From field of dreams to back to the future? Exploring barriers to participating in continuing professional development (CPD) programs | BMC Medical Education

Context

Saskatchewan is one of Canada’s 13 provinces and territories with a population of over 1 million, half of which live in major cities, Saskatoon, and Regina [28]. The province boasts a distinct population distribution that includes urban, metropolitan, indigenous communities and rural and remote areas [29]. As of March 31, 2020, Saskatchewan had 2,622 licensed physicians, of whom 1,330 were family physicians, with 52% in urban areas, 25% in rural areas and 23% in smaller cities [30]. Most physicians in the province have an academic appointment with the College of Medicine at the University of Saskatchewan.

Positionality and reflexivity

CM, JB, TSW, and CH are Canadian board-certified practicing physicians with leadership positions in FD, CME and DME in the College of Medicine. UO is a physician and PhD candidate with the University’s College of Medicine and is not affiliated with the University’s FD, CME or DME departments. UO facilitated participant recruitment, data collection, and data management (collection, analysis, and interpretation). The research team met biweekly via videoconference to discuss concerns, resolve conflicts, and ensure strict adherence to research protocols.

Study design and methods

This study design was guided by a collaborative inquiry framework, which is grounded on the principles of participatory research [31]. Within this participatory framework, and from the participants perspectives, we gain insights into how we might work collaboratively to explore faculty concerns and what barriers exist to enhanced participation. Within this framework, we actively engage participants to learn from their perspectives how we could collaboratively address the concerns of faculty engagement delineated in our study objectives. Our study methods included focus group discussions and interviews.

Study setting

This study was conducted in the Faculty Development office of the University of Saskatchewan. All focus group discussions and interviews were conducted using Zoom (Zoom Video Communications, San Jose, CA) and Webex (Cisco Systems, Milpitas, CA) platforms. Participants included physicians (MDs) and other academics (i.e., PhDs) irrespective of their attendance at university organized CPD events.

Participant recruitment and sampling strategy

We employed a mixture of purposive and convenience sampling approaches while estimating that a sample size between 15 and 30 participants would achieve outcome saturation for our study. Invitations were sent from the FD office to all registered physicians and medical faculty members with the University of Saskatchewan via e-mails and word of mouth.

Ethical considerations

This study was reviewed by the University of Saskatchewan behavioral ethics board and received exemption status as per Article 2.5 of the Tri-Council Policy Statement (TCPS): Ethical Conduct for Research Involving Humans [32].

Data collection methods and instruments

Informed consent was sought prior to data collection. We conducted three separate focus group discussions for each category of participants (i.e., attendees, non-attendees, and PhDs). Participants who could not join any of the discussion sessions had individual interviews. Each focus group discussion session lasted approximately 60 min, while the interviews lasted between 30 and 45 min. In both methods, we explained the purpose of the study, guiding the discussions using a semi-structured interview guide for consistency (see Supplementary File A for guiding questions for all sessions). The pilot tested interview guide explored the following questions: (a) What discourages you from attending university-organized CPD programs, and (b) What ways do you think can enhance participation in CPD university-organized programs? All sessions were audio recorded, and field notes were taken. All data were stored in the FD office under the supervision of the principal investigator (CM).

Data processing and analysis

All audio-recorded data were transcribed for thematic analysis following the steps prescribed by Braun and Clarke [33]. Individual transcripts and field notes were analyzed line-by-line and categorized based on interview questions. We used NVivo version 12 (QSR International, Burlington, MA) to code, categorize, and quantify participant responses by frequency and emerging themes. The University’s Canadian Hub for Applied and Social Research (CHASR) also independently analyzed the transcripts for contents and themes. The team determined the study had reached data saturation after non new information emerged nearing the end of the data collection. All themes and subthemes were shared with participants and research team members for feedback and validation of interpretation.

Techniques used to enhance rigour and trustworthiness

We employed the strategies for ensuring trustworthiness in qualitative research as proposed by Guba [34], Shenton [35], and Patton [36]. Credibility was established through member-checking with participants. Confirmability was ensured through independent data analysis, triangulation and comparing codes and emerging themes for similarities. For validation and clarity, we pilot-tested our interview questions with 5 individuals prior to commencement. Research biases were addressed via researcher reflexivity and debriefing meetings. We achieved transferability by adhering to the Standards for Reporting Qualitative Research [37] for study reporting.

Findings

Demographic information of all participants

We interviewed 34 faculty members. Of all our participants, 32 were physicians, and 2 were PhDs. Seventeen were male, 25 were urban physicians, and nine were rural physicians. Eighteen were family physicians, while other specialists included anesthetists, surgeons, emergency medicine physicians, critical care specialists, internists, and pathologists. The duration of professional practice ranged from 3 years to over 20 years. Seventeen were White. Twenty were identified as non-attendees to CPD programs. Detailed descriptions are presented in Table 1.

