lack of time was expressed as a barrier by the largest proportion of doctors, as was insufficient clinical cover, lack of funding, and remoteness from main education centres. The strength of perceived need for particular CPD activities and the perceived barriers to CPD varied significantly by doctors’ job and personal characteristics. An understanding of the perceived needs and barriers to CPD among doctors is an important precursor to developing effective educational and training programmes that cover their professional practice and also in supporting doctors towards successful revalidation. © 2014 Published by Elsevier Ireland Ltd.
1. Introduction The importance of continuing professional development (CPD) among doctors is well recognised by medical regulatory bodies and medical associations. The United Kingdom (UK) regulatory body, the General Medical Council (GMC), states as part of its good medical practice guidance that doctors must keep their “professional knowledge and skills up to date” and “regularly take part in activities that maintain and develop competence
∗ Corresponding author at: Health Economics Research Unit, University of Aberdeen, Aberdeen AB25 2ZD, Aberdeenshire, Scotland, United Kingdom. Tel.: +44 0 1224 437178. E-mail address: [email protected] (D. Ikenwilo).
and performance”. This reflects the role of CPD in maintaining or improving physician performance and ultimately improving patient outcomes (for a review of the effects of CPD see Bloom [1]). In the United States for instance, the vast majority of State regulatory medical boards require a set number of continuing medical education credits per year as a requirement of licensure renewal. The American Board of Medical Specialities (ABMS) also provides a voluntary system where physicians can demonstrate competency within a speciality area. The Maintenance of Certification (MOC) programme includes a “Lifelong Learning and Self-Assessment” process. This outlines specialty specific continuing medical education recertification requirements. In Canada, the Royal College of Physicians and Surgeons lead the standards for specialty post-graduate medical education. Their Maintenance
http://dx.doi.org/10.1016/j.healthpol.2014.04.006 0168-8510/© 2014 Published by Elsevier Ireland Ltd.
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of Competency (MOC) programme is a mandatory programme of continuing professional development for its members which sets out minimum number of CPD activity credits within a 5-year cycle. The College of Family Physicians of Canada offer a similar membership scheme with evidence of CPD a requirement. The Medical Council of New Zealand is the body charged with registering doctors and include CPD as part of their requirements for renewal or recertification of the practicing certificate. The Medical Board of Australia also require participation in CPD for registration renewal. In the U.K. compulsory revalidation for all doctors has been recently introduced (renewable every five years) as further assurance to patients and the general public that doctors are “up to date and fit to practice”.1 Within this new revalidation framework, CPD is one key type of supporting information used to demonstrate how doctors are maintaining good practice, and where CPD is not only concerned with the updating of clinical knowledge but the need to maintain competence across the whole range of behaviours including management, research and teaching activities. With the importance of CPD as a means to achieve better patient outcomes and as a practical requirement for licensing or revalidation there also exists a growing body of literature looking at perceived barriers to continuing medical education [2–6]. Researchers identify several key barriers to professional development, which can generally be grouped in terms of organisational, logistic and funding issues. Commonly perceived barriers to CPD have included lack of time, funding or motivation, or lack of access either due to the paucity or unavailability of CPD opportunities or insufficient organisational support for CPD (e.g. through sufficient clinical cover). Most researchers have however concentrated on reporting perceived barriers to CPD, without necessarily reporting what the (level of) perceived need for CPD are. There are exceptions but these studies are generally based on small samples [6]. It should be noted that the concentration on doctors’ perception of their needs and barriers to CPD assumes that doctors are able to accurately identify or self-assess their own CPD needs. The “unskilled and unaware of it” phenomenon, as outlined albeit in a non-medical setting [7], suggests that subjects who were unskilled in an area, tended to overestimate their own ability, make errors and then do not have the ability to recognise these failings. Within the medical area there has been research that considers clinicians and medical students self-assessment abilities [8,9] with a review of the accuracy of physician self-assessment concluding physicians have only a limited ability for accurate self-assessment [10]. Whether CPD needs may be identified by individuals’ own assessment or set to some extent as mandatory requirements, it is important to document this need from the perspective of doctors, not only as a planning tool, but also as a reference guide for other (especially new or younger) doctors.
1
Revalidation is set out in line with the Good Medical Practice Guide, which is available through the following link www.gmc-uk.org/ GMP-framework for appraisal and revalidation.pdf 41326960.pdf.
The objective of this paper is to analyse perceived need and barriers to CPD among doctors as a way of providing information necessary to support doctors towards successful revalidation newly introduced in the UK. We test for differences between doctor grades and also consider differences in other characteristics such as gender, age, contract type and specialty. Such information (on need and barriers to CPD) is not routinely collected or published by secondary data sources for the U.K., hence this analysis is expected to help advice policy makers and practitioners about identifying and dealing with potential barriers to CPD among doctors, especially following to the roll out of compulsory revalidation in the UK. 2. Methods 2.1. Sample Data for this analysis were obtained from two national postal surveys of non-training grade doctors working in NHS Scotland in the periods 2005/06 and 2011/12. Both surveys gathered a wealth of information relating to working conditions including specific questions relating to continuing professional development. Data are available for two types of doctors; specialty and associate specialist (SAS) doctors and consultants. Consultants are senior physicians who have completed all relevant specialist training and are entered on a specialist register. SAS doctors include staff grade, speciality doctors and associate specialists and are fully qualified but non-consultant grade doctors and as such are not entered on a specialist register. Response rates from these surveys were 60% and 39% for specialty doctors and 56% and 41% for consultants in 2005/06 and 2011/12 respectively. Although there were overall lower response rates from the second surveys, the samples were generally representative of the population of doctors working in NHS Scotland in terms of age and gender. More details about the surveys including the representativeness of the samples are reported elsewhere [11].2 Within both surveys, one set of questions asked doctors to state the areas they felt they needed (further) education/training. Another set of questions sought to assess the factors that restrict doctors’ participation in CPD activities. Doctors were presented with a wide range of training areas as well as various factors that could potentially restrict their participation in CPD activities. The training areas map well to the areas outlined in the GMC good medical practice guidance which form the basis of the appraisal and revalidation process within the U.K. The guidance sets out how clinicians should be meeting their professional values where, along with the need to maintain and develop good clinical practice, the requirement to be competent in all aspects of work including management and teaching and the need to be able to communicate effectively are also referred to. The inclusion of the general area of
2 See the following link for details about the 2011/2012 survey http://www.aomrc.org.uk/publications/reports-a-guidance/doc details/ 9507-the-impact-of-revalidation-on-the-clinical-and-non-clinicalactivity-of-hospital-doctors.html.
