|Year : 2014 | Volume
| Issue : 1 | Page : 13-19
Continuing medical education in Saudi Arabia: Experiences and perception of participants
Mohammad A Alkhazim1, Alaa Althubaiti2
1 College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
|Date of Web Publication||30-Jan-2014|
Mohammad A Alkhazim
College of Applied Medical Sciences, King Saud Bin Abdualziz University for Health Sciences, National Guard Health Affairs, Riyadh
Introduction: Continuing medical education (CME) is important in developing competencies of medical practitioners with all the different influencing factors that have impact on their opinions and preferences. Despite the broad range of work on CME, very few studies have examined participants' opinions and attitudes towards CME. However, understanding them is critical in improving the practice of CME.
Purpose: The purpose of this study was to explore attendees' perception of CME in Saudi Arabia regarding the different aspects of its practices and preferences.
Materials and Methods: A survey composed of demographic questions, frequency of reading habits and 24 other related items was developed for CME participants. Participants were asked to indicate the extent to which they agreed or disagreed with each of the 24 items on a 5-point Likert scale. In total, 601 surveys were analysed.
Results: The response to each item in the questionnaire was compared on the basis of demographic variables. The results showed that healthcare practitioners acknowledged the importance of CME in improving their knowledge, attitudes, clinical and academic skills, as well as improve their clinical practice outcome. Differences of opinion were categorised by gender, profession, nationality and age.
Conclusion: The study showed that opinions related to CME varied among different disciplines and nationalities. Moreover, it raised questions related to the system of sponsoring participants to attend CME events and its consideration for ethical issues. There is a need to embed the concept of lifelong learning into the education of basic health professions. In addition, the policies related to sponsoring and accrediting CME in Saudi Arabia should be improved. We recommend further research into this matter.
Keywords: Continuous medical education, general opinions, methods of conducting, Saudi Arabia
|How to cite this article:|
Alkhazim MA, Althubaiti A. Continuing medical education in Saudi Arabia: Experiences and perception of participants. J Health Spec 2014;2:13-9
|How to cite this URL:|
Alkhazim MA, Althubaiti A. Continuing medical education in Saudi Arabia: Experiences and perception of participants. J Health Spec [serial online] 2014 [cited 2019 Aug 25];2:13-9. Available from: http://www.thejhs.org/text.asp?2014/2/1/13/126059
| Introduction|| |
Developing human resources requires extending education and training beyond basic qualification. In healthcare, continuing medical education (CME) is a major tool needed to update and refresh a practitioner's experience, as a result, supports the goal of being a lifelong learner. CME is composed of 'educational activities' that serve to maintain, develop, or increase the knowledge, skills, performance and relationships that a physician/clinician uses to provide services for patients, the public or the profession.  Activities, such as conferences, workshops, symposia, courses, departmental targeted educational meetings and others are considered to be types of formal CME. This does not exclude personal efforts such as frequent/habitual reading and inquires which help a person to be updated about his/her professional development.
A term that is often used interchangeably with CME is continuing professional development (CPD). It includes educational methods beyond typical educational formats including self-directed and learner-centred approaches.  Depending on its purpose, CPD can be viewed as a method to keep track on clinical, managerial and professional development, and is closely associated with revalidation and appraisal.  Both terms are equally important in maintaining high quality health services.
Successful conducting of CME activities depends on several factors which may include social or regulatory aspects, such as healthcare setting, culture of education, funding, accreditation requirements and credit hour regulations. Equally important are individual learners, team members, time management and professionalism. All these factors need to be considered for developing strategic planning and determining priorities, goals and understanding of trends/barriers related to effective CME. 
Saudi Arabia is not different from other parts of the world, in which its human capital development in health sciences is facing several challenges and obstacles that need to be studied from different perspectives. Al-Shehri et al.,  listed several challenges that face Saudi CME. These are coherence between educational activities and work experience, co-operation and co-ordination among multiple providers, resources, assessment of needs, effectiveness and quality control.
