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Original Research

Perceptions of Continuing Medical Education, Professional Development, and Organizational Support in the United Arab Emirates

HASSAN YOUNIES, PHD; BELAL BERHAM, PHD; PAMELA C. SMITH, PHD Introduction: This paper investigates the views of health care providers on continuous medical education (CME). To our knowledge, this is one of the first surveys to examine perspectives of CME in the United Arab Emirates (UAE). Methods: A 6-part questionnaire focused on the following areas of CME: the workshop leaders/trainers, the training experience, the relevance of CME information provided in the training session, the training approach, the convenience of CME sessions, and organizational support. Results: Results from 147 respondents indicated moderate satisfaction with these 6 CME areas. Respondents did not indicate satisfaction with organizational support received. Furthermore, participants agreed with the importance of CME to professional development. Discussion: In our sample of UAE health care workers, they agree on the importance and relevance of CME to the development of their profession, even though the majority of health care workers are expatriates. However, several issues must be addressed, such as organizational, logistical, and financial support to attend CME programs. These issues must be addressed in order to sustain the viability of healthcare workers attending CME. Key Words: continuing medical education, professional development, benefits, evaluation, workforce

Introduction This era in history is characterized by continuing advances in technology and breakthroughs in all fields of science. The field of medical science is no exception, with new medicines, medical procedures, and technologies being introduced to the benefit of humanity. Medical practitioners need to keep their knowledge updated after their formal education at medical school. Governments in different parts of the world set criteria and incentives for medical practitioners to attend continuing formal programs of medical education.1 Peck et al reviewed continuing medical education in the Western hemi-

Disclosures: The authors report none. Dr. Younies: Associate Professor, School of Management, New York Institute of Technology; Dr. Berham: Associate Professor, College of Business Administration, Abu Dhabi University; Dr. Smith: Associate Professor, College of Business, University of Texas at San Antonio. Correspondence: Hassan Younies, School of Management, New York Institute of Technology, Muror Street, Abu Dhabi, United Arab Emirates; e-mail: hassan.younies@ gmail.com. C

2010 The Alliance for Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Council on Continuing Medical Education, Association for Hospital Medical Education. r Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/chp.20090

sphere, mainly in the United Kingdom, Europe, the United States, Australia, and New Zealand. However, little research exists investigating continuing medical education (CME) in the United Arab Emirates (UAE). Prior studies have provided an overview of CME in other Middle Eastern countries, such as Iraq and Turkey.2,3 Research also notes the existence of one unique CME program in the Middle East, sponsored by the Canadian International Scientific Exchange Program, which incorporates a multidisciplinary team approach across various departments and health disciplines.4 The United Arab Emirates is a federation of seven emirates, and is considered one of the richest countries in the world by per capita gross domestic product.5 TABLE 1 presents the population figures for each of the seven emirates as of 2005. The largest two emirates (by population) are Abu Dhabi and Dubai. The UAE health sector is divided into a public and private sector. The public sector is governmentowned and operates under the Ministry of Health, with different health authorities in each emirate. According to the 2007 Dubai Healthcare Provision Report, more than 69% of hospitals are government-run.6 The private sector varies in its size in each emirate and in the level of health care services it offers.7 In terms of work force, the private sector employed more than 4644 physicians in 2007.6 One contributing factor to more physicians moving to the public sector is salary. For public sector employees, the United Arab Emirates’ Ministry

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS, 30(4):251–256, 2010

Younies et al. TABLE 1. UAE Population

Emirate

Population

Abu Dhabi

1 292 119

Dubai

1 200 309

Sharja

724 859

Ras Al-Khaimah (RaK)

197 571

Ajman

189 849

Al-Fujeira

118 617

Umm al-Qaiwain (UAQ)

45 756

TOTAL

3 769 080

Population figures as of 2005 based on the General Census, available at: http://www.tedad.ae/english/population-results.html.