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Table 1 Specific areas of perceptions of need and barriers to CPD among doctors. Perceived CPD need
Perceived CPD barriers
Clinical Management Communication Teaching Time Management Information Technology (IT)
Lack of time Insufficient clinical cover Insufficient study leave Lack of funding Lack of good quality CPD activities Information overload Remoteness from main education centres Lack of motivation Fatigue
information technology reflects the continuing increase in the use of electronic tools to support clinicians in the preparation for revalidation and appraisals. A summary of these need and barrier factors questions are presented in Table 1. For each need factor, respondents were asked to tick one of four response options, depending on whether they strongly agreed, agreed, disagreed or strongly disagreed with requiring the specific CPD. In addition, doctors were invited to state whether they strongly agreed, agreed, disagreed or strongly disagreed with each of the CPD barriers presented. For analysis, the survey responses were transformed into two categories, one for agreement (‘strongly agree’ and ‘agree’) and another for disagreement (‘strongly disagree’ and ‘disagree’) with specific needs and barriers to CPD presented in the questionnaires and summarised in Table 1. We first consider doctors views on how perceived CPD need and barriers to CPD have changed between the two survey dates using a simple two sample proportions test. We then test for differences in perceived need and barriers to CPD between SAS doctors and consultants using multiple regression analysis to control for differences in other characteristics such as gender, age, contract type and specialty for the more recent 2011 sample. To do this, we recognise the possibility that doctors may perceive a need for more than one CPD activity. For example, a doctor may perceive a need for clinical training as well as IT training, while another doctor may perceive the need for all six CPD training activities elicited. In a similar way, a doctor may perceive more than one barrier to CPD. 2.2. Estimation technique We estimate the following multivariate probit model [12] of probabilities that doctors would like further training in one or more of the CPD activities elicited (m). CPDneedim ∗ = ˇm Xim + εim , m = 1, . . ., 6
CPDneedim = 1 if CPDneedim * >0 and 0 otherwiseεim , m = 1, . . ., 6 are error terms distributed as multivariate normal, each with a mean of zero and variance-covariance matrix V, where V has values of 1 on the leading diagonal and correlations jk = kj as off-diagonal elements. The X’s represent a vector of explanatory variables that define differences between doctors, age, gender, contract type and specialty group. For simplicity, we include the same set of explanatory variables in all
3
Table 2 Summary characteristics of sample of doctors in NHS Scotland. n Consultants Male Full time Age group ≤40 41–45 46–50 51–55 Over 55 Specialty group Medicine Surgery Psychiatry Anaesthetics Others Specialty doctors Male Full time Age group ≤40 41–45 46–50 51–55 Over 55 Specialty group Medicine Surgery Psychiatry Anaesthetics Others
1861 1803 1920
2005/06 %
n
2011/12 %
70.18 87.63
1690 1717
64.62 80.20
16.88 22.50 21.72 17.50 21.40
1716 1716 1716 1716 1716
19.23 22.26 22.03 19.99 16.49
26.41 16.96 13.83 17.43 25.37
1718 1718 1718 1718 1718
19.97 18.22 12.51 12.28 37.02
28.51 52.27
374 322
32.89 48.14
17.72 18.35 18.14 22.36 23.42
374 374 374 374 374
22.73 17.38 21.12 16.84 21.93
23.89 12.68 16.91 8.03 38.48
370 370 370 370 370
20.81 10.81 13.78 4.86 49.73
1916
456 463 474
473
six equations. The model is then analysed using the Geweke–Hajivassiliou–Keane (GHK) smooth recursive conditioning simulator to estimate the maximum likelihood of the mvprobit model. We also employ the mvprobit model to evaluate differences (if any) that may exist between doctors in their perceptions of barrier to CPD. In other words, CPDbarriersim ∗ = ˇm Xim + εim , m = 1, . . ., 9
The sample characteristics are presented in Table 2 and show a total sample of 848 specialty doctors and 3636 consultants over the two time periods (2005/06 and 2011/12). The proportion of male SAS doctors increased by 4 percentage points, while there was an almost 6 percentage points reduction in the proportion of male consultants over the two surveys. There were general reductions in the proportion of full time doctors from both grades, more so among consultants. The most represented specialty group (for all doctor grades) was medicine (the ‘others’ category is made up of specialties such as accident and emergency, gynaecology, paediatrics, for which the sample of respondents were too small to be analysed as separate categories). All analyses were performed in Stata 12. 3. Results 3.1. Comparison over time Doctors expressed the most perceived need for further education and training in clinical areas in both survey years, as shown in Table 3. A total of 71% of SAS doctors perceived
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4 Table 3 NHS Scotland doctors’ perceived CPD needs. 2006
2011
n Consultant Clinical Management Communication Teaching Time management IT SAS Clinical Management Communication Teaching Time management IT * **
Proportion
n
Change Proportion
1856 1847 1825 1831 1832 1558
66.06% 64.86% 30.25% 51.56% 47.60% 63.48%
1614 1598 1553 1564 1573 1312
68.90% 63.77% 29.81% 52.24% 41.83% 59.45%
2.84* −1.09 −0.43 0.68 −5.77** −4.03**
450 447 437 437 443 365
71.33% 64.88% 29.29% 61.78% 48.76% 70.96%
333 305 291 288 305 234
80.48% 64.26% 36.77% 59.38% 53.44% 67.52%
9.15** −0.61 7.48** −2.41 4.68 −3.44
Two sample proportion test significance at 10%. Two sample proportion test significance at 1%.
a need for clinical training in 2006 compared 66% of consultants with corresponding figures of 69% and 80% in 2011. Agreement with the need for further education and training in management and IT are the next highest proportions in both years for consultants and SAS doctors where generally over 60% of respondents indicated that further education and training were needed in these areas. The need for further training in communication was clearly the least desired among both doctor grades, both in 2006 and in 2011, with proportions of respondents indicating a need for further training ranging between only 29% and 40%. In terms of changes in perceived CPD training need over time, the largest significant increase (at the 1% level) among SAS doctors was for clinical training where the proportion increased by 9 percentage points compared to less than 3 percentage points increase for consultants although this was still significant at the 10% level. There was also
a significant reduction in those consultants desiring training in time management and IT. For SAS doctors the only other significant change was an increased agreement on the need for CPD in communication. However even after this increase, the proportion of SAS doctors agreeing that there was further need for education and training within this area still remained the smallest of all areas in 2011. The most perceived barrier to CPD was lack of time, both among SAS doctors and among consultants and in each year of survey (Table 4). Indeed the position as the most perceived barrier for consultants was strengthened with the largest increase between 2006 and 2011 of 7 percentage points. The second highest proportion related to insufficient clinical cover as a perceived barrier to CPD, again for both doctor groups, with this barrier exhibiting the largest increase for SAS doctors of over 11 percentage points. There were also other significant increases (over time) in the
Table 4 NHS Scotland doctors’ perceived barriers to CPD. 2006 n Consultants Lack of time Insufficient clinical cover Insufficient study leave Lack of funding Lack of good quality CPD Information overload Remoteness Lack of motivation Fatigue SAS Lack of time Insufficient clinical cover Insufficient study leave Lack of funding Lack of good quality CPD Information overload Remoteness Lack of motivation Fatigue * **
2011 Mean
N
Change Mean
1865 1839 1824 1832 1817 1802 1812 1811 1689
79.36% 60.96% 25.44% 41.38% 27.63% 39.79% 30.02% 14.80% 33.98%
1668 1610 1552 1589 1563 1561 1589 1569 1482
86.81% 63.66% 20.81% 47.51% 30.33% 38.69% 36.63% 18.48% 33.87%
7.45* 2.71 −4.63* 6.14* 2.70** −1.10 6.60* 3.68* −0.11
445 443 436 443 436 417 436 430 399
72.81% 51.92% 25.46% 40.63% 42.66% 22.54% 45.41% 22.09% 30.33%
340 321 296 311 306 292 318 302 274
84.12% 67.29% 30.41% 50.48% 44.77% 30.82% 45.91% 20.20% 31.39%
11.31* 15.37* 4.95 9.85* 2.11 8.28* 0.50 −1.89 1.06
Two sample proportion test significance at 10%. Two sample proportion test significance at 1%.
