Family Practice Vol. 20, No. 2, 192-198
© Oxford University Press 2003
Education in Primary Care |
Continuing professional development (CPD): GPs’ perceptions of post-graduate education-approved (PGEA) meetings and personal professional development plans (PDPs)
Community Clinical Sciences (Primary Medical Care Group), University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton SO15 6ST, UK.
Correspondence to Dr Paul Little; E-mail: psl3{at}soton.ac.uk
Little P and Hayes S. Continuing professional development (CPD): GPs’ perceptions of post-graduate education-approved (PGEA) meetings and personal professional development plans (PDPs). Family Practice 2003; 20: 192–198.
Received 13 March 2002; Revised 5 September 2002; Accepted 4 November 2002.
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Abstract |
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Background. Conventional post-graduate meetings—typically ‘lunchtime’ meetings outside practices—have been heavily criticized. Revalidation is also impending, and there has been associated pressure for the widespread introduction of personal development plans (PDPs). However, there is very little empirical evidence about the usefulness to GPs of different kinds of educational meeting or of PDPs.
Objectives. Our aim was to assess the utility to GPs of different types of post-graduate meeting and PDPs.
Methods. A postal questionnaire was sent to 921 GP principals in three health authorities, who were asked to recall their most recent post-graduate education-approved (PGEA) meetings (practice-based and ‘outside’) and the latest major learning ‘undertaken’ in their PDP.
Results. A total of 698 GPs (76%) returned questionnaires. A substantial minority (208; 30%) had a PDP. Most had undertaken education recently [median time elapsed (weeks): meeting ‘outside’ practice, 4; ‘practice-based’, 5; PDP, 3]. Education had not changed clinical practice for many GPs (‘practice-based’ 39% reported no change; ‘outside’ meetings 50% and PDPs 57%). A change in practice after a practice meeting was related to relevance to everyday practice [disagree/neutral, agree, strongly agree odds ratios: 1.00, 4.22 (95% CI 2.1–8.6) and 5.9 (2.6–13.3), respectively], to lecturer factors (enthusiasm, summarizing important points, handouts) and to social enjoyment. PDPs were less likely to be perceived relevant to practice (practice-based meeting, ‘outside’ meeting, PDPs: 89, 87 and 72%, respectively), as a break from practice (54,72 and 18%), good socially (63, 72 and 15%), good for professional networking (54, 70 and 19%) and glad to have done it (84, 86 and 44%). Being glad to use a PDP was more likely if the learning was clinically relevant, a break from practice, and incorporated professional networking.
Conclusion. Changes in practice after post-graduate meetings are not only related to clinical relevance and lecturer factors, but also to professional and social factors. PDPs may not be providing better learning opportunities or enjoyment than traditional meetings, although GPs who are glad to use PDPs incorporate clinical relevance, a break from practice and networking. Post-graduate tutors should probably continue to support and monitor the lecturer quality and clinical relevance of a balanced portfolio of both practice-based and ‘outside’ meetings.
Keywords. Continuing professional development, GPs, PDPs, PGEA meetings.
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Introduction |
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Continuing professional development (CPD) is likely to be key to maintaining and improving the quality of clinical care, and is likely to be an important element in whatever format revalidation takes. For some time, it has been apparent that GPs will be required to develop personal professional development plans1 (PDPs) and practice PDPs based on the premise that adult learning methods, i.e. that self-directed learning and not more didactic teaching, is more likely to cause doctors to change practice.2 PDPs can include the whole range of learning opportunities—including outside lectures, practice meetings, reading, small group work, significant event audits and Internet searches.