Synthesis and interpretation

Given the wide range of participants, we used the term ‘CPD’ to refer to both FD and CME unless specified. It is important to highlight that not all our participants had a strong teaching role. Those who were not engaged in much teaching put stronger emphasis on the role of CME (rather than FD) in their affiliation with the university. Figures 1 and 2 provide an overview of the findings from this study categorized for sub-groups (Fig. 1 categorized for urban, rural, specialist and PhDs; Fig. 2 categorized by attendees and non-attendees). For this study, we only report findings to the questions that explored: (a) reasons for non-participation in university-organized CPD programs and (b) ways to enhance participation in CPD university-organized programs. We grouped our findings into the following themes and subthemes:

What are the barriers to participating in CPD programs?

We noted seven themes on why faculty members did not participate in university organized CPD programs:

Time constraints and lack of remuneration models for participation

Time constraints were the most common theme and reason given for nonparticipation in CPD activities. Twenty-one (61.8%) participants reported time constraints due to competing priorities such as clinical work, research, personal time with family, administrative demands, and the impacts of burnout.

There is limited time available for educational activities…I have been given 10% of my time toward teaching and research at the university. 10% is very tiny, but then asking me to attend College of Medicine activities like the FD is an extra ask of my time rather than my employer’s time.

Time constraints were also closely related to faculty members’ contract type/remuneration model. Physicians with the College of Medicine are remunerated in several ways that interplay with their perceived response to physician engagement. Models of remuneration include salaried, contracts and fee-for-service (FFS).

So, I work fee for service, so if I’m not working, I am not earning money.

Trying to convince people to do more than they are paid for is truly a challenge. So… that’s the main impediment to faculty development.

Organizational and logistical concerns

Organizational and logical concerns were another common theme (19/34; 55.9%) identified as barriers to participating in CPD programs. These included the relevance and applicability of CPD topics to practice, the perceived academic quality of presenters, modes, and nature of advertisements for CPD programs (e.g., verbose and lengthy e-mails versus concisely worded catchy titles), meeting venue (in-person versus virtual), location (centralized versus scattered), time of the event, travel distance, parking, and the general organizational structure of university-organized CPD programs. Fifteen (15/34; 44.1%) participants cited that the topics advertised for CPD were either too lengthy to read, difficult to sign up for, lacking in catchy phrases that ignite enthusiasm, or showed no relevance to their fields of practice.

I am a family physician in a niche field…I stopped attending because I didn’t find what is discussed relevant to advancing my knowledge in my field….

FD and CME programs don’t have punchy lines or topics that are appealing to my field….

The quality of CPD program delivery also challenged participation. Two urban physicians described their unwillingness to participate in locally organized CPD programs due to the perceived poor quality of program organization and the caliber of presenters invited to these events.

…in my humble opinion, we need to increase the calibre of the delivery of the CME so people can be interested….

I have been here for many years, and I haven’t seen anything change in the type of speakers presenting….

Participants also cited that centralized CPD programs were nearly impossible for faculty members working outside of Saskatoon to attend in person. Additionally, connecting virtually to a CPD event designed to be attended in person was not preferred because of other issues, such as the feeling of exclusion and other technical problems associated with connectivity.

It is overwhelming when all you do is interact with others through a screen…it is even more overwhelming when I am the host….

A perceived lack of accountability

Some physicians expressed a feeling of frustration with the lack of accountability, direction and supervision by the university’s leadership structures, describing these as barriers to engaging in CPD programs.

If the College was valuing my teaching, they would actually have somebody come and look at it and then tell me how to do it better.

As far as the university goes, there are no reviews, no quantification of the teaching or effort or learning activities or growth. We don’t [have them], and there are no reviews or anything of what work we do for the university.

Additionally, although the tracking of credits for CME appeared to ease the question of accountability for some, there was still that challenge for FD events causing physicians to prioritize clinical work and its competencies over their academic commitments.

Physicians who identify themselves mostly as clinical physicians, feel that patient care and safety, are more important than teaching….

A perceived lack of a sense of community and collegiality among faculty

The lack of community and camaraderie was a recurring theme among most rural physicians (7/9; 77.7%), a few urban physicians in niche specialties (3/25; 12.0%), and the PhD faculty. A newly employed faculty member speaking about the reasons for not engaging in CPD programs commented on the challenges of navigating between work and other faculty-related activities.

It’s a weird position I feel like I’m in, because…nobody knows me when I try to engage with them… not only is there disconnectedness, but it is also like nobody truly cares….

In addition to the lack of community and camaraderie, approximately 30% of physicians spoke about their experiences with racism and discrimination being internationally trained medical professionals and the hostile working environment this created.

…there is racism. In addition, so, coming into a CPD meeting as a person of color, people look like, what are you doing here, and act surprised to see you.

…There is also the distinction between international medical graduates and Canadian medical graduates, which determines how they engage with you….

Two physicians in niche specialties expressed a feeling of disconnection from the College, as most events were tailored to areas outside their specialties.