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proportion of doctors perceiving different types of CPD barriers. For example among consultants, there were increased perceptions of remoteness from main education centres and also of lack of funding. Among SAS doctors, there were significant increased perceptions of lack of funding and information overload. Consultants indicated a significant reduction in the proportions perceiving insufficient study leave as a barrier to CPD. Lack of motivation was the least likely barrier to restrict participation in CPD activities for both doctor groups in both years of survey. 3.2. Model results of differences in perceived need and barriers to CPD We now consider where variations arise in the perceptions of need and barriers to CPD using multivariate probit regression methods. We investigate differences between SAS doctors and consultants and for other characteristics such as gender, age, contract type and specialty for the more recent 2011 sample. The full results are provided in Appendix A with significant characteristics summarised in Table 5. 3.2.1. Doctor grade Consultants were significantly less likely to perceive the need for CPD in clinical training and education, compared to SAS doctors (Table 5). There is some evidence that consultants were also less likely to perceive the need for further education and training in the areas of teaching and time management (significant at the 10% level) compared with SAS doctors. Consultants were significantly less likely to perceive insufficient study leave or the lack of good quality CPD as a barrier to further education and training compared to SAS doctors. There was also some weak evidence (10% level) that consultants were less likely to perceive the lack Table 5 A summary of statistically significant differences in perceived need and barriers to CPD among doctors in NHS Scotland (full model results are available as Appendix A, Tables 6 and 7). Perceived CPD need Clinical
Management Communication Teaching Time management IT Perceived CPD barriers Lack of time Insufficient clinical cover Insufficient study leave Lack of funding Lack of good quality CPD Information overload Remoteness Lack of motivation Fatigue
Positive effects Age 51–55, medicine, psychiatry Full time, age ≤50 Age 41–45 Age ≤55 Age ≤50
Negative effects Consultant
Age ≤55, medicine Full time, age ≤40, medicine Full time, age ≤40
Male, anaesthetics Consultant, psychiatry Consultant, anaesthetics, psychiatry Anaesthetics Consultant
Surgery
Anaesthetics Consultant Consultant Male, age ≤40
Consultant, male
Age ≤40
Anaesthetics Anaesthetics
Male, medicine Age ≤40
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of clinical cover and more likely to perceive information overload as barriers to CPD than their SAS counterparts. 3.2.2. Gender There was little evidence of differences across gender in the perceived need for CPD apart from in IT where male doctors were significantly less likely to report perceived need for further training. However there were some significant gender differences in perceived barriers to CPD where males were significantly less likely to perceive a lack of time or remoteness from a main education centre as a barrier to their professional development compared to female doctors but were significantly more likely to agree that information overload restricted their participation in CPD activities. 3.2.3. Contract type There was little evidence of differences in perception of the need for CPD between fulltime and part-time doctors with only weak evidence at the 10% level that full-time doctors were more likely to perceive a need for further training in management. In terms of perceived barriers to CPD, full-time doctors were significantly more likely to see the lack of clinical cover as a barrier to their further education and training than their part-time counterparts. There was some evidence (at the 10% level) that full-time doctors were more likely to indicate that insufficient study leave restricted their participation in CPD activities compared to part-time doctors. 3.2.4. Age groups There were a number of significant age group differences in perceptions of CPD need. Compared to doctors aged over 55 years, doctors in the 51–55 age group were associated with a significant additional perceived need for further education and training in the clinical area. Doctors aged up to 50 indicated significantly higher perceived need for CPD in the areas of management and time management compared to those over the age of 55 years. Doctors up to age of 55 years indicated a higher need for CPD in teaching compared to those over 55 years. Finally the youngest group of doctors indicated a significantly smaller need for CPD (at the 10% level) for further education and training in IT. Doctors aged up to 55 years indicated that a lack of time posed a significant restriction on their participation in CPD activities compared to colleagues aged over 55 years. There was evidence that the youngest group of doctors felt that a lack of study leave significantly restricted their participation in CPD but were significantly less likely than their older colleagues to see a lack of motivation impacting on their CPD activities. There was also weak evidence (at the 10% level) that this youngest age group’s lack of clinical cover significantly restricted their participation in CPD, but they were less likely than their older colleagues to see information overload restricting their CPD activities. 3.2.5. Specialty There was little evidence of significant differences in perception of CPD need across the specialty groups with only weak evidence at the 10% level that doctors within
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the medicine or psychiatry specialties were more likely to perceive a need for clinical CPD. Similarly there was only weak evidence that anaesthetists were associated with a reduced perception of the need for further management training. In terms of perceived CPD barriers, there were significant variations across specialty groups over a wide variety of perceived barriers to professional development. Anaesthetists were significantly less likely to indicate that lack of time, study leave or funding restricted their participation in CPD but more likely to indicate that remoteness to main education centres or lack of motivations were barriers to CPD activities than the non-specified “other” specialty group, made up of specialties such as accident and emergency, paediatrics, gynaecology, etc. Doctors within the medical specialty were significantly more likely to indicate a lack of time and lack of clinical cover as barriers to CPD activity but less likely to indicate that remoteness from a main education centre was a barrier. Doctors within the surgical specialty were significantly more likely to indicate a lack of funding restricted their participation in CPD activities than those in the unspecified group of specialties. Finally those within psychiatry were significantly less likely to indicate insufficient clinical cover or study leave as restricting their CPD activity. 4. Conclusions This is the first paper to evaluate both doctors’ perceived need and barriers to CPD within the same context in Scotland. Such analysis, also comparing differences between specialty doctors and consultants, male and female doctors, age and specialty groups, as well as differences over time, is an important precursor to developing effective educational and training programmes in supporting doctors to remain up-to-date especially with the introduction of compulsory revalidation for all UK doctors. The most expressed CPD need was for clinical training, while lack of time was the most reported barrier to CPD among all doctors. Our results mirror some other findings in the literature on barriers to CPD. For example, our results showing lack of time as the most identified barrier to CPD (by 81.24% of all doctors) is similar to 85% reported among hospitalbased prevocational doctors in Australia [3]. In addition, Price et al. [13] also find that the most frequently reported barrier to implementing learning, among a group of health care professionals in Colorado, was lack of time (26% of all responses). In terms of policy, especially as it relates to the roll out of revalidation in the UK and other issues with appraisals and CPD, the results of this paper highlight the need to consider these differences in perceived need and barriers to CPD when formulating policy. The perceived barriers could help in designing CPD activities, especially in ensuring adequate funding for doctors, the provision of good quality CPD activities and instituting flexible working practices to allow doctors time to engage and participate in available CPD activities. CPD planners should be aware that, with lack of time being the largest perceived barrier for both consultants and SAS doctors, CPD activities should be organised as efficiently as possible to make the best use of the time
available. CPD planners should also ensure that time within doctors job plans that is identified for activities such as CPD are protected. Doctors within the UK currently have job plans which identify blocks of activity relating to direct clinical care time and other activities such as supporting professional activities (SPAs) which includes CPD activities. The results suggest that it is vital that time allocated within the contract for these supporting professional activities is maintained and protected. The consultant contract within the UK specifies a 75:25 split between direct clinical care and SPA time. However there is increasing pressure for newly appointed consultants to accept job plans with a 90:10 split representing a reduction in time for SPA and CPD activities. In addition SAS doctors have no specific proportion of their time within their job plans allocated to supporting professional activities. CPD planners need to monitor and support doctors in finding protected time for their activities. Our results suggest that while on aggregate there is a clear message that there is a perceived need for further education and training in clinical areas with lack of time a clear restriction on participation in CPD activities, that there are also significant differences across doctor grades and characteristics of doctors. This finding supports the GMC stand that CPD activities should be shaped by assessment of specific professional needs and the needs of the service and the people who use it. Consequently, this means that one size does certainly not fit all, and these differences should be taken into account when rolling out revalidation. While there is no reason as to question the respondents’ ability to assess the barriers to CPD, the perceptions of CPD need are tempered by the findings in the literature that physicians have a limited ability to correctly self-assess and self-direct their continuing professional development needs. This may be reflected by the fact that some countries operate a more prescriptive requirement of a minimum number of hours of CPD activity or where specific CPD courses by specialty are required for continued medical registration. In the UK there is no such prescriptive requirement on CPD activity as part of the revalidation framework. If self-assessment is indeed limited in its ability to identify CPD needs, this suggests that CPD planners within the UK should evaluate through independent assessment the areas in which to encourage CPD. This analysis is not without its limitations. Firstly, despite a real possibility of repeat respondents over the two surveys, we were unable to determine these due to the anonymity of the datasets used. There is also a possibility of bias in that those doctors with specific CPD needs were more likely to respond to the questions and to provide strong views about CPD, hence our findings may reflect these rather than the general views. Funding We would like to acknowledge the support of the Pay Modernisation Team at the former Scottish Executive Health Department who funded the 2005/06 survey, and the UK Academy of Medical Royal Colleges and Faculties who funded the 2011/12 survey.HERU is supported by the Chief Scientist Office (CSO) at the Scottish
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Government Health and Social Care Directorate. All views are of the authors alone. Acknowledgements We would like to thank all the doctors who responded to the surveys and all temporary staff who helped in managing the questionnaires and entering the data. Special thanks also go to Ms Fiona French and Professor Gillian Needham (NHS Education for Scotland) who were part of the research teams for both surveys and all others involved with either the first or second survey. Appendix A. See Tables 6 and 7. Table 6 mvprobit model differences in perceived CPD need among doctors. CPD Need Clinical Doctor grade (consultant) Male Full time age≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons Management Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons Communication Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons Teaching Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine
Coefficient
Std. error
P > |z|
−0.334** −0.041 −0.162 0.074 0.183 0.187 0.368** 0.192 0.197* 0.060 0.238* 0.664**
0.123 0.086 0.100 0.121 0.122 0.125 0.127 0.123 0.102 0.112 0.125 0.151
0.007 0.632 0.104 0.543 0.134 0.136 0.004 0.120 0.054 0.593 0.058 0.000
0.155 −0.080 0.165* 1.213** 0.954** 0.670** 0.180 −0.232* −0.048 −0.057 0.004 −0.520**
0.115 0.086 0.097 0.127 0.124 0.124 0.123 0.123 0.102 0.114 0.123 0.145
0.177 0.357 0.089 0.000 0.000 0.000 0.144 0.060 0.640 0.618 0.973 0.000
−0.165 0.045 −0.073 0.182 0.247* 0.018 −0.070 0.124 0.102 −0.111 −0.119 −0.537**
0.115 0.088 0.099 0.127 0.126 0.131 0.132 0.124 0.102 0.117 0.127 0.148
0.153 0.608 0.460 0.150 0.050 0.892 0.598 0.320 0.318 0.343 0.348 0.000
−0.220* −0.087 0.120 0.582** 0.462** 0.356** 0.285* 0.132 −0.054
0.113 0.083 0.094 0.120 0.120 0.122 0.122 0.118 0.098
0.051 0.291 0.202 0.000 0.000 0.004 0.019 0.264 0.583
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Table 6 (Continued ) CPD Need Surgery Psychiatry cons Time management Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons It Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons Sample Wald Chi2 (prob > chi2 ) Log likelihood LR test of Rho’s (prob) * **
Std. error
P > |z|
0.048 0.189 −0.155
0.109 0.118 0.142
0.658 0.111 0.275
−0.188* −0.070 0.014 0.220* 0.342** 0.278* 0.200 −0.023 −0.057 −0.145 −0.110 −0.326*
0.111 0.084 0.095 0.123 0.123 0.125 0.126 0.120 0.098 0.112 0.119 0.143
0.091 0.401 0.880 0.074 0.005 0.027 0.110 0.845 0.562 0.195 0.356 0.023
−0.080 −0.329** 0.039 −0.232* −0.194 −0.176 −0.071 0.082 −0.121 0.081 0.035 0.604** 1251.00 270.11** −4450.38 568.72**
0.113 0.084 0.095 0.120 0.121 0.123 0.122 0.120 0.097 0.109 0.119 0.144
0.480 0.000 0.680 0.052 0.107 0.151 0.564 0.493 0.212 0.460 0.768 0.000
Coefficient
˛ < 0.10. ˛ < 0.01.