The current post-graduate education-approved (PGEA) system introduced in the UK since 1990 provides income for GPs if they attend approved meetings: each meeting earns accredited PGEA points, and meetings are approved and points awarded by the local post-graduate tutors. There has been marked criticism of the PGEA system, especially of meetings outside practice3—traditionally lecture format ‘lunchtime’ meetings. However, this criticism has been countered by several GPs and tutors with arguments that PGEA-approved meetings have encouraged personal responsibility for CPD, provide rapid updating, allow for professional networking and allow for meeting and quizzing specialists.3 One of the problems in this argument is that there has been very little empirical evidence either way. In particular, there is a paucity of evidence regarding GPs’ perceptions of the usefulness of educational meetings or of PDPs, despite evidence of the importance to GPs of education being related to improved clinical care.4 Interviews with selected GPs who attended a course which included workshops suggested a favourable attitude towards PDPs in principle, although the representativeness of this group of GPs is unclear, and none had experienced this form of learning.1 At a time of rapid change in CPD in primary care, there is clearly a need for better documentation of GPs’ perceptions about different methods of providing post-graduate education.
To maintain enthusiasm for high quality CPD, we also need to understand what factors make GPs glad to perform CPD, and what factors are associated with a change in practice. There is some evidence that structural, practice and demographic factors make a difference in GPs’ motivation to attend.3,5,6 However, there is very little evidence related to particular meetings regarding what predicts overall enjoyment or a change in practice.
We report a questionnaire study where GPs were asked to recall their most recent PGEA-approved meetings—both traditional meetings outside the practice such as lunchtime meetings and refresher course meetings, and practice-based meetings—and also, where appropriate, the most recent entry of learning ‘undertaken’ in their PDP.
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Methods |
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Participants
All 921 GP principals from the principal lists provided by three health authorities were sent a postal questionnaire asking them to recall their most recent PGEA-approved meetings in three separate sections (i) the latest practice-based meeting; (ii) the latest meeting outside the practice (e.g. lunchtime meetings, refresher course meeting, evening meeting); and (iii) the latest major entry of learning ‘undertaken’ in their PDP. Up to two reminders were sent to non-respondents.
Questionnaire
GP characteristics..
The questionnaire contained information about list size, number of partners in the practice, time since qualification, MRCGP status (membership of the Royal College of GPs) gender.
Impact of CPD.. For each form of activity (PGEA-approved practice-based meetings, meetings outside the practice and most recent major entry to PDPs), GPs were asked to document whether there had been a change in practice. Many changes in practice cannot be audited (e.g. type of advice, timing and targeting of advice, decision making underlying the decisions to screen or treat, type of treatment offered to different individuals, etc.) due to the limited documentation provided by notes. These limitations were acknowledged within the questionnaire by asking GPs to indicate whether they had made changes that could be audited (an ‘auditable’ change in practice), a change but which they felt was not auditable, an intended change (to capture wishful thinking) and no change. On a 5-point Likert scale (from strongly agree to strongly disagree), respondents were asked whether the activity had been good socially, a good break from practice, good for professional networking and if they were glad they had done it/attended.
Characteristics of CPD.. For each form of activity (PGEA practice-based meetings, meetings outside the practice and most recent major entry to PDPs), GPs were asked to document the time in weeks since the activity. For practice-based meetings, respondents were asked if the lecturer/facilitator was internal or external, and for both kinds of meeting whether it was a lunchtime meeting, evening meeting or other event (and in the case of ‘outside’ meetings whether it was a refresher course). For both practice-based and outside meetings, the respondents were asked to document the enthusiasm of the lecturer/facilitator, clarity of content, the use of handouts and a summary of important points, and the use of small group work.
Questionnaire development and validity
Face and content validity.11.
A one-page questionnaire was developed to maximize response. It was developed after discussion amongst staff of the undergraduate and post-graduate medical education departments of Southampton University, and then piloting among post-graduate tutors and GPs. The issues raised by educators and GPs included the social and professional benefits of different kinds of meetings, whether a change in practice had occurred, what factors were likely to predict change in practice and whether the GP had been glad to have attended each kind of meeting. This process also ensured that within the limits of a one-page questionnaire, the questions made sense, asked relevant questions and contained the most important domains.