There’s almost no sense of community in the other people who may be attending…the connectedness to my niche is sometimes overlooked. In addition, so, I go elsewhere for CME….

The PhD faculty members also expressed some level of disconnectedness or exclusion from CPD programs organized within the College of Medicine.

… I fully understand that being part of the College of Medicine… has been to produce MDs as well as support their continuing medical education… but we don’t feel included as part of the College…they don’t feel the need to pass on information with us.

Lastly, with the world engaged in only virtual events over the year of the study, it was even harder for some participants to start or renew a sense of community when all attendees were sitting in their own spaces and unable to communicate in a way that fostered collaboration and community.

This last year has been a lot of virtual retreats, webinars, and that kind of thing. In addition, I truly miss the interaction, the more direct interaction with colleagues. I truly miss the contact. It’s just not quite the same over video.

… it’s harder to engage over a virtual platform casually. I think that is the biggest problem.

A perceived lack of recognition and incentives

A few participants (4/34; 11.8%) expressed the absence of recognition and incentives (financial or nonfinancial) for their roles and efforts in the areas of teaching and research as barriers.

Speaking about FD activities, I will be on the borderline of that and say, there’s very little incentive for participation….

…there’s no recognition if we do an extra teaching or involvement or education or other things anyway.

…there’s no remuneration. I was not deducted time in any way. I was allowed to have some time from my employment to attend as a continuing education opportunity; still, there was no financial incentive for doing that.

Fear of being vulnerable, and lack of motivation

Three participants described the fear of being vulnerable or being perceived as less competent as their peers as a barrier to participating in university organized CPD programs.

I think some people might find it embarrassing to reveal themselves as perhaps being less capable compared to their peers. I think it’s put some of them in a vulnerable position which can be threatening.

Two participants mentioned a lack of external motivation for personal development regarding teaching as a challenge to CPD attendance.

…we truly struggle with faculty development… there’s truly no motivation…, I guess other than internal motivation, you know, to be a better teacher and a better educator.

How can faculty engagement in CPD programs be enhanced in the college?

Participants suggested ways faculty engagement could be enhanced to encourage participation. These included:

Building stronger communities of practice

All participants cited community building as a critical factor in engagement. A few ways suggested are listed below:

Involving physicians in decision-making processes to ensure programs are designed to match professional needs.

I guess if people were to reach out to us and determine what we’re interested in and maybe what topics would generate some attendance over time.

Building personal and interpersonal relationships among colleagues in the College of Medicine.

…the vast majority are not going to see the benefit until we start building relationships among ourselves.

Promote diversity within CPD program delivery.

…we should find a way to recruit diverse people, for example, someone of Nigerian ancestry comes in, you want to attend;… some Pakistani or (an) Indian person.

Building empathy toward physicians to nurture their inherent love for learning

Participants expressed that they are more than simply faculty – they have multiple roles, and often these roles are at odds with one another. Continuing professional development was identified as important to their faculty roles but must not be delivered and collected in a way that is further burdensome or neglectful of the inherent love of learning that most identified within themselves.

So having CME that is flexible, that doesn’t feel like one has to sacrifice time against life-work-balance, and where the love of learning is utilized.

Incentivizing participation in CPD activities

This was a common theme among young faculty members with fee-for-service remuneration. While financial incentives were acknowledged, the participants expressed other ways to incentivize CPD programs (such as the caliber of the speaker, the topic of discussion, method of delivery, quality of presentation, acknowledgments, awards, credits, and recognition) to encourage participation.

“You need to spark interest for the physicians to be partnered. It should be considered as part of not only the requirement but also their achievement. I’d like to see a better incentive… It’s not always about the money; it’s the respect.

Integration of programs and activities delivered to physicians

Physicians feel they receive many e-mails from several affiliated programs under the same organization and other medical organizations. Therefore, integrating multiple programs into a singular platform would be a way to encourage participation.

…I get tonnes of emails from different medical bodies under the University about their own CME… they’re not well integrated. Having them work together would help.

Providing more support for medical faculty to thrive in their career pursuits

With the multiple complaints with the lack of accountability for CPD, participants felt that the College could do much more, starting with the hiring process. Participants suggested that the College should attract and retain higher calibre physicians with expectations clearly defined at the time of hiring. They also recommended that CPD events not be add-ons (e.g., tagged into pre-existing meetings) but separate events with engaging speakers that discuss interesting, relevant, experiential, and consensus- chosen topics. Finally, physicians recommended having local support to assist faculty in achieving CPD deliverables and expectations. Supports such as funding, grants, mentorship, and accountability exemplified.

Determining areas of interest or need among faculty members

There were advocates among the participants to have CPD topics that were consensus driven. Many participants highlighted the importance of an engaging and relevant topic for CPD. A couple of participants suggested surveying the faculty to determine how to proceed with CPD in the future:

I think that the content should also be consensus driven. What do the majority want to learn and experience?