Table 7 mvprobit model results of differences in perceived CPD barriers among doctors. CPD barriers Lack of time Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons Insufficient clinical cover Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons Insufficient study leave Doctor grade (consultant)
Coefficient
Std. Error
P > |z|
0.141 −0.277** 0.043 0.436** 0.586** 0.409** 0.223* −0.539** 0.334** 0.133 −0.058 0.761**
0.130 0.103 0.114 0.137 0.141 0.135 0.135 0.129 0.127 0.129 0.132 0.159
0.280 0.007 0.706 0.001 0.000 0.002 0.099 0.000 0.008 0.302 0.662 0.000
−0.195* −0.086 0.216* 0.225* 0.175 0.187 0.052 −0.064 0.308** 0.032 −0.285** 0.228*
0.109 0.081 0.091 0.117 0.117 0.117 0.120 0.117 0.097 0.103 0.108 0.137
0.073 0.287 0.017 0.056 0.133 0.110 0.665 0.586 0.001 0.758 0.008 0.096
−0.304**
0.115
0.008
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Table 7 (Continued )
Table 7 (Continued ) CPD barriers
Coefficient
Male 0.080 Full time 0.174* Age ≤40 0.285* Age 41–45 0.063 Age 46–50 −0.061 Age 51–55 0.088 Anaesthetics −0.379** Medicine −0.095 Surgery 0.083 Psychiatry −0.312* cons −0.793** Lack of funding Doctor grade (consultant) −0.055 Male −0.008 Full time 0.068 Age ≤40 0.080 Age 41–45 0.053 Age 46–50 −0.050 Age 51–55 0.005 Anaesthetics −0.402** −0.015 Medicine Surgery 0.255* Psychiatry 0.154 cons −0.130 Lack of good quality CPD activities −0.377** Doctor grade (consultant) 0.098 Male 0.014 Full time 0.055 Age ≤40 0.075 Age 41–45 Age 46–50 0.011 Age 51–55 0.070 Anaesthetics 0.186 Medicine −0.146 0.123 Surgery Psychiatry 0.030 cons −0.331* Information overload 0.207* Doctor grade (consultant) Male 0.206* Full time −0.077 Age ≤40 −0.218* Age 41–45 −0.187 0.073 Age 46–50 0.060 Age 51–55 0.179 Anaesthetics −0.044 Medicine Surgery 0.044 −0.131 Psychiatry cons −0.548** Remoteness from main education centres −0.163 Doctor grade (consultant) Male −0.210** −0.114 Full time 0.097 Age≤40 0.137 Age 41–45 0.129 Age 46–50 −0.049 Age 51–55 0.298* Anaesthetics −0.200* Medicine 0.023 Surgery 0.069 Psychiatry cons −0.083 Lack of motivation −0.143 Doctor grade (consultant) 0.128 Male −0.022 Full time −0.282* Age ≤40 −0.089 Age 41–45 −0.067 Age 46–50 −0.174 Age 51–55
Std. Error
P > |z|
CPD barriers
0.090 0.105 0.131 0.134 0.136 0.138 0.145 0.105 0.112 0.131 0.153
0.371 0.096 0.030 0.641 0.657 0.523 0.009 0.364 0.458 0.017 0.000
0.104 0.079 0.089 0.116 0.115 0.116 0.119 0.119 0.092 0.102 0.107 0.134
0.596 0.917 0.444 0.490 0.647 0.663 0.969 0.001 0.875 0.012 0.150 0.332
Anaesthetics Medicine Surgery Psychiatry cons Fatigue Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons sample Wald Chi2 (prob > chi2 ) Log likelihood LR test of Rho’s (prob)
0.106 0.083 0.094 0.122 0.121 0.121 0.124 0.119 0.099 0.106 0.114 0.138
0.000 0.238 0.885 0.651 0.532 0.926 0.575 0.119 0.139 0.245 0.795 0.017
0.111 0.081 0.092 0.118 0.117 0.116 0.120 0.115 0.095 0.104 0.113 0.139
0.061 0.011 0.402 0.066 0.110 0.531 0.615 0.121 0.642 0.668 0.247 0.000
0.105 0.081 0.090 0.119 0.119 0.119 0.124 0.116 0.097 0.105 0.110 0.137
0.122 0.009 0.206 0.415 0.248 0.275 0.694 0.010 0.038 0.825 0.534 0.544
0.124 0.095 0.106 0.137 0.132 0.131 0.137
0.248 0.175 0.837 0.039 0.499 0.608 0.203
* **
Std. Error
P > |z|
0.260* −0.067 0.156 −0.042 −0.832**
0.131 0.112 0.117 0.132 0.153
0.047 0.547 0.183 0.753 0.000
0.070 −0.087 0.099 0.086 0.166 0.197 0.165 −0.173 −0.064 0.037 −0.187 −0.638** 1391 281.01** 6719.33 857.90**
0.110 0.081 0.092 0.121 0.120 0.120 0.123 0.120 0.095 0.103 0.114 0.140
0.523 0.282 0.283 0.475 0.167 0.101 0.181 0.152 0.500 0.719 0.101 0.000
Coefficient
˛ < 0.10. ˛ < 0.01.
References [1] Bloom BS. Effects of continuing medical education on improving physician clinical care and patient health: a review of systematic reviews. International Journal of Technology Assessment in Health Care 2005;21:380–5. [2] Dolcourt JL, Zuckerman G, Warner K. Learners’ decisions for attending Paediatric Grand Rounds: a qualitative and quantitative study. BMC Medical Education 2006;6:1–8. [3] Glazebrook RM, Harrison SL. Obstacles and solutions to maintenance of advanced procedural skills for rural and remote medical practitioners in Australia. Rural Remote Health 2006;6:1–14. [4] Neate SL, Dent AW, Weiland TJ, Farish S, Jolly BC, Crotty B. Barriers to continuing medical education in Australian prevocational doctors. Australian Health Review 2008;32:292–300. [5] Savoldelli GL, Naik VN, Hamstra SJ, Morgan PJ. Barriers to use of simulation-based education. Canadian Journal of Anaesthetics 2005;52:944–50. [6] Younies H, Berham B, Smith PC. Perceptions of continuing medical education, professional development, and organisational support in the United Arab Emirates. Journal of Continuing Education in the Health Professions 2010;30:251–6. [7] Kruger J, Dunning D. Unskilled and unaware of it: How difficulties in recognizing one’s own incompetence lead to inflated self-assessments. Journal of Personality and Social Psychology 1999;77:1121–34. [8] Eva KW, Regehr G. I’ll never play professional football and other fallacies of self-assessment. Journal of Continuing Education in the Health Professions 2008;28:14–9. [9] Eva KW, Cunnington JP, Reiter HI, Keane DR, Norman GR. How can I know what I don’t know? Poor self assessment in a well-defined domain. Advances in Health Sciences Education Theory and Practice 2004;9:211–24. [10] Davis DA, Mazmanian PE, Fordis M, Van Harrison RR, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. JAMA 2006;296:1094–102. [11] French F, Geue C, Ikenwilo D, Needham G, Rooke C, Skåtun D, et al. Second national survey of consultants in NHS Scotland: responses to individual questions and comparisons with first survey. Resource Document for the Scottish Executive Health Department, January; 2007. [12] Cappellari L, Jenkins SP. Multivariate probit regression using simulated maximum likelihood. Stata Journal 2003;3:278–94. [13] Price DW, Mille EK, Rahm AK, Brace NE, Larson RS. Assessment of barriers to changing practice as CME outcomes. Journal of Continuing Education in the Health Professions 2010;30:237–45.