Mansoor  suggested that despite theoretical shifts in thinking and rise in the importance of evidence-based medicine, traditional styles of expert-led teaching still prevail in Saudi Arabia's postgraduate CME. At the undergraduate level, due to changing theoretical and practical perspectives, many changes have taken place in the curricula of medical schools. Less is known about the extent to which the new theoretical bases of undergraduate medical education have translated into CME.
The Saudi Commission for Health Specialties (SCFHS) is the national body that approves and accredits all CME in Saudi Arabia. During the year 2010, it approved 5,610 activities and accredited 41,735 CME hours.  The SCFHS has imposed that all healthcare practitioners must acquire a certain number of CME hours as a prerequisite for re-licensing to practice in the Kingdom. The underlying assumption behind these regulations is that attending CME events assures the development of attendees' knowledge and skills, etc. Al-Shehri et al., argues this assumption and called for a better way to evaluate CME and its mandate for practitioners.
CME is an activity that involves many players such as: Providers, sponsors, participants/learners and regulators. Participants of CME events are the main benefiters of its outcome. Attention to adult learning principles includes enabling learners to be active contributors to training and the necessity of tailoring curricula according to learners' goals.  Thus, understanding trainees' views about different aspects of CME will help in developing related policies and regulations. In Saudi Arabia, there have been no significant studies that evaluate such aspects.
The purpose of this study was to present the opinions of CME participants in Saudi Arabia in regards to the importance and preferred method of conducting CME. The study is the first of its kind to explore the differences of opinion related to CME among professions, age groups, years of experience, genders and different nationalities.
| Materials and Methods|| |
This was a survey type study. The initial draft of the survey was developed by researchers, then reviewed by three experts specialised in CME, medical education and statistics. Subsequently, a pilot sample of 30 surveys was run and analysed. Finally, there was another round of review by the same experts prior to accepting the survey in its final form. The survey contained demographic questions, 24 items on general opinion about CME (11 items) and about appropriate methods of conducting (13 items). In addition, there were questions regarding CME events attendees' source of sponsorship and the frequency participants read scientific resources, such as scientific journals or books. Participants were asked to indicate the extent to which they agreed or disagreed with each of the items on a 5-point Likert scale with endpoints that were labelled 'strongly disagree' and 'strongly agree'.
The survey was distributed at 30 CME events over a 6-month period (May-October 2012). It was distributed at the beginning of the event and then collected towards the end of the event by research assistants. The study sample consisted of 601 surveys out of 1,400 distributed surveys from participants who were attending CME activities in Riyadh from May-October 2012. The participants completed the survey during their attendance at a number of conferences, workshops, symposia, journal clubs and short courses.
Most of the data was collected in the form of ordinal scales. The categorical data was expressed as frequencies and percentages. For each item, the 5-point Likert scale was grouped into 'agree', 'disagree' and 'neutral' for the purpose of easy analysis and interpretation. The mean and standard deviation (SD) is given for each response. Data was analysed using SPSS version 16 for Windows. The response to each item in the questionnaire was compared on the basis of profession, age, years of experience, gender and nationality using Mann-Whitney U and Wilcoxon signed-rank tests, followed by post-hoc analysis for difference between comparison groups using Mann-Whitney U tests. A P-value or P < 0.05 was considered significant. Bonferroni correction to modify significant levels was used for multiple comparisons.
| Results|| |
[Table 1] shows the distribution of the sample based on gender, nationality, age, profession and attained highest degree. Out of 1,400 distributed surveys, the study included 601 surveys from participants, a response rate of 43%. The response distribution is displayed in [Table 2] for each of the 24 items in the survey. A comparative analysis showed statistically significant differences in responses to some items based on profession, age, gender and nationality. Significant differences in agreement were found between: the profession on items (3, 14, 19 and 24), age groups on items (3, 4, 12, 14 and 17), years of experience on items (3, 4, 12, 14 and 17), gender on items (8, 10, 15, 19 and 24) and nationality on items (2, 4, 5, 6, 9, 10, 14, 15, 17 and 21). [Table 3] and [Table 4] illustrate these results. Participants' sponsorship sources to attend the surveyed events are shown in [Figure 1], while the frequency of reading scientific resources is shown in [Figure 2].