Construct validity.11.
- We hypothesized that there would be an inverse relationship between time since the last meeting and having been glad to attend (i.e. participants who enjoyed meetings would go less often). This was confirmed: compared with those who reported 0–2 weeks since the last meeting, those reporting 3–5 weeks, 6–8 weeks and 9+ weeks odds ratios (ORs) were progressively less likely to be glad to have attended the meeting (ORs 1, 0.78, 0.70 and 0.38 respectively; z trend –3.1, P < 0.001).
- We hypothesized that reported changes in practice would be related to relevance and to being glad to have attended meetings. This was confirmed for both relevance (see main results) and being glad to attend (Kendall tau b 0.37, 0.31, 0.34, all P < 0.001 for ‘outside’ meetings, practice meetings and PDPs, respectively).
Internal reliability.. We hypothesized that there would be broad agreement between lecture content variables, and also between social/professional variables. This was confirmed by factor analysis (which indentifies whether groups of variables are inter-related) using varimax rotation (which helps ensures ‘factors’, i.e. interrelated variables, are distinct). Thus for ‘practice’ meetings, factors analysis suggested two factors: the first factor related to ‘content’, and loaded clinical relevance, enthusiasm of the lecturer and clarity of content. Cronbach’s alpha for the internal reliability of this three-item scale was 0.83, i.e. in the optimal range.6 The second factor (‘social/professional’) loaded ‘break from practice’, enjoyable socially and good for professional networking (alpha 0.80). Very similar results of factor analysis were found for ‘outside’ meetings, i.e. a content scale (alpha 0.78) and a social scale (alpha 0.80).
Test–re-stest reliability..
We mailed the same questionnaire to 30 consecutive respondents after the questionnaire was returned. Test–re-test reliability is difficult to assess if there is significant underlying change in the variables. The median time elapsed since meetings was the same in test and re-test questionnaires despite the second questionnaire being 3 weeks later. This suggests that many GPs were remembering different meetings, confirmed by the modest test–re-test correlation between the time elapsed time since meetings (Spearman r = 0.50). In this context (i.e. a maximal correlation likely to be 
0.50), there was acceptable test–re-test reliability for reported change in practice (Kendall’s tau b 0.38), relevance (0.36) and having been glad to go (0.57).
Sample size (for 80% power and 95% confidence)
To detect a 10% difference in the number reporting an auditable change in their practice, comparing practice-based meetings with ‘outside’ meetings (i.e. 20% compared with 10%) required 438 GPs, or 626 in total allowing for 30% non-response.
Data entry and analysis
Data were entered and analysed using SPSS for Windows and Stata for Windows. Differences in group percentages for ‘outside’ meetings and PDPs compared with practice-based meetings were assessed using the chi-square test. To assess what variables were associated with a change in practice and being glad to undertake the activity, we used logistic regression, and the likelihood ratio test. Variables were entered in the model if they were significant at the 5% level, and if they remained significant.
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Results |
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A total of 698 GPs (76%) returned questionnaires. A substantial minority (208; 30%) had a PDP. Most respondents had undertaken post-graduate education recently [median time since meeting ‘outside’ practice (e.g. lunchtime meeting), 4 weeks (interquartile range 2–10); ‘practice-based’, 5 weeks (2–8); and major learning undertaken in PDP, 3 weeks (1–6)].
Responder characteristics
Non-responders came from slightly smaller practices (responders mean 5.4 partners, non-responders 5.2), and were more likely to be male (72%). However, responders were similar in characteristics to national statistics—most were male (415; 61%) had the MRCGP (413; 61%), had been in practice for a mean of 13 years and were from training practices (372; 55%) with a mean of 5.4 partners per practice.