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Perceived need and barriers to continuing professional development among doctors Divine Ikenwilo ∗ , Diane Skåtun Health Economics Research Unit, University of Aberdeen Scotland, United Kingdom
a r t i c l e
i n f o
Article history: Received 29 January 2014 Received in revised form 1 April 2014 Accepted 9 April 2014
Keywords: Scotland National Health Service Continuing professional development Revalidation Consultant Specialty and associate specialist
a b s t r a c t There is growing need for continuing professional development (CPD) among doctors, especially following the recent introduction of compulsory revalidation for all doctors in the United Kingdom (UK). We use unique datasets from two national surveys of non-training grade doctors working in the National Health Service in Scotland to evaluate doctors’ perceptions of need and barriers to CPD. We test for differences over time and also examine differences between doctor grades and for other characteristics such as gender, age, contract type and specialty. Doctors expressed the greatest need for CPD in clinical training, management, and information technology. In terms of perceived barriers to CPD, lack of time was expressed as a barrier by the largest proportion of doctors, as was insufficient clinical cover, lack of funding, and remoteness from main education centres. The strength of perceived need for particular CPD activities and the perceived barriers to CPD varied significantly by doctors’ job and personal characteristics. An understanding of the perceived needs and barriers to CPD among doctors is an important precursor to developing effective educational and training programmes that cover their professional practice and also in supporting doctors towards successful revalidation. © 2014 Published by Elsevier Ireland Ltd.
1. Introduction The importance of continuing professional development (CPD) among doctors is well recognised by medical regulatory bodies and medical associations. The United Kingdom (UK) regulatory body, the General Medical Council (GMC), states as part of its good medical practice guidance that doctors must keep their “professional knowledge and skills up to date” and “regularly take part in activities that maintain and develop competence
∗ Corresponding author at: Health Economics Research Unit, University of Aberdeen, Aberdeen AB25 2ZD, Aberdeenshire, Scotland, United Kingdom. Tel.: +44 0 1224 437178. E-mail address: [email protected] (D. Ikenwilo).
and performance”. This reflects the role of CPD in maintaining or improving physician performance and ultimately improving patient outcomes (for a review of the effects of CPD see Bloom [1]). In the United States for instance, the vast majority of State regulatory medical boards require a set number of continuing medical education credits per year as a requirement of licensure renewal. The American Board of Medical Specialities (ABMS) also provides a voluntary system where physicians can demonstrate competency within a speciality area. The Maintenance of Certification (MOC) programme includes a “Lifelong Learning and Self-Assessment” process. This outlines specialty specific continuing medical education recertification requirements. In Canada, the Royal College of Physicians and Surgeons lead the standards for specialty post-graduate medical education. Their Maintenance
http://dx.doi.org/10.1016/j.healthpol.2014.04.006 0168-8510/© 2014 Published by Elsevier Ireland Ltd.
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of Competency (MOC) programme is a mandatory programme of continuing professional development for its members which sets out minimum number of CPD activity credits within a 5-year cycle. The College of Family Physicians of Canada offer a similar membership scheme with evidence of CPD a requirement. The Medical Council of New Zealand is the body charged with registering doctors and include CPD as part of their requirements for renewal or recertification of the practicing certificate. The Medical Board of Australia also require participation in CPD for registration renewal. In the U.K. compulsory revalidation for all doctors has been recently introduced (renewable every five years) as further assurance to patients and the general public that doctors are “up to date and fit to practice”.1 Within this new revalidation framework, CPD is one key type of supporting information used to demonstrate how doctors are maintaining good practice, and where CPD is not only concerned with the updating of clinical knowledge but the need to maintain competence across the whole range of behaviours including management, research and teaching activities. With the importance of CPD as a means to achieve better patient outcomes and as a practical requirement for licensing or revalidation there also exists a growing body of literature looking at perceived barriers to continuing medical education [2–6]. Researchers identify several key barriers to professional development, which can generally be grouped in terms of organisational, logistic and funding issues. Commonly perceived barriers to CPD have included lack of time, funding or motivation, or lack of access either due to the paucity or unavailability of CPD opportunities or insufficient organisational support for CPD (e.g. through sufficient clinical cover). Most researchers have however concentrated on reporting perceived barriers to CPD, without necessarily reporting what the (level of) perceived need for CPD are. There are exceptions but these studies are generally based on small samples [6]. It should be noted that the concentration on doctors’ perception of their needs and barriers to CPD assumes that doctors are able to accurately identify or self-assess their own CPD needs. The “unskilled and unaware of it” phenomenon, as outlined albeit in a non-medical setting [7], suggests that subjects who were unskilled in an area, tended to overestimate their own ability, make errors and then do not have the ability to recognise these failings. Within the medical area there has been research that considers clinicians and medical students self-assessment abilities [8,9] with a review of the accuracy of physician self-assessment concluding physicians have only a limited ability for accurate self-assessment [10]. Whether CPD needs may be identified by individuals’ own assessment or set to some extent as mandatory requirements, it is important to document this need from the perspective of doctors, not only as a planning tool, but also as a reference guide for other (especially new or younger) doctors.
1
Revalidation is set out in line with the Good Medical Practice Guide, which is available through the following link www.gmc-uk.org/ GMP-framework for appraisal and revalidation.pdf 41326960.pdf.
The objective of this paper is to analyse perceived need and barriers to CPD among doctors as a way of providing information necessary to support doctors towards successful revalidation newly introduced in the UK. We test for differences between doctor grades and also consider differences in other characteristics such as gender, age, contract type and specialty. Such information (on need and barriers to CPD) is not routinely collected or published by secondary data sources for the U.K., hence this analysis is expected to help advice policy makers and practitioners about identifying and dealing with potential barriers to CPD among doctors, especially following to the roll out of compulsory revalidation in the UK. 2. Methods 2.1. Sample Data for this analysis were obtained from two national postal surveys of non-training grade doctors working in NHS Scotland in the periods 2005/06 and 2011/12. Both surveys gathered a wealth of information relating to working conditions including specific questions relating to continuing professional development. Data are available for two types of doctors; specialty and associate specialist (SAS) doctors and consultants. Consultants are senior physicians who have completed all relevant specialist training and are entered on a specialist register. SAS doctors include staff grade, speciality doctors and associate specialists and are fully qualified but non-consultant grade doctors and as such are not entered on a specialist register. Response rates from these surveys were 60% and 39% for specialty doctors and 56% and 41% for consultants in 2005/06 and 2011/12 respectively. Although there were overall lower response rates from the second surveys, the samples were generally representative of the population of doctors working in NHS Scotland in terms of age and gender. More details about the surveys including the representativeness of the samples are reported elsewhere [11].2 Within both surveys, one set of questions asked doctors to state the areas they felt they needed (further) education/training. Another set of questions sought to assess the factors that restrict doctors’ participation in CPD activities. Doctors were presented with a wide range of training areas as well as various factors that could potentially restrict their participation in CPD activities. The training areas map well to the areas outlined in the GMC good medical practice guidance which form the basis of the appraisal and revalidation process within the U.K. The guidance sets out how clinicians should be meeting their professional values where, along with the need to maintain and develop good clinical practice, the requirement to be competent in all aspects of work including management and teaching and the need to be able to communicate effectively are also referred to. The inclusion of the general area of
2 See the following link for details about the 2011/2012 survey http://www.aomrc.org.uk/publications/reports-a-guidance/doc details/ 9507-the-impact-of-revalidation-on-the-clinical-and-non-clinicalactivity-of-hospital-doctors.html.