|Table 2: Frequency (%) of disagreement, neutral and agreement levels on general opinions and the appropriate method of conducting CME across the sample|
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|Table 3: Mean ± SD and P-value for items with significant difference on responses according to profession, age groups and years of experience|
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|Table 4: Mean ± SD and P-value using for items with significant difference according to gender and nationality|
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| Discussion|| |
The purpose of this study was not designed to explain the demographic data of healthcare workers in Saudi Arabia, however, the sample distribution explained it to some extent. For example, non-Saudi nurses formed 85.5% of the total number of participating nurses. This result resembles to a certain degree the actual data produced by the Saudi Ministry of Health, where non-Saudi nurses form 75% of the total number of nurses working in Saudi Arabia.  Another indicator of the nature of health workers' level is the lower number of nurses and other healthcare professionals who hold postgraduate qualifications compared to physicians (participants with postgraduate qualifications were 60.4% physicians, 6% nurses and 17.6% other profession). The age of population reflects the fact that most of the CME participants were young (more than 70% were younger than 40 years and about 40% were younger than 30 years), indicating that the Saudi Health System is a young one. Participants who were physicians tended to be consultants and associate consultants who, presumably, had postgraduate training (60.4%); this suggests that Saudi hospitals provide more support for consultants to attend CME activities rather than junior physicians. According to the by-laws of health systems in Saudi hospitals, funding of professional/scientific paid leaves are for consultants only. 
It was expected to have far more non-physician participants considering their size among healthcare institutions. However, this was not the case where health professions numbered 181 as compared to physicians 151. It is possible that physicians are more involved and/or more aware of the importance of CME. This also might indicate that healthcare professionals are not encouraged or supported enough by their institutions to attend CME activities. Therefore, it is essential that career pathways for other health professionals include appropriate components of CME.
Moreover, sponsoring CME through a third party (commercial agency) is a continuing debate issue due to the conflicts that it might pose between the beneficiary and sponsors. In about half of the samples 289 (48.1%), respondents reported that they attended the CME activity at their own expenses and 198 (32.9%) at the expenses of their institutions. However, 54 (9%) did not disclose their sponsorship source and 60 (10%) indicated 'others'. Hence, it is not clear who sponsored 19% of the sample. This issue needs further investigation, particularly because the SCFHS does not provide clear guidelines or regulations related to conflicts of CME sponsorship. 
The results also illustrated that the differences in educational background and clinical practice influenced the views of participants on CME. This was clear in the way they answered the question related to their familiarity with CME; physicians were significantly more familiar with CME (2.38 ± 0.131; P < 0.001), when compared to other health professions (1.61 ± 0.124). Physicians tend to prefer short courses (1 - 5 days), journal clubs and international meetings (outside Saudi Arabia), when compared to nurses and other health professions with P-values ≤ 0.001.
Age was another major factor affecting participants' attitude towards CME. Those in age groups 41 - 50 and older than 50 years were significantly more familiar with CME than those in the age group 20 - 30 (P < 0.001). Moreover, those older than 50 years believed in the importance of having individual assessment for CME compared to respondents younger than 30 years (P < 0.001). Older age groups (31 - 40 and 41 - 50 year old) also seemed to agree more on conducting CME using conferences (P ≤ 0.001) or regular departmental in-service meetings than the younger age group (20 - 30 years). In contrast, the young participants preferred short courses (1 - 5 days) compared to the older (41 - 50 years old) age group (P < 0.004). This is understandable if explained according to individual needs. Young practitioners with less experience need specific focused training presented in, for example, workshops or courses, compared to older practitioner groups. The latter, presumably, have more experience and are looking for updated trends presented in, for example, conferences or peers' discussion during in-service meetings.
