Paul Little and Stephen Hayes. Introduction

Transcription

1 Family Practice Vol. 20, No. 2 Oxford University Press 2003, all rights reserved. Doi: /fampra/ , available online at Printed in Great Britain Continuing professional development (CPD): GPs perceptions of post-graduate educationapproved (PGEA) meetings and personal professional development plans (PDPs) Paul Little and Stephen Hayes Little P and Hayes S. Continuing professional development (CPD): GPs perceptions of postgraduate education-approved (PGEA) meetings and personal professional development plans (PDPs). Family Practice 2003; 20: 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, agree odds ratios: 1.00, 4.22 (95% CI ) and 5.9 ( ), 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. Introduction Received 13 March 2002; Revised 5 September 2002; Accepted 4 November Community Clinical Sciences (Primary Medical Care Group), University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton SO15 6ST, UK. Correspondence to Dr Paul Little; psl3@soton.ac.uk 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 192

2 GPs perceptions of PGEA meetings and PDPs 193 personal professional development plans 1 (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 practice 3 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. Methods 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 practicebased 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 (PGEAapproved 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 agree to 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 postgraduate tutors and GPs. The issues raised by educators and GPs included the social and professional benefits of

3 194 Family Practice an international journal 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 (i) 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). (ii) 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 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 practicebased 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. Results 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%).

4 GPs perceptions of PGEA meetings and PDPs 195 TABLE 1 Perceptions and change in practice following most recent PGEA meeting attended/recent major entry to PLP Change in practice Auditable Change but Intend to No change Chi-square (P) change not auditable change Practice meeting 114 (20%) 227 (41%) 108 (19%) 112 (20%) PG lecture outside practice 56 (10%) 225 (40%) 117 (21%) 163 (29%) 24.5 (0.003) PDP 20 (12%) 52 (31%) 57 (34%) 39 (23%) 13.3 (0.148) Relevant to everyday clinical practice Neutral/ Agree Agree disagree Practice meeting 61 (10%) 330 (56%) 196 (33%) PG lecture outside practice 79 (14%) 361 (62%) 147 (25%) 40.7 ( 0.001) PDP 53 (28%) 102 (54%) 35 (18%) 19.8 (0.001) A good break from practice Neutral/ Agree Agree Practice meeting 269 (47%) 222 (39%) 85 (15%) PG lecture outside practice 162 (28%) 291 (51%) 123 (21%) 63.2 ( 0.001) PDP 152 (82%) 27 (14%) 7 (4%) 31.4 ( 0.001) Enjoyable socially Neutral/ Agree Agree Practice meeting 214 (37%) 278 (48%) 91 (15%) PG lecture outside practice 164 (28%) 306 (53%) 113 (19%) 55.6 ( 0.001) PDP 160 (85%) 23 (12%) 5 (3%) 17.5 ( 0.002) Useful for professional networking Neutral/ Agree Agree Practice meeting 265 (46%) 233 (40%) 83 (14%) PG lecture outside practice 178 (30%) 294 (51%) 109 (19%) 88 ( 0.001) PDP 149 (81%) 27 (15%) 8 (4%) 22 ( 0.001) Overall, I m glad I went/glad I did it Neutral/ Agree Agree Practice meeting 92 (16%) 342 (59%) 148 (25%) PG lecture outside practice 85 (15%) 364 (63%) 133 (23%) 70.6 ( 0.001) PDP 104 (55%) 59 (31%) 25 (13%) 19.3 ( 0.001) Practice-based meetings were compared with PDPs and outside meetings using cross-tabulation, and the chi-square test for differences between expected and observed proportions. Marginal totals from the tables of cross-tabulations are quoted for simplicity of presentation. 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, agree, ORs 1.00, 4.22 (95% CI ) and 5.9 ( ), 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. 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, ) and professional networking (24.9, ), 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. Discussion 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.

5 196 Family Practice an international journal TABLE 2 Predictors of reported change in practice following most recent PGEA meeting or most recent major entry in PDP Changed Did not Crude OR Adjusted OR LR test (P) practice change n (%) (95% CI) n (%) Lecture outside practice Type of meeting Other 26 (8) 33 (11) (0.008) Evening 107 (33) 99 (32) 1.37 ( ) 1.25 ( ) Refresher 78 (24) 34 (11) 2.91 ( ) 2.57 ( ) Lunchtime 111 (35) 148 (47) 0.95 ( ) 1.14 ( ) Lecturer summarized important points 276 (85) 210 (67) 2.96 ( ) 2.01 ( ) 9.8 (0.002) Relevant to everyday practice /neutral 9 (3) 75 (24) ( 0.001) Agree 208 (63) 189 (61) 9.17 ( ) 7.76 ( ) Strongly agree 112 (34) 48 (15) 19.4 ( ) ( ) Content clear /neutral 11 (3) 51 (16) (0.009) Agree 228 (70) 220 (70) 4.80 ( ) 2.88 ( ) Strongly agree 88 (27) 42 (13) 9.71 ( ) 3.58 ( ) Practice-based meeting Relevant to everyday practice /neutral 12 (3) 48 (21) ( 0.001) Agree 199 (55) 126 (56) 6.32 ( ) 4.22 ( ) Strongly agree 151 (42) 51 (23) 11.8 ( ) 5.91 ( ) Lecturer enthusiastic /neutral 14 (4) 41 (18) (0.015) Agree 206 (58) 133 (59) 4.54 ( ) 2.75 ( ) Strongly agree 138 (39) 51 (23) 7.92 ( ) 2.69 ( ) Lecturer summarized important points 326 (91) 160 (71) 4.27 ( ) 2.70 ( ) 14.4 ( 0.001) Handout provided 197 (55) 83 (37) 2.11 ( ) 1.76 ( ) 8.6 (0.003) Socially enjoyable /neutral 109 (30) 110 (49) 1 1 z trend 2.28 Agree 179 (50) 93 (41) 1.94 ( ) 1.47 ( ) (0.023) Strongly agree 71 (20) 22 (10) 3.26 ( ) 1.84 ( ) PDP Relevant to everyday practice /neutral 11 (14) 35 (36) ( 0.001) Agree 45 (56) 53 (54) 2.70 ( ) 2.70 ( ) Strongly agree 25 (31) 10 (10) 7.95 ( ) 7.95 ( ) MRCGP 62 (77) 65 (61) 2.06 ( ) 1.97 ( ) 3.64 (0.057) Change in practice: we included reported auditable and non-auditable change in practice as the outcome. Variables tested in model: MRCGP, gender, training practice, list size, enthusiasm of lecturer, clinical relevance, clarity of content, socially enjoyable, good for professional networking, break from practice, use of handouts, summary of main points made, time since meeting. 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;