of Health is currently reevaluating health care pay scales in order to increase wage fairness. A Medical Times survey indicate pay scales vary substantially across the Middle East within professional groups.7,8 The blend of public and private sector health care services in the United Arab Emirates contribute to the area’s developmental growth, and further study of the region’s political and cultural aspects is warranted.9 The physicians breakdown as shown in TABLE 2. Requirements for CME vary by region of the world. Peck et al.1 find that half of the countries in the Western hemisphere are using a credit hours system, with one credit per hour of attendance. The number of credits required varies from 50– 100 hours per year. In the United Arab Emirates, the Abu Dhabi Health Authority requires a mandatory 50 hours of CME per year.10 Of those 50 hours, a minimum of 25 must be formal education as provided by accredited medical institutions or professional bodies. The other 25 hours can be in the form of informal self-learning. This 50-hour requirement is mandatory for license renewal. Debates have ensued regarding the professional bodies that conduct such training. An article in the newspaper Al Bayan on medical conventions in the United Arab Emirates sheds light on several problems regarding CME training in the country.11 The Under-Secretary for Health TABLE 2. Health Care Worker Breakdown According to Specialty in Abu Dhabi and Dubai

Abu Dhabi Dubai

Consultant

Specialist

General Practitioner

Total

333

482

432

1247

98

565

669

2465

2005 MOH census, available at: www.moh.gov.ae. 252

noted that some conventions are held on the same topic within the same week, with no benefit to the medical profession, who say, “no new developments in knowledge could take place in a week.”11 This repetition of course offerings within such a short timeframe illustrates a lack of focus on training in favor of an emphasis on maximizing session profit. Dr. Mustafawi, the head of the Emirates Medical Association, concurs that these conventions are aimed only to make a profit. In the same article, a pharmaceutical company manager admits that his company arranges conventions after the release of new medicines. Considering the views of medical society, medical professionals, and existing literature, the purpose of this study is to explore the views of the UAE medical professions on CME. Taking into account the various opinions of CME in the region, the article authors conducted several personal interviews with practitioners in the health care system, which yielded mixed opinions. Public sector physicians did not complain about CME; they normally attend CME sessions in public hospitals without major issues of conflict over time scheduling. However, private sector physicians spoke of several problems they encounter by attending CME training at medical conventions and seminars. These problems are similar to the problems cited in existing literature.12 Writers note that more than 60% of CME in the United States is funded by pharmaceutical companies,13 and that such CME places a financial burden on medical professionals in Canada, though measures have been taken by different government bodies to ease this burden and to remove the bias of CME sessions arranged by pharmaceutical companies. Noyek et al note that the Canadian government assists in financially sponsoring various CME conferences.4 Studies by Elliott12 and Hasan et al14 report that in Wales geriatricians lose their leave entitlement by attending CME programs. The issue of CME efficiency has been discussed by Hayes,15 who points out that there is little evidence that CME training has any effect on medical professional performance and competence. Padki16 agrees with Hayes15 in concluding that “unless the needs of the scheme are set objectively,” there will be a danger of CME’s becoming an “end in itself,” with the only beneficiaries being the “proliferating” CME suppliers. Their major complaints were about the following: the financial burden, the lack of logistical assistance in attending the sessions, the lack of interest among the attendees. Kempkens et al examined opinions of CME by German ambulatory physicians.17 Their findings indicate that physicians desire other parties (ie, insurance or government) to share financial responsibility for CME. Other CME concerns center on the relevance of the material and the seriousness of the session itself, in that participants were getting credits by paying for the sessions without attending most of them.17 Based on these documented concerns on the relevance, cost, and logistics of CME in various countries, this study examines the opinions of CME medical professionals in the United Arab Emirates. This is one of the first surveys to examine perspectives of CME in the United Arab Emirates, and

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—30(4), 2010 DOI: 10.1002/chp

Perceptions of CME in the UAE

seeks to expand knowledge surrounding CME and training in the Middle East. Our focus on the United Arab Emirates contributes to literature examining health care training and skill level in the United Arab Emirates. Prior research documents that UAE physicians’ ability to interpret radiographs did not improve with additional training, yet their skill level was comparable to U.S. subjects.18,19 For health care to improve in the Middle East, concentrated attention on CME availability, cost, and content are crucial.