Another reason could be in the way CME is organised in Saudi Arabia, where it is rarely classified as an activity suited to different levels of experience. Al-Shehri et al., , in their review for CME quality and challenges in Saudi Arabia indicated the issue of recognising doctors' needs as a main challenge. Mostly, CME events in Saudi are not categorised into levels, such as beginner, intermediate and advanced. Categorising CME in levels and linking them to career competencies means meeting different expectations from such activities. It also strongly suggests that more people need to move from simple CME into advanced CPD, since it allows room to better develop competences relevant to the practice profile of practitioners. 
The majority of participants were females (357 female to 226 male). This is expected since the majority of the study samples were nurses, with females being the dominant gender in the nursing profession. Medical male physicians were double the number of female physicians, which is again an indicator of the dominant gender in this profession in Saudi Arabia. Females significantly agreed more than males that CME is important in improving clinical and managerial skills (P = 0.046); moreover, they also agreed more that the main driving force for attending CME was licensing/accreditation. However, this result might be due to the nature of practice or profession where most females were nurses and their professional focus centers on developing clinical and managerial skills.
Significant differences were observed between Saudi and non-Saudi participants' opinion about the importance of CME for all the specialties, assessment needs, importance of knowledge retention, importance of improving attitude and importance of improving clinical practice, with P < 0.001 and P = 0.008, 0.001, 0.017 and 0.034, respectively. As such, the study suggests that basic health profession education in Saudi Arabia needs to promote the importance of lifelong learning among their basic health professions' curricula. Interestingly, it is not believed that the main driving force for attending CME is the accreditation or licensing system in Saudi Arabia (P < 0.001). This might be attributed to the relatively undeveloped accreditation system in the country.
Saudi versus non-Saudi preferences on the appropriate method of conducting CME were also significantly different. Saudis prefer short (P = 0.002) and long courses (P < 0.001) compared with non-Saudis who prefer regular departmental meetings (P < 0.001), such as in-service, reading books and journal clubs (P = 0.035). These differences could be explained by the culture of practice in Saudi Arabia and/or their educational background. However, this issue should be investigated in more detail.
This study also addressed personal development through simple questions about frequency of reading scientific materials, such as journal articles and scientific reports [see [Figure 2]. Self-development outside the formal CME meeting is important for lifelong learning. Such development happens through daily practice and personal reading of updated scientific literature. The majority of participants read scientific articles or reports only once a month (48.5% male and 46.2% female) or once a week (33.5% male and 27.4% female). About 2.4% of participants do not read scientific article at all. It seems that healthcare practitioners in Saudi are not much used to reading in their professions. This is another alarming sign that basic education does not build the habit of reading scientific literature among its graduates. However, the study did not explore in depth the habits of reading in the Saudi culture compared to others, or the reasons behind such results or trends. Thus, it suggests further studies in this regard.
| Conclusion|| |
Attendees of different CME events were compared with regards to their profession, age, years of experience, gender and nationality. The participants' opinion offered useful feedback that can be used by educators and CME developers. This study showed that a large number of differences in the attendees' view are likely to be affected by demographic factors. Therefore, the study suggests that the Saudi healthcare system should support all health professions at all levels in attending CME, rather than focusing on one profession or one level of qualification.
CME practice in Saudi Arabia is also not often linked to practical competencies. Thus, there is a need to move from the concept of general CME to more continuous, competency-linked professional development for each profession. More studies are needed to connect learners' opinion with an effective learning strategy, explore other trends in CME, such as electronic CME, in addition to exploring opinions of other players in the field of CME, such as providers and regulators of CME.
The study concludes with two major recommendations. The first one is related to educators in Saudi Arabia who need to imbed the concept of lifelong learning in basic curriculum education, for example, at the undergraduate programmes in all health professions. Lifelong learning includes updating scientific information through reading, engaging and attending CME activities at their different forms. The second recommendation is related to policy makers who need to update policies of sponsoring CME equally and fairly among all members of the health team, as well as observe conflict of interest related to the issue of sponsoring CME. Moreover, the regulator bodies, such as SCFHS should include measures of quality and conflict of interest in its accreditation policies.
Further studies are recommended in terms of utilising new technologies in delivering, sponsoring and regulating CME in Saudi Arabia.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]