Perceptions of meetings and PDPs
There had been no reported change in practice for many GPs, and for the majority using a PDP (practice-based, 39%; ‘outside’ meetings, 50%; PDPs, 57%). Most of the changes GPs felt could not be audited (see Table 1
). Compared with practice-based and ‘outside’ meetings, PDPs were slightly less likely to be perceived to be relevant to clinical practice (practice-based, ‘outside’ and PDPs, 89, 87 and 72%, respectively), to be a break from practice (54, 72 and 18%), good socially (63, 72 and 15%), for professional networking (54, 70 and 19%) and glad to have done it (84, 86 and 44%).
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Predictors of reported change in practice
The most important factor predicting a change in practice following a practice meeting was relevance to everyday practice [disagree/neutral, agree, strongly agree, ORs 1.00, 4.22 (95% CI 2.1–8.6) and 5.9 (2.6–13.3), respectively]. Lecturer factors (enthusiasm, summarizing important points, handouts) and social enjoyment also predicted change (see Table 2
). Similar factors were important for meetings outside practices.
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Predictors of being glad to have attended a meeting
The most important factors predicting being glad to have attended a practice meeting were relevance to everyday practice (OR 12, 4.6–31.5) and professional networking (24.9, 7.02–88.4), but lecturer factors (clear content, enthusiasm) and social factors (break from practice, good socially) were also important (see Table 3
). There were similar findings for meetings outside practices. For PDPs, GPs who were glad to be using a PDP incorporated clinical relevance, a break from practice and networking.
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Discussion |
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This is, to our knowledge, the first study to compare quantitatively GPs’ perceptions of different educational meetings and PDPs, and to explore quantitatively what factors are most important in determining changes in clinical practice, and being glad to have attended meetings.
Limitations of the study
Retrospective study..
A significant limitation of this study is its retrospective nature: this study should form the basis of further prospective studies.
Non-response bias and generalizeability.. Although responders were more likely to be female and from larger practices, the responder sample had characteristics similar to national figures.
Validity of measures.. We have shown that the questionnaire has reasonable construct validity and reliability, and, due to the short time interval, recall bias due to memory lapses should not be a major problem. The main limitation in the data is that there is no good ‘objective’ way to capture valuable changes in clinical practice relevant to CPD (e.g. changes in diagnosis, screening behaviour, reasons for investigation, nature of advice, use of medication according to particular clinical indications, etc.), supported by the fact that GPs estimated that most changes in practice could not be audited. However, we tried to capture the wishful thinking element by ‘intended change’ (which we did not count), and errors in reporting change should not affect comparisons between types of post-graduate activity.
What factors are related to change in practice?
Compared with practice-based meetings, there was less reported change following ‘outside’ meetings and PDPs; however, a substantial minority reported no change following meetings, and a majority in the case of PDPs. A major problem for both the current and future systems of CPD is needs assessment,7 particularly since GPs may not be the best judge of their own learning needs.2,8 However, assuming some form of needs assessment is performed, then these results suggest that there should be no great disadvantage of using meetings outside or inside the practice which relate to these needs. Although practice-based meetings perform particularly well, there is no very clear justification from these results to abolish traditional meetings outside practices—which provide important enjoyable opportunities to learn, have a break from practice and encourage professional networking.
The most important factor predicting a change in practice following a practice meeting was relevance to everyday practice, but lecturer factors (enthusiasm, summarizing important points, handouts) and social enjoyment also predicted change. The importance of perceived ‘relevance to everyday practice’ supports previous research about the importance to GPs of education improving clinical care.4 It also supports learning in practice—which should be relevant if it arises from a clinical need identified in the practice, given the provisos discussed above about learning needs assessment. Although many post-graduate meetings do not necessarily have a traditional lecturer (e.g. some may use a facilitator and/or small group work), the significant ‘lecture’ factors identified in this study support the previous literature about effective lecturing.9 Since formal approval of meetings is no guarantee of quality,10 these results also have practical implications for assessing and maintaining quality in post-graduate meetings:
- although in many meetings the social/professional networking aspects ‘happen’ anyway, post-graduate tutors should consider social aspects of meetings;
- the perceived clinical relevance of meetings should be monitored;
- whilst it may be difficult to ensure that the lecturer/ facilitator is enthusiastic, enthusiasm of the lecturer could at least be monitored, and fed back to the lecturer;
- lecturers should be encouraged to summarize important points and provide handouts, and their use in meetings monitored.