TABLE 3. Respondents’ Profile (n = 143)

Profile

Sector

Education level

Category

Frequency

Percent

Public

62

43.4

Private

73

51

Self Employed

7

4.9

Others

1

0.7

Diploma

31

21.7

Research Methodology

Professional

28

19.6

Sample and Questionnaire

BSc

40

28

This study was conducted during December 2008 through February 2009 using a 6-part questionnaire. The English language questionnaires were personally distributed to 4 of the 5 public hospitals and 6 private hospitals and clinics in Abu Dhabi and Dubai by 2 of the study’s authors, along with research assistants. These are the two largest emirates in which CME is offered. Three hundred sixty questionnaires were distributed to doctors, nurses, and dentists. Researchers noticed that 2 private hospitals refused permission to participate in the survey when asked by surveyors, and hospital administrators failed to provide specific reasons for the refusal, which limited the number of respondents. A total of 169 questionnaires were completed, of which 26 were discarded due to incomplete information. Our final sample of 143 represents a 40% response rate. Demographic information of the sample is reported in TABLE 3. Of the 143 respondents, 62 work in the public sector and 73 in the private sector. Only 7 reported themselves as self-employed. 50.3 percent of the sample respondents are male. The respondents’ roles in the organization are as follows: 27 (18.9%) are physicians (general practitioners); 37 (25.9%) are specialists; 51 (35.7%) are nurses; and 28 (19.6%) are dentists. The education level varies among the respondents: 19 (13.2%) have a PhD, 25 (17.5%) a Master’s degree, and 40 (28%) hold a Bachelor’s of Science degree. Of the respondents, 80 (56%) work for organizations that employ 200 employees or more. In terms of ethnic diversity, 73 (51%) are Arab, 40 (28%) are Indian, and 3 (2.1%) are Chinese. Concerning income level, more than 44% of the sample report income greater than 10 000 dirhams (US$1.00=AED3.67). The questionnaire was developed by the authors because of the criticality of CME to the health profession and to the society in general. The authors focused on one aspect of CME training in the United Arab Emirates—the general health practitioners’ view of CME training and CME itself. Based on feedback obtained from personal interviews with various industry leaders and physicians, and from the authors’ own training experience, 6 different issues of interest to the medical body could be identified. These 6 areas (which are common in CME training) are: the workshop leaders/trainers, the training experience, the relevance of CME information

Type of post

Gender

Ethnicity

MSc

25

17.5

PhD

19

13.2

Physician

27

18.9

Specialist

37

25.9

Nursing

51

35.7

Dentist

28

19.6

Male

72

50.3

Female

71

49.7

Arab

73

51

Chinese

Size of employing organization

Income (in dirhams)

3

2.1

Indian

40

28

Other

27

18.9

Less than 100

28

19.6

100–200

35

24.5

200–300

17

11.9

more than 300

63

44.1

0–5,000

39

27.3

5,000–10,000

41

28.7

10,000–15,000

30

21

more than 15,000

33

23.1

provided in the training session, the training approach, the convenience of CME sessions, and organizational support. The 6-part questionnaire consisted of 28 questions covering these issues and was designed to investigate the views on CME in the United Arab Emirates. A five-point Likert scale was used for the answers, ranging from 1 (strongly agree) to 5 (strongly disagree). In addition, respondents were asked to give an overall rating of CME with a four levels of satisfaction, from 1 (excellent) to 4 (poor). The questionnaire also included space for comments from respondents, where they could freely express their views on any issues. The last section of the questionnaire solicited demographic information. The reliability test for the study is represented in TABLE 4. It reveals a Cronbach’s alpha level of 0.816, which is considered an acceptable level.