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Table 1 Specific areas of perceptions of need and barriers to CPD among doctors. Perceived CPD need
Perceived CPD barriers
Clinical Management Communication Teaching Time Management Information Technology (IT)
Lack of time Insufficient clinical cover Insufficient study leave Lack of funding Lack of good quality CPD activities Information overload Remoteness from main education centres Lack of motivation Fatigue
information technology reflects the continuing increase in the use of electronic tools to support clinicians in the preparation for revalidation and appraisals. A summary of these need and barrier factors questions are presented in Table 1. For each need factor, respondents were asked to tick one of four response options, depending on whether they strongly agreed, agreed, disagreed or strongly disagreed with requiring the specific CPD. In addition, doctors were invited to state whether they strongly agreed, agreed, disagreed or strongly disagreed with each of the CPD barriers presented. For analysis, the survey responses were transformed into two categories, one for agreement (‘strongly agree’ and ‘agree’) and another for disagreement (‘strongly disagree’ and ‘disagree’) with specific needs and barriers to CPD presented in the questionnaires and summarised in Table 1. We first consider doctors views on how perceived CPD need and barriers to CPD have changed between the two survey dates using a simple two sample proportions test. We then test for differences in perceived need and barriers to CPD between SAS doctors and consultants using multiple regression analysis to control for differences in other characteristics such as gender, age, contract type and specialty for the more recent 2011 sample. To do this, we recognise the possibility that doctors may perceive a need for more than one CPD activity. For example, a doctor may perceive a need for clinical training as well as IT training, while another doctor may perceive the need for all six CPD training activities elicited. In a similar way, a doctor may perceive more than one barrier to CPD. 2.2. Estimation technique We estimate the following multivariate probit model [12] of probabilities that doctors would like further training in one or more of the CPD activities elicited (m). CPDneedim ∗ = ˇm Xim + εim , m = 1, . . ., 6
CPDneedim = 1 if CPDneedim * >0 and 0 otherwiseεim , m = 1, . . ., 6 are error terms distributed as multivariate normal, each with a mean of zero and variance-covariance matrix V, where V has values of 1 on the leading diagonal and correlations jk = kj as off-diagonal elements. The X’s represent a vector of explanatory variables that define differences between doctors, age, gender, contract type and specialty group. For simplicity, we include the same set of explanatory variables in all
3
Table 2 Summary characteristics of sample of doctors in NHS Scotland. n Consultants Male Full time Age group ≤40 41–45 46–50 51–55 Over 55 Specialty group Medicine Surgery Psychiatry Anaesthetics Others Specialty doctors Male Full time Age group ≤40 41–45 46–50 51–55 Over 55 Specialty group Medicine Surgery Psychiatry Anaesthetics Others
1861 1803 1920
2005/06 %
n
2011/12 %
70.18 87.63
1690 1717
64.62 80.20
16.88 22.50 21.72 17.50 21.40
1716 1716 1716 1716 1716
19.23 22.26 22.03 19.99 16.49
26.41 16.96 13.83 17.43 25.37
1718 1718 1718 1718 1718
19.97 18.22 12.51 12.28 37.02
28.51 52.27
374 322
32.89 48.14
17.72 18.35 18.14 22.36 23.42
374 374 374 374 374
22.73 17.38 21.12 16.84 21.93
23.89 12.68 16.91 8.03 38.48
370 370 370 370 370
20.81 10.81 13.78 4.86 49.73
1916
456 463 474
473
six equations. The model is then analysed using the Geweke–Hajivassiliou–Keane (GHK) smooth recursive conditioning simulator to estimate the maximum likelihood of the mvprobit model. We also employ the mvprobit model to evaluate differences (if any) that may exist between doctors in their perceptions of barrier to CPD. In other words, CPDbarriersim ∗ = ˇm Xim + εim , m = 1, . . ., 9
The sample characteristics are presented in Table 2 and show a total sample of 848 specialty doctors and 3636 consultants over the two time periods (2005/06 and 2011/12). The proportion of male SAS doctors increased by 4 percentage points, while there was an almost 6 percentage points reduction in the proportion of male consultants over the two surveys. There were general reductions in the proportion of full time doctors from both grades, more so among consultants. The most represented specialty group (for all doctor grades) was medicine (the ‘others’ category is made up of specialties such as accident and emergency, gynaecology, paediatrics, for which the sample of respondents were too small to be analysed as separate categories). All analyses were performed in Stata 12. 3. Results 3.1. Comparison over time Doctors expressed the most perceived need for further education and training in clinical areas in both survey years, as shown in Table 3. A total of 71% of SAS doctors perceived
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4 Table 3 NHS Scotland doctors’ perceived CPD needs. 2006
2011
n Consultant Clinical Management Communication Teaching Time management IT SAS Clinical Management Communication Teaching Time management IT * **
Proportion
n
Change Proportion
1856 1847 1825 1831 1832 1558
66.06% 64.86% 30.25% 51.56% 47.60% 63.48%
1614 1598 1553 1564 1573 1312
68.90% 63.77% 29.81% 52.24% 41.83% 59.45%
2.84* −1.09 −0.43 0.68 −5.77** −4.03**
450 447 437 437 443 365
71.33% 64.88% 29.29% 61.78% 48.76% 70.96%
333 305 291 288 305 234
80.48% 64.26% 36.77% 59.38% 53.44% 67.52%
9.15** −0.61 7.48** −2.41 4.68 −3.44
Two sample proportion test significance at 10%. Two sample proportion test significance at 1%.
a need for clinical training in 2006 compared 66% of consultants with corresponding figures of 69% and 80% in 2011. Agreement with the need for further education and training in management and IT are the next highest proportions in both years for consultants and SAS doctors where generally over 60% of respondents indicated that further education and training were needed in these areas. The need for further training in communication was clearly the least desired among both doctor grades, both in 2006 and in 2011, with proportions of respondents indicating a need for further training ranging between only 29% and 40%. In terms of changes in perceived CPD training need over time, the largest significant increase (at the 1% level) among SAS doctors was for clinical training where the proportion increased by 9 percentage points compared to less than 3 percentage points increase for consultants although this was still significant at the 10% level. There was also
a significant reduction in those consultants desiring training in time management and IT. For SAS doctors the only other significant change was an increased agreement on the need for CPD in communication. However even after this increase, the proportion of SAS doctors agreeing that there was further need for education and training within this area still remained the smallest of all areas in 2011. The most perceived barrier to CPD was lack of time, both among SAS doctors and among consultants and in each year of survey (Table 4). Indeed the position as the most perceived barrier for consultants was strengthened with the largest increase between 2006 and 2011 of 7 percentage points. The second highest proportion related to insufficient clinical cover as a perceived barrier to CPD, again for both doctor groups, with this barrier exhibiting the largest increase for SAS doctors of over 11 percentage points. There were also other significant increases (over time) in the
Table 4 NHS Scotland doctors’ perceived barriers to CPD. 2006 n Consultants Lack of time Insufficient clinical cover Insufficient study leave Lack of funding Lack of good quality CPD Information overload Remoteness Lack of motivation Fatigue SAS Lack of time Insufficient clinical cover Insufficient study leave Lack of funding Lack of good quality CPD Information overload Remoteness Lack of motivation Fatigue * **
2011 Mean
N
Change Mean
1865 1839 1824 1832 1817 1802 1812 1811 1689
79.36% 60.96% 25.44% 41.38% 27.63% 39.79% 30.02% 14.80% 33.98%
1668 1610 1552 1589 1563 1561 1589 1569 1482
86.81% 63.66% 20.81% 47.51% 30.33% 38.69% 36.63% 18.48% 33.87%
7.45* 2.71 −4.63* 6.14* 2.70** −1.10 6.60* 3.68* −0.11
445 443 436 443 436 417 436 430 399
72.81% 51.92% 25.46% 40.63% 42.66% 22.54% 45.41% 22.09% 30.33%
340 321 296 311 306 292 318 302 274
84.12% 67.29% 30.41% 50.48% 44.77% 30.82% 45.91% 20.20% 31.39%
11.31* 15.37* 4.95 9.85* 2.11 8.28* 0.50 −1.89 1.06
Two sample proportion test significance at 10%. Two sample proportion test significance at 1%.