6 GPs perceptions of PGEA meetings and PDPs 197 TABLE 3 Predictors of having been glad to attend meeting or do PDP Glad Not glad Crude OR Adjusted OR Chi-square n (%) n (%) (95% CI) (95% CI) (P) Lecture outside practice Relevant to everyday practice 532 (94) 44 (45) 20.0 ( ) 23.0 ( ) 71.3 ( 0.001) Content clear 538 (96) 60 (62) 13.3 ( ) 5.68 ( ) 18.2 ( 0.001) Good break from practice 454 (82) 21 (22) 16.0 ( ) 7.64 ( ) 28.7 ( 0.001) Good networking 436 (77) 22 (23) 11.4 ( ) 5.82 ( ) 22.5 ( 0.001) Good socially 450 (80) 28 (29) 9.64 ( ) 2.98 ( ) 7.3 (0.007) MRCGP 317 (58) 67 (74) 0.49 ( ) 0.34 ( ) 8.1 (0.005) Practice-based meeting Relevant to everyday practice 492 (96) 53 (56) 19.5 ( ) ( ) 29.5 ( 0.001) Content clear 489 (96) 58 (61) 15.6 ( ) 3.43 ( ) 5.8 (0.016) Lecturer enthusiastic 486 (96) 59 (62) 13.5 ( ) 6.18 ( ) 13.7 ( 0.001) Good break from practice 312 (62) 10 (11) 13.7 ( ) 3.82 ( ) 9.7 (0.002) Good professional networking 324 (64) 4 (4) 39.8 ( ) 24.9 ( ) 46.2 ( 0.001) Good socially 363 (71) 18 (19) 10.6 ( ) 2.19 ( ) 4.2 (0.040) PDP Relevant to everyday practice 89 (95) 58 (52) 16.3 ( ) 11.7 ( ) 31.4 ( 0.001) Good break from practice 35 (38) 3 (3) 22.3 ( ) 9.56 ( ) 14.9 ( 0.001) Good networking 32 (35) 4 (4) 14.4 ( ) 4.80 ( ) 7.2 (0.007) Variables tested in models: MRCGP, gender, training practice, list size, enthusiasm of lecturer, clinical relevance, clarity of content, socially enjoyable, good for professional networking, break from practice, use of handouts, summary of main points made, time since meeting. 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,

7 198 Family Practice an international journal BOX 1 What is known Selected GPs in previous qualitative studies were happy with the principles of PDPs, but there has been no assessment of GPs perceptions since the introduction of PDPs There has been debate about the utility of traditional meetings outside practices, and a move towards practice-based education, but very little empirical evidence either way What this study adds A large minority of GPs report no change in practice following educational meetings and a majority in the case of those using PDPs Fewer GPs are glad to be using PDPs to learn than attending meetings Being glad to use a PDP was related to clinical relevance, a break from practice and networking Clinical relevance, lecturer factors and professional/social factors were all associated with changes in practice following meetings 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. Acknowledgements 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. References 1 Pitts J, Curtis A, While R, Holloway I. Practice professional development plans : general practitioners perspectives on proposed changes in general practice education. Br J Gen Pract 1999; 49: Cantillon P, Jones R. Does continuing medical education in general practice make a difference? Br Med J 1999; 318: Toon P. Educating doctors to improve patient care. A choice between self directed learning and sitting in lectures struggling to stay awake: editorial, and subsequent correspondence. Br Med J 1997; 315: Smith LF, Eve R, Crabtree R. Higher professional education for general medical practitioners: key informant interviews and focus group findings. Br J Gen Pract 2000; 50: Murray T, Campbell L. Finance, not learning needs, makes general practitioners attend courses: a database survey. Br Med J 1997; 315: Pitts J, Vincent S. General practitioners reasons for not attending a higher professional education course. Br J Gen Pract 1994; 44: Myers P. The objective assessment of general practitioners educational needs: an under-researched area? Br J Gen Pract 1999; 49: Tracey J, Arroll B, Richmond D, Barham P. The validity of general practitioners self assessment of knowledge: cross sectