The Journd ofcontinuing Education in rhe Health Professions, Volume 23, pp. ... a continuing medical education (CME) program to teach and encourage ...
The Journd ofcontinuing Education in rhe Health Professions, Volume 23, pp. 162-167. Printed in the U.S.A. Copyright 0 2003 The Alliance for Continuing Medical Education, the Society for Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education. All rights reserved.
Original Article
Continuing Medical Education: What Delivery Format Do Physicians Prefer? Nancy Stancic, PhD, Patricia Dolan Mullen, DrPH, Alexander V. Prokhorov, MD, PhD, Ralph F. Frankowski, PhD, and Alfred L. McAlister, PhD
Abstract
Background: Although physicians are in a unique position to prevent life-threatening outcomes by counseling patients to stop smoking, many of them miss the opportunity to intervene in their patients’ use of tobacco. Nicotine Dependence Across the Lifespan was developed as a continuing medical education (CME)program to teach and encourage physicians to deliver effective tobacco prevention and tobacco cessation counseling. Methods: This CME program was offered to Texas physicians, free of charge, in three formats: live lectures, videotapes, and World Wide Web-based training. The program targeted physicians in four rural areas of Texas (San Angelo, Harlingen, Tylel; and Lubbock), where high smoking rates are prevalent and the number of professional smoking cessation services is low. We examined the sociodernographic characteristics of the participating physicians, factors in their decisions to participate in the program, and the extent to which their reported CMEformat preferences were associated with age, gendel; race, profession, and location. Results: The four factors identified-professional development, cost, personal control, and convenience/corrzplexity-explained 76.9% of the variance describing the reasons physicians participated in the CME offering. The physicians’ preferred CME format was live lectures; based on responses, this did not differ across age, gendel; race/ethnicity, and location. Discussion: Live lecture continues to be a preferred format of CME for physicians in four rural areas of Texas, yet research continues to show that lecture results in only the lowest level of behavioral change. Key Words: Cessation counseling, change, continuing medical education (CME), lecture, tobacco prevention, Web-based training Background
disease, coronary heart disease, stroke, and cancer of the larynx, esophagus, mouth, and bladder, smoking is responsible for more than 430,000 deaths a year.’ Physicians are uniquely able to counsel patients to stop smoking. They can evaluate their patients’ needs and draw on an inventory of smoking cessation aids, such as behavior modification and diverse pharmacotherapies. The Clinical Practice Guideline Treating Tobacco Use and Dependence, written with the goal of improving physicians’ tobacco use counseling, offers evidence-based recommendations that physicians can use to increase the likelihood that their patients’ attempts to quit smoking will be successful.’We conducted this study as a step to finding out what format of continuingmedical education (CME) physicians preferred; how they applied the information awaits further study.
The negative consequencesof tobacco use and smoking are well known in the United Statestoday. Causally related to chronic and fatal diseases that include lung DI: Stancic: Senior Research Coordinator, Department of Behavioral Science, The University of Texas M.D. Anderson Cancer Center, Houston, Texas; DI: Mullen: Professor, School of Public Health, The University of Texas Health Science Center Houston, Houston, Texas; D K Prokhorov: Assistant Professor, Department of Behavioral Science, The University of Texas M.D. Anderson Cancer Center, Houston, Texas: Lk Frankowski: Professor, School of Public Health, The University of Texas Health Science Center Houston, Houston, Texas; D KMcAlister: Professor, School o f Public Health, The University of Texas Health Science Center Houston, Houston, Texas. Reprint requests: Nancy Stancic, PhD, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 243, Houston, TX 77030-4730.
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Stancic et al. The guideline can be taught as a CME program. For more than 25 years, CME linked physicians to methods of enhancing their medical knowledge and training.2Several CME formats are available today. Traditional lecture-based CME is considered least effective for changing physicians’ medical pract i c e ~ , although ~-~ it remains the format physicians prefer. Second-generationCME methods of videoand audiotaped programs are now joined by Internet-based curricula. This latest learning method allows physicians to learn at their own pace and provides the most up-to-date information.6 As part of Nicotine DependenceAcross the Lifespan, a CME program of The University of Texas M.D. Anderson Cancer Center’s Tobacco Outreach Education Program (TOEP), we studied the CME preferences of physicians in four Texas cities (San Angelo, Harlingen,Tyler, and Lubbock). The sociodemographic characteristics of the participating physicians, factors involvedin their decisions to participate in the CME program, and the extent to whch their CME format preferences were associated with age, gender, race, specialty, and location were examined.
Association,local county medical societies, and lists of physicians with staff privileges in local hospitals. Eligibility was based on (1) medical specialty (emergency medicine, family practice, general practice, general preventive medicine, internal medicine, obstetrics, oncology, pediatrics, public health, geriatrics, cardiovascular diseases, pediatric hematology/oncology, neonatal pediatrics, and pediatric cardiology); (2) location of practice in 1 of 36 counties located within approximately 100miles from the targeted cities (Figure 1); and (3) being licensed in Texas. Both medical doctors and doctors of osteopathy were recruited. Although nonphysician health care providers were able to participate in the TOEP, they were not included in this analysis.
Notification of CME Program Active and passive methods were used to announce the program. Approximately 1 month before the start of the live CME presentation, physicians were mailed a brochure describing the three TOEP CME formats and schedules. Announcements were made at professional meetings, articles appeared in newspapers and the newsletters of professional associations, and posters were displayed at clinics and hospitals. Interested physicians could register for their preferred CME format by electronic mail, mail, telephone, or fax.
Methods From October 2000 to August 2001, data on the physicians’characteristics, their reasons for participating in the CME program, and associations between their characteristics and their CME preferences were measured. The participants’registration and earned CME credits were paid for with Texas tobacco settlement grant funds. The program included four topics: (1) Smoking and Adolescents: Too Young to be Hooked? (2) Cancer Patients: Stopping Smoking Is Good Medicine; (3) The Challenge of Treating Tobacco Dependence: Translating Research into Practice; and (4)Treating Tobacco Dependence: Genes, Moods, and Drugs. The program was available as live lectures, videotaped lectures, and World Wide Webbased training.
Data Collection and Measures After completing each program (in the case of live lectures, after each lecture), physicians were asked to complete a one-page TOEP evaluation questionnaire that included 13 5-point Likert-scale questions with responses ranging from strongly agree to strongly disagree. The statements were based on the diffusion of innovations theory attributes (relative advantage, compatibility, and comp l e ~ i t y as ) ~they related to reasons for participating in the program. Questions about the physicians’ demographic characteristics and practice features, CME preferences, and means by which they heard about the program were included. Completion of the TOEP evaluation was not required for earning CME credits. Nine of the 13 statements that loaded on factors significantly, as demonstrated in the factor matrix, were included in the final analysis.
Study Population The TOEP participants, who were 205 of the 4,061 physicians to whom the CME brochure was mailed, were recruited from the four targeted areas based on membership lists provided by the Texas Medical
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Physicians ’ Preferred Delivery Format for CME
I
Student’s t test was used to test for age differences between CME format preferences. Because of the small number of respondents overall and in some subgroups, four variables were recoded: the physicians’ CME format participation, CME format preference, ethnicity, and specialty. CME format participation was recoded to live lectures versus not live lectures (videotapes or Web-based). Race/ethnicity was recoded as white or not whte (Hispanic,African American, Native American, or other). The CME format preference was recoded as either live lectures or not live lectures. Specialty was recoded as general practice (general practice, family practice, or internal medicine) or not general practice (obstetrics, pediatrics, or other). Age remained a continuous variable. The total number of factors was based on four criteria: (1) a one-factor model was first fitted, (2) the percentage of variance explained by a factor had to be 2 20%, (3) residuals were analyzed, and (4) the “elbow” in the scree plot was examined to help evaluate the adequate number of factors for the exploratory factor analysis.
1. San Angelo 2. Tyler 3. Harhgen 4. Lubbock
Figure 1 Four original Tobacco Outreach Education Program sites in Texas.
Physicians who registered for the videotaped program were mailed, overnight, a package containing requested videotapes, corresponding CME tests as proof of participation, and a postage-paid, return-addressed envelope for submittingCME tests and evaluations to the TOEP staff. If tests and evaluations were not returned 3 months after the video request had been filled, reminders were mailed with a second copy of the tests and evaluation. Web-based participants received the same TOEP evaluation as the live and videotaped lecture participants by mail after they completed the on-line course. A postage-paid, return-addressed envelope was mailed with the earned CME certificate. If the physician did not return the evaluation within 3 months, a reminder letter with a second copy of the evaluation packet was sent.
Results Of the 4,061 physicians who received the CME brochure, 205 participated in the TOEP; 183 attended live presentations, 10 returned CME videotape tests, and 12 completed the Web-based course. Sixty-two physicians (30%) completed the TOEP evaluation form: 53 of those who attended live presentations, 9 of those who viewed the videotapes, and none of those who completed the on-line course (Table 1).
Statistical Analysis
Respondents’ Characteristics
SPSS 10.0 software was used for statistical analysis. Descriptive statistics (means, medians, and frequencies) were used to describe the study population. An exploratory factor analysis of the Likert-scale statements was conducted to identify factors in the physicians’ decision to participate in the CME program. Fisher’s exact test and Pearson’s chi-square were used for the categorical demographic characteristicsand practice feature variables of the univariate analysis of Ch4E format preference.
The respondents’characteristicsare listed in Table 2.
Reasons for Participating Four factors in the CME participation explained 76.9% of the total variance: professional development, cost, personal control, and convenience/complexity. Explained reliability, as measured by a values, was as follows: professional development, 0.7548; cost, 0.8641; personal control, 0.9472; and convenience/complexity, 0.84 15 (Table 3).