What makes GPs glad to undertake CPD?
Whilst enjoying CPD is clearly secondary to the ultimate aim of changing practice to improve patient care,3 motivation for CPD is related to the desire to improve clinical care,4 and if GPs are not glad to undertake CPD (i.e. an overall positive evaluation) they will do it half heartedly. Understanding motivation and the factors contributing to positive evaluation are important in maintaining the enthusiasm and momentum for CPD. Previous work suggests that numerous factors may be involved in GPs’ motivation to attend PGEA meetings, including demographic factors and financial motives.3,5,6 This study documents that the most important factors predicting an overall positive evaluation were relevance to everyday practice and professional networking, but lecturer factors (clear content, enthusiasm) and social factors (break from practice, good socially) were also important.
Why are many GPs not glad to be doing PDPs?
There is a tension between assessing a change after it is well established (by which time it may be more difficult to influence) or in the process of change (when teething problems may occur). It may also be that the GPs who introduce PDP first are by definition happier with innovation, in which case we may have underestimated the dissatisfaction with PDPs. With these provisos, a striking finding was that only a minority of those GPs who were keeping a PDP currently were glad to be doing it. This is somewhat surprising as there is no inherent ‘conflict’ between PDPs and other activities. Thus PDPs can include the whole range of learning opportunities including outside lectures, practice meetings, reading, small group work, significant event audits, Internet searches, etc. GPs should be able to use PDPs flexibly to undertake learning methods that are enjoyable for them and suit them personally. Nevertheless, the inference of these results is that GPs currently enjoy traditional meetings more than those elements of PDPs performed predominantly in isolation. This contrasts with qualitative work where the concepts were welcomed,1 although in the latter study GPs had not yet used PDPs. One issue may be that PDPs are new, and many GPs are not yet used to them. Some GPs have also commented about the lack of time, and yet more time spent on another change in the organization of primary care—a change that they perceive might not last. However, this study provides evidence that one important factor in the lack of enthusiasm for PDPs is that professional and social factors are important in GP enjoyment of CPD (and these occur less with the self-directed elements of PDPs). Post-graduate tutors may need to explore best practice, i.e. what makes PDPs work for the minority who are glad to do them, and encourage GPs to use the great potential flexibility of PDPs to learn in ways they want. One solution to the potential isolation of PDPs may be the use of mentoring, Balint group work, significant event audits as part of PDPs—although this will require a change in the culture for GPs to be able to discuss mistakes more freely. The current study provides direct evidence that GPs are more likely to be glad to undertake learning using PDPs if they are clinically relevant, provide a break from practice (e.g. build in protected time) and incorporate opportunities for networking
Conclusion
Changes in practice following educational meetings are related to clinical relevance, lecturer factors and professional/social factors. PDPs may not be providing better learning opportunities or enjoyment than ‘traditional’ meetings, although GPs who are glad to be learning using PDPs make them clinically relevant, a break from practice and build in networking. Tutors should probably continue to support a balanced portfolio of both practice-based and ‘outside’ meetings. These results also suggest that monitoring the quality of meetings should include assessment of the clinical relevance, opportunities for professional networking, enthusiasm of the lecturer and the use of summary points and handouts.
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Acknowledgments |
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We are grateful to the GPs who helped with this study, and for the advice of Angela Fenwick, Tony Kendrick, Frank Smith, Steve Vincent and Stuart Skeates. PL is supported by the Medical Research Council. This study was support by a small grant from the post-graduate faculty.
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References |
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