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proportion of doctors perceiving different types of CPD barriers. For example among consultants, there were increased perceptions of remoteness from main education centres and also of lack of funding. Among SAS doctors, there were significant increased perceptions of lack of funding and information overload. Consultants indicated a significant reduction in the proportions perceiving insufficient study leave as a barrier to CPD. Lack of motivation was the least likely barrier to restrict participation in CPD activities for both doctor groups in both years of survey. 3.2. Model results of differences in perceived need and barriers to CPD We now consider where variations arise in the perceptions of need and barriers to CPD using multivariate probit regression methods. We investigate differences between SAS doctors and consultants and for other characteristics such as gender, age, contract type and specialty for the more recent 2011 sample. The full results are provided in Appendix A with significant characteristics summarised in Table 5. 3.2.1. Doctor grade Consultants were significantly less likely to perceive the need for CPD in clinical training and education, compared to SAS doctors (Table 5). There is some evidence that consultants were also less likely to perceive the need for further education and training in the areas of teaching and time management (significant at the 10% level) compared with SAS doctors. Consultants were significantly less likely to perceive insufficient study leave or the lack of good quality CPD as a barrier to further education and training compared to SAS doctors. There was also some weak evidence (10% level) that consultants were less likely to perceive the lack Table 5 A summary of statistically significant differences in perceived need and barriers to CPD among doctors in NHS Scotland (full model results are available as Appendix A, Tables 6 and 7). Perceived CPD need Clinical
Management Communication Teaching Time management IT Perceived CPD barriers Lack of time Insufficient clinical cover Insufficient study leave Lack of funding Lack of good quality CPD Information overload Remoteness Lack of motivation Fatigue
Positive effects Age 51–55, medicine, psychiatry Full time, age ≤50 Age 41–45 Age ≤55 Age ≤50
Negative effects Consultant
Age ≤55, medicine Full time, age ≤40, medicine Full time, age ≤40
Male, anaesthetics Consultant, psychiatry Consultant, anaesthetics, psychiatry Anaesthetics Consultant
Surgery
Anaesthetics Consultant Consultant Male, age ≤40
Consultant, male
Age ≤40
Anaesthetics Anaesthetics
Male, medicine Age ≤40
5
of clinical cover and more likely to perceive information overload as barriers to CPD than their SAS counterparts. 3.2.2. Gender There was little evidence of differences across gender in the perceived need for CPD apart from in IT where male doctors were significantly less likely to report perceived need for further training. However there were some significant gender differences in perceived barriers to CPD where males were significantly less likely to perceive a lack of time or remoteness from a main education centre as a barrier to their professional development compared to female doctors but were significantly more likely to agree that information overload restricted their participation in CPD activities. 3.2.3. Contract type There was little evidence of differences in perception of the need for CPD between fulltime and part-time doctors with only weak evidence at the 10% level that full-time doctors were more likely to perceive a need for further training in management. In terms of perceived barriers to CPD, full-time doctors were significantly more likely to see the lack of clinical cover as a barrier to their further education and training than their part-time counterparts. There was some evidence (at the 10% level) that full-time doctors were more likely to indicate that insufficient study leave restricted their participation in CPD activities compared to part-time doctors. 3.2.4. Age groups There were a number of significant age group differences in perceptions of CPD need. Compared to doctors aged over 55 years, doctors in the 51–55 age group were associated with a significant additional perceived need for further education and training in the clinical area. Doctors aged up to 50 indicated significantly higher perceived need for CPD in the areas of management and time management compared to those over the age of 55 years. Doctors up to age of 55 years indicated a higher need for CPD in teaching compared to those over 55 years. Finally the youngest group of doctors indicated a significantly smaller need for CPD (at the 10% level) for further education and training in IT. Doctors aged up to 55 years indicated that a lack of time posed a significant restriction on their participation in CPD activities compared to colleagues aged over 55 years. There was evidence that the youngest group of doctors felt that a lack of study leave significantly restricted their participation in CPD but were significantly less likely than their older colleagues to see a lack of motivation impacting on their CPD activities. There was also weak evidence (at the 10% level) that this youngest age group’s lack of clinical cover significantly restricted their participation in CPD, but they were less likely than their older colleagues to see information overload restricting their CPD activities. 3.2.5. Specialty There was little evidence of significant differences in perception of CPD need across the specialty groups with only weak evidence at the 10% level that doctors within
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the medicine or psychiatry specialties were more likely to perceive a need for clinical CPD. Similarly there was only weak evidence that anaesthetists were associated with a reduced perception of the need for further management training. In terms of perceived CPD barriers, there were significant variations across specialty groups over a wide variety of perceived barriers to professional development. Anaesthetists were significantly less likely to indicate that lack of time, study leave or funding restricted their participation in CPD but more likely to indicate that remoteness to main education centres or lack of motivations were barriers to CPD activities than the non-specified “other” specialty group, made up of specialties such as accident and emergency, paediatrics, gynaecology, etc. Doctors within the medical specialty were significantly more likely to indicate a lack of time and lack of clinical cover as barriers to CPD activity but less likely to indicate that remoteness from a main education centre was a barrier. Doctors within the surgical specialty were significantly more likely to indicate a lack of funding restricted their participation in CPD activities than those in the unspecified group of specialties. Finally those within psychiatry were significantly less likely to indicate insufficient clinical cover or study leave as restricting their CPD activity. 4. Conclusions This is the first paper to evaluate both doctors’ perceived need and barriers to CPD within the same context in Scotland. Such analysis, also comparing differences between specialty doctors and consultants, male and female doctors, age and specialty groups, as well as differences over time, is an important precursor to developing effective educational and training programmes in supporting doctors to remain up-to-date especially with the introduction of compulsory revalidation for all UK doctors. The most expressed CPD need was for clinical training, while lack of time was the most reported barrier to CPD among all doctors. Our results mirror some other findings in the literature on barriers to CPD. For example, our results showing lack of time as the most identified barrier to CPD (by 81.24% of all doctors) is similar to 85% reported among hospitalbased prevocational doctors in Australia [3]. In addition, Price et al. [13] also find that the most frequently reported barrier to implementing learning, among a group of health care professionals in Colorado, was lack of time (26% of all responses). In terms of policy, especially as it relates to the roll out of revalidation in the UK and other issues with appraisals and CPD, the results of this paper highlight the need to consider these differences in perceived need and barriers to CPD when formulating policy. The perceived barriers could help in designing CPD activities, especially in ensuring adequate funding for doctors, the provision of good quality CPD activities and instituting flexible working practices to allow doctors time to engage and participate in available CPD activities. CPD planners should be aware that, with lack of time being the largest perceived barrier for both consultants and SAS doctors, CPD activities should be organised as efficiently as possible to make the best use of the time