253

Younies et al. TABLE 4. Reliability Statistics

TABLE 5. Responses According to Organization Size

Org Size < 100

Cronbach’s Alpha Based on Cronbach’s Alpha

Standardized Items

N of Items

.851

28

.816

Results and Discussion Results indicate moderate satisfaction on the first 6 CME issues (mean = 2.11), with respondents saying that they are not happy with the organizational support received (mean = 3.07). Their level of satisfaction with the workshop leader was moderate (mean = 2.25). This aspect of CME satisfaction should be high (300) expressed overall satisfaction with CME (mean 1.98). These employees ranked their satisfaction with the workshop leader (mean = 2.11), workshop experience (mean = 2.15), and CME relevance (mean = 1.81) higher than the trainees from smaller organizations. Smaller organizations include clinics or hospitals generally with few specialties, staffed mainly by general practitioners (GPs) or clinics with a few staff specializing in areas of high demand (ie, pediatricians, gynecologists). It seems that the CME sessions are not targeting the needs of these health care providers. Testing for mean differences showed a significant difference in organizational support between samples from organizations employing fewer than 100 and large organizations employing more than 300 (t = 3.210, p = 0.003). The CME is a source of greater satisfaction for the trainees who are diploma holders (mean = 1.98) than are the other five items. Diploma holders, usually working as nurses, consider CME as an opportunity to increase their knowledge (see TABLE 6). Apart from the diploma holders, the PhD holders felt most overall satisfaction with the different items. However, they consider the approach (mean = 2.5), convenience (mean = 2.62), and organizational support (mean = 2.98) less than adequate. To investigate this issue further, TABLE 7 shows the response based on job type, which to our knowledge has not been examined in the literature. We found that nurses and physicians are the most satisfied overall by CME (mean = 1.92; mean = 2.07). Mean comparisons shows significant differences in the level of satisfaction with CME convenience felt by nurses and specialists (t = −2.81, p = 0.006) and nurses and physicians (t =−2.309, p = 0.025), as well as the difference in overall satisfaction between nurses and spe254

Minimum Maximum Mean Variance Median

Workshop Leader

1

5

2.46

0.337

2.5

Workshop Experience

1

5

2.45

0.298

2.4

CME Relevance

1

5

2.48

0.421

2.375

CME Approach

1

5

2.55

0.222

2.75

CME Convenience

1

5

2.74

0.373

2.625

Org. Support

1

5

3.28

0.278

3.33

Overall

1

4

2.39

0.396

2

Org Size 100–200


Workshop Leader

1

5

2.21

0.262

2.25

Workshop Experience

1

5

2.22

0.264

2.2

CME Relevance

1

5

2.17

0.672

2

CME Approach

1

5

2.66

0.31

2.5

CME Convenience

1

5

2.63

0.391

2.5

Org. Support

1

5

3.21

0.755

3.1667

Overall

1

4

2.14

0.42

2

Org Size 201–300


Workshop Leader

1

5

2.42

0.147

2.5

Workshop Experience

1

5

2.44

0.126

2.4

CME Relevance

1

5

2.19

0.246

2

CME Approach

1

5

2.60

0.257

2.25

CME Convenience

1

5

2.41

0.515

2.5

Org. Support

1

5

2.74

0.32

2.6667

Overall

1

4

2.06

0.684

2

Org Size > 300


Workshop Leader

1

5

2.11

0.516

2

Workshop Experience

1

5

2.15

0.504

2.2

CME Relevance

1

5

1.81

0.327

1.75

CME Approach

1

5

2.52

0.255

2.5

CME Convenience

1

5

2.51

0.678

2.75

Org. Support

1

5

3.00

0.389

3

Overall

1

4

1.98

0.597

2

cialists (t = 2.579, p = 0.012). Generally speaking, nurses’ salaries are significantly lower than those of other health care workers in the United Arab Emirates, and many nurses lack their own means of transportation to the venue of CME meetings. Based on interviews with health care professionals, health care organizations are recommended to provide


Perceptions of CME in the UAE TABLE 6. Responses According to Educational Level

Item

Diploma

Professional

BSc

MSc

PhD

Workshop Leader

2.16 (0.293)