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Stancic et al. Table 2 Physicians’ Characteristics
Table 1 Participation Eligibility
Characteristic
Brochures Mailed to Physicians (N = 4,061)
Participated* Returned evaluations
Live
Video
Web
183 53
10 9
12 0
Percentage (n)
Age (n = 57) Mean 49.6 (range = 28-81) Missing Gender (n = 62) Female Male Race (n = 61) Not white African American Asian American Hispanic Native American White Other Missing Specialty (n = 62) General Family practice General practice Internal medicine Other Obstetrics/gynecology Pediatrics Other
*Defined as went to live lecture, returned videotape continuing medical education (CME) tests, or completed on-line CME tests.
CME Preference and Physician Demographics The answers indicated that CME preferences did not differ across age, gender, race, or specialty, and no differences were seen among preferences for program sites (Table 4).
Discussion CME is the recognized method by which physicians maintain their proficiency in medical practice. As we examined the characteristics of participants in our CME program, their reasons for participating, and their format preferences, the evidence supported four factors for participation: professional development, cost, personal control, and conveniencekomplexity. Contrary to our expectations, the factors were not as tightly related to the R ~ g e r sdiffusion ’~
8.0 ( 5 )
35.5 (22) 64.5 (40)
4.8 (3) 6.4 (4) 22.6 (14) 1.6 (1) 59.7 (37) 3.2 (2) 1.6 (1)
11.3 (7) 8.1 (5) 21.0 (13)
12.9 (8) 9.7 (6) 37.1 (23)
attributes. However, these findings were similar to Casebeer and colleagues’8recent study on physicians and their Internet use for medical information.
Table 3 Explanatory Factor Analysis of Reasons for Participation Rotated Factor Loading Items Tobacco counseling is relevant to my practice My professional effectiveness was enhanced as a result of participating in this activity No cost to participate CME credits were free I can design my personal learning experience I can choose my personal learning environment Participation was convenient Program was available when I was available Access to program was easy Eigenvalues Reliability a values
(1) Professional Development
(2) cost
(3) Control
(4) Convenience
0.650 -
0.728 0.926
-
0.989 0.884 -
1.o 0.7548
1.5 0.8641
-
1.8 0.9472
-
0.85 1 0.778 0.690 3.4 0.8415
Each was rated on a scale of 1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, 5 = strongly disagree, 6 = not applicable. CME = continuing medical education.
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Physicians’ Preferred Delivery Format f o r CME Table 4 CME Format Preference by Physician Characteristics CME Format Not Live (n) Age Gender (n = 49) Men Women Race (n = 49) Nonwhite White Specialty (n = 50) Specialists General practice Location (n = 50) The Lower Rio Grande Valley Tyler Lubbock
Live (n)
25 17
6 1
11 31
3 4
28 15
4 3
2 1 4
Missing Values
Test Values
12 13
t test = .782; p = .438 Fisher’s exact significance 0.238
13
Fisher’s exact significance 0.392
12
Fisher’s exact significance 0.692
12
Pearson’s chi-square 2.609; p = .27 1
15 16 12
however. In 2000,l.1% of CME hours were earned via the Web, a 72% increase over the number of hours earned on the Web in 1999.9Acontinuing increase in physicians’ Internet use for CME may be expected. Web CME programs fit the changing CME Although physicians may prefer didactic presentations because of the opportunity to spend time with colleague^,^,^ the lecture format was consistently found to produce the lowest level of behavior change in physicians’ p r a ~ t i c e s . ~ ~Interactive ’~-’~ and self-directed approaches, such as computer learning and academic detailing,5J3,’4are better suited to adult learning’5~’6 and produce greater changes in physicians’ medical practice behaviors than do traditional CME lecture^.^.'^-*^
The respondents’stated CME preferences were similar across the sociodemographic characteristics measured here. Most physicians who participated in the survey had attended live lectures. Not surprisingly, these were their CME preferences, which corresponds to the Accreditation Council for Continuing Medical Education records of CME participation. The on-line CME alternative (captured in the nonlecture category)is growing in favor nationwide,
lessons for Practice Four factors can contribute to physicians’ preferences when deciding to participate in a continuing medical education program: personal control over content, personal development, cost, and convenience of access to the program. Live programs were the preferred method for earning continuing medical education hours. To improve survey response, data collection should be conducted simultaneously with the continuing medical education program offering, not at a later date.
Study Strengths and Limitations The TOEP evaluation questionnaire was developed specifically for this study and is among a few designed solely to examine physicians’ preferences regarding CME format. The factors’ reliability demonstrated the desired high degree of interrelatedness among the variables. During the past 6 years, the American Medical Association21conducted two studies of physicians’ use of the Internet for general use, but the studies did not examine the Internet as a viable CME format preference.
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Stancic et al. Available at: http://www.stanford.edu/ group/sigss/Press-Releaselinternetstudy.htm1. Accessed November 28,2002.
Limitations are related to the low and presumably biased response rate. The findings cannot be generalized beyond our sample. Most of the questionnaires were collected from participants in the controlled atmosphere of live lectures.Also, adult learning theory may be a better framework for this study than the diffusion of innovations theory.
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