available. CPD planners should also ensure that time within doctors job plans that is identified for activities such as CPD are protected. Doctors within the UK currently have job plans which identify blocks of activity relating to direct clinical care time and other activities such as supporting professional activities (SPAs) which includes CPD activities. The results suggest that it is vital that time allocated within the contract for these supporting professional activities is maintained and protected. The consultant contract within the UK specifies a 75:25 split between direct clinical care and SPA time. However there is increasing pressure for newly appointed consultants to accept job plans with a 90:10 split representing a reduction in time for SPA and CPD activities. In addition SAS doctors have no specific proportion of their time within their job plans allocated to supporting professional activities. CPD planners need to monitor and support doctors in finding protected time for their activities. Our results suggest that while on aggregate there is a clear message that there is a perceived need for further education and training in clinical areas with lack of time a clear restriction on participation in CPD activities, that there are also significant differences across doctor grades and characteristics of doctors. This finding supports the GMC stand that CPD activities should be shaped by assessment of specific professional needs and the needs of the service and the people who use it. Consequently, this means that one size does certainly not fit all, and these differences should be taken into account when rolling out revalidation. While there is no reason as to question the respondents’ ability to assess the barriers to CPD, the perceptions of CPD need are tempered by the findings in the literature that physicians have a limited ability to correctly self-assess and self-direct their continuing professional development needs. This may be reflected by the fact that some countries operate a more prescriptive requirement of a minimum number of hours of CPD activity or where specific CPD courses by specialty are required for continued medical registration. In the UK there is no such prescriptive requirement on CPD activity as part of the revalidation framework. If self-assessment is indeed limited in its ability to identify CPD needs, this suggests that CPD planners within the UK should evaluate through independent assessment the areas in which to encourage CPD. This analysis is not without its limitations. Firstly, despite a real possibility of repeat respondents over the two surveys, we were unable to determine these due to the anonymity of the datasets used. There is also a possibility of bias in that those doctors with specific CPD needs were more likely to respond to the questions and to provide strong views about CPD, hence our findings may reflect these rather than the general views. Funding We would like to acknowledge the support of the Pay Modernisation Team at the former Scottish Executive Health Department who funded the 2005/06 survey, and the UK Academy of Medical Royal Colleges and Faculties who funded the 2011/12 survey.HERU is supported by the Chief Scientist Office (CSO) at the Scottish
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Government Health and Social Care Directorate. All views are of the authors alone. Acknowledgements We would like to thank all the doctors who responded to the surveys and all temporary staff who helped in managing the questionnaires and entering the data. Special thanks also go to Ms Fiona French and Professor Gillian Needham (NHS Education for Scotland) who were part of the research teams for both surveys and all others involved with either the first or second survey. Appendix A. See Tables 6 and 7. Table 6 mvprobit model differences in perceived CPD need among doctors. CPD Need Clinical Doctor grade (consultant) Male Full time age≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons Management Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons Communication Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons Teaching Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine
Coefficient
Std. error
P > |z|
−0.334** −0.041 −0.162 0.074 0.183 0.187 0.368** 0.192 0.197* 0.060 0.238* 0.664**
0.123 0.086 0.100 0.121 0.122 0.125 0.127 0.123 0.102 0.112 0.125 0.151
0.007 0.632 0.104 0.543 0.134 0.136 0.004 0.120 0.054 0.593 0.058 0.000
0.155 −0.080 0.165* 1.213** 0.954** 0.670** 0.180 −0.232* −0.048 −0.057 0.004 −0.520**
0.115 0.086 0.097 0.127 0.124 0.124 0.123 0.123 0.102 0.114 0.123 0.145
0.177 0.357 0.089 0.000 0.000 0.000 0.144 0.060 0.640 0.618 0.973 0.000
−0.165 0.045 −0.073 0.182 0.247* 0.018 −0.070 0.124 0.102 −0.111 −0.119 −0.537**
0.115 0.088 0.099 0.127 0.126 0.131 0.132 0.124 0.102 0.117 0.127 0.148
0.153 0.608 0.460 0.150 0.050 0.892 0.598 0.320 0.318 0.343 0.348 0.000
−0.220* −0.087 0.120 0.582** 0.462** 0.356** 0.285* 0.132 −0.054
0.113 0.083 0.094 0.120 0.120 0.122 0.122 0.118 0.098
0.051 0.291 0.202 0.000 0.000 0.004 0.019 0.264 0.583
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Table 6 (Continued ) CPD Need Surgery Psychiatry cons Time management Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons It Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons Sample Wald Chi2 (prob > chi2 ) Log likelihood LR test of Rho’s (prob) * **
Std. error
P > |z|
0.048 0.189 −0.155
0.109 0.118 0.142
0.658 0.111 0.275
−0.188* −0.070 0.014 0.220* 0.342** 0.278* 0.200 −0.023 −0.057 −0.145 −0.110 −0.326*
0.111 0.084 0.095 0.123 0.123 0.125 0.126 0.120 0.098 0.112 0.119 0.143
0.091 0.401 0.880 0.074 0.005 0.027 0.110 0.845 0.562 0.195 0.356 0.023
−0.080 −0.329** 0.039 −0.232* −0.194 −0.176 −0.071 0.082 −0.121 0.081 0.035 0.604** 1251.00 270.11** −4450.38 568.72**
0.113 0.084 0.095 0.120 0.121 0.123 0.122 0.120 0.097 0.109 0.119 0.144
0.480 0.000 0.680 0.052 0.107 0.151 0.564 0.493 0.212 0.460 0.768 0.000
Coefficient
˛ < 0.10. ˛ < 0.01.
Table 7 mvprobit model results of differences in perceived CPD barriers among doctors. CPD barriers Lack of time Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons Insufficient clinical cover Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons Insufficient study leave Doctor grade (consultant)
Coefficient
Std. Error
P > |z|
0.141 −0.277** 0.043 0.436** 0.586** 0.409** 0.223* −0.539** 0.334** 0.133 −0.058 0.761**
0.130 0.103 0.114 0.137 0.141 0.135 0.135 0.129 0.127 0.129 0.132 0.159
0.280 0.007 0.706 0.001 0.000 0.002 0.099 0.000 0.008 0.302 0.662 0.000
−0.195* −0.086 0.216* 0.225* 0.175 0.187 0.052 −0.064 0.308** 0.032 −0.285** 0.228*
0.109 0.081 0.091 0.117 0.117 0.117 0.120 0.117 0.097 0.103 0.108 0.137
0.073 0.287 0.017 0.056 0.133 0.110 0.665 0.586 0.001 0.758 0.008 0.096
−0.304**
0.115
0.008
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Table 7 (Continued )
Table 7 (Continued ) CPD barriers
Coefficient
Male 0.080 Full time 0.174* Age ≤40 0.285* Age 41–45 0.063 Age 46–50 −0.061 Age 51–55 0.088 Anaesthetics −0.379** Medicine −0.095 Surgery 0.083 Psychiatry −0.312* cons −0.793** Lack of funding Doctor grade (consultant) −0.055 Male −0.008 Full time 0.068 Age ≤40 0.080 Age 41–45 0.053 Age 46–50 −0.050 Age 51–55 0.005 Anaesthetics −0.402** −0.015 Medicine Surgery 0.255* Psychiatry 0.154 cons −0.130 Lack of good quality CPD activities −0.377** Doctor grade (consultant) 0.098 Male 0.014 Full time 0.055 Age ≤40 0.075 Age 41–45 Age 46–50 0.011 Age 51–55 0.070 Anaesthetics 0.186 Medicine −0.146 0.123 Surgery Psychiatry 0.030 cons −0.331* Information overload 0.207* Doctor grade (consultant) Male 0.206* Full time −0.077 Age ≤40 −0.218* Age 41–45 −0.187 0.073 Age 46–50 0.060 Age 51–55 0.179 Anaesthetics −0.044 Medicine Surgery 0.044 −0.131 Psychiatry cons −0.548** Remoteness from main education centres −0.163 Doctor grade (consultant) Male −0.210** −0.114 Full time 0.097 Age≤40 0.137 Age 41–45 0.129 Age 46–50 −0.049 Age 51–55 0.298* Anaesthetics −0.200* Medicine 0.023 Surgery 0.069 Psychiatry cons −0.083 Lack of motivation −0.143 Doctor grade (consultant) 0.128 Male −0.022 Full time −0.282* Age ≤40 −0.089 Age 41–45 −0.067 Age 46–50 −0.174 Age 51–55
Std. Error
P > |z|
CPD barriers
0.090 0.105 0.131 0.134 0.136 0.138 0.145 0.105 0.112 0.131 0.153
0.371 0.096 0.030 0.641 0.657 0.523 0.009 0.364 0.458 0.017 0.000
0.104 0.079 0.089 0.116 0.115 0.116 0.119 0.119 0.092 0.102 0.107 0.134
0.596 0.917 0.444 0.490 0.647 0.663 0.969 0.001 0.875 0.012 0.150 0.332
Anaesthetics Medicine Surgery Psychiatry cons Fatigue Doctor grade (consultant) Male Full time Age ≤40 Age 41–45 Age 46–50 Age 51–55 Anaesthetics Medicine Surgery Psychiatry cons sample Wald Chi2 (prob > chi2 ) Log likelihood LR test of Rho’s (prob)
0.106 0.083 0.094 0.122 0.121 0.121 0.124 0.119 0.099 0.106 0.114 0.138
0.000 0.238 0.885 0.651 0.532 0.926 0.575 0.119 0.139 0.245 0.795 0.017
0.111 0.081 0.092 0.118 0.117 0.116 0.120 0.115 0.095 0.104 0.113 0.139
0.061 0.011 0.402 0.066 0.110 0.531 0.615 0.121 0.642 0.668 0.247 0.000
0.105 0.081 0.090 0.119 0.119 0.119 0.124 0.116 0.097 0.105 0.110 0.137
0.122 0.009 0.206 0.415 0.248 0.275 0.694 0.010 0.038 0.825 0.534 0.544
0.124 0.095 0.106 0.137 0.132 0.131 0.137
0.248 0.175 0.837 0.039 0.499 0.608 0.203
* **
Std. Error
P > |z|
0.260* −0.067 0.156 −0.042 −0.832**
0.131 0.112 0.117 0.132 0.153
0.047 0.547 0.183 0.753 0.000
0.070 −0.087 0.099 0.086 0.166 0.197 0.165 −0.173 −0.064 0.037 −0.187 −0.638** 1391 281.01** 6719.33 857.90**
0.110 0.081 0.092 0.121 0.120 0.120 0.123 0.120 0.095 0.103 0.114 0.140
0.523 0.282 0.283 0.475 0.167 0.101 0.181 0.152 0.500 0.719 0.101 0.000
Coefficient
˛ < 0.10. ˛ < 0.01.
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