2.52 (0.414)

2.21 (0.439)

2.29 (0.264)

1.96 (0.458)

Workshop Experience

2.18 (0.304)

2.52 (0.357)

2.23 (0.435)

2.28 (0.26)

1.96 (0.414)

CME Relevance

1.98 (0.512)

2.258 (0.331)

1.91 (0.377)

2.24 (0.404)

2.06 (0.947)

CME Approach

2.4 (0.283)

2.53 (0.428)

2.68 (0.225)

2.7 (0178)

2.5 (0.261)

CME Convenience

2.21 (0.682)

2.73 (0.356)

2.61 (0.445)

2.75 (0.552)

2.62 (0.531)

Org Support

2.97 (0.339)

3.39 (0.618)

2.95 (0.338)

3.12 (0.524)

2.98 (0.568)

Overall

1.967 (0.566)

2.178 (0.374)

1.975 (0.589)

2.28 (0.377)

2.27 (0.801)

Their views about the significance of CME for professional development in the United Arab Emirates were consensual.

TABLE 7. Responses According to Type of Post Held

Item

Physicians

Specialists

Nursing

Dentist

Conclusions Workshop Leader

2.33 (0.51) 2.30 (0.372) 2.12 (0.351) 2.31 (0.364)

Workshop

2.34 (0.519) 2.32 (0.37) 2.15 (0.317) 2.28 (0.336)

Experience CME Relevance

2.24 (.459)

2.24 (.654)

1.94 (.386)

1.93 (.369)

CME Approach

2.65 (.299)

2.62 (.277)

2.48 (.242)

2.57 (.266)

CME Convenience 2.63 (.468)

2.83 (0.40)

2.28 (.548)

2.68 (.521)

Org Support

3.08 (.533)

3.21 (.571)

3.07 (.318)

2.88 (.531)

Overall

2.07 (.533)

2.32 (.559)

1.92 (.474)

2.21 (.545)

more logistical support for this group of health care workers when they attend CME sessions. In terms of ethnicity and gender, we expected the female respondents to be more concerned about convenience and organizational support than male respondents—an assumption based upon the conservative society within the Arabic culture that values female privacy. The study did not, however, find any significant difference in the response according to gender, ethnicity, or type of organization. Exploring the questionnaire items individually, it was found that 31% of respondents said they would not take CME if it was not necessary for their license. Approximately 63% agreed or strongly agreed that the cost of CME is excessive. Of the respondents, 65% said that their organization would not support CME if it was not necessary for their license. An overwhelming majority (90%) agreed that CME is necessary to set standards in practice, particularly licensing standards. Medical technology trends in the region also support the need for relevant CME for health care professionals to meet expanding licensing standards established by the Dubai Health Authority.20 The majority of respondents who supplied the one-page comment complained about the cost and convenience of CME. Those respondents must have felt strongly about these issues to have added to their answers in this way.

Professional development in health care is an important issue, as indicated by the global growth of the health care sector. Several forms of professional development are sought by health care professionals, including self-education, conferences, online cases, subscriptions to medical journals and research.21 Furthermore, research indicates that the growing globalization of the health sector supports the need for multidisciplinary collaboration efforts within CME.4 Our sample of UAE health care workers agreed on the importance and relevance of CME to the development of their profession, even though the majority of healthcare workers are expatriates. However, several issues must be attended to, such as organizational, logistical, and financial support to attend CME programs. These issues must be addressed in order to sustain the viability of health care workers attending CME. The UAE government works hard to develop the health services in the United Arab Emirates and has launched several projects at a cost of hundreds of millions for the infrastructure of the health service and its personnel. They are making efforts to ensure the quality of health services by the development of local human resources and through outsourcing. The quality of CME programs should be part of this development. Further studies will be needed to cover other issues related to CME, such as the effect of such continuing education on the competency and efficiency of health care workers.

Lessons for Practice •

UAE health care workers agreed CME is an important tool for professional development.

•

Logistical and financial support should be provided, especially for private health care workers.


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Younies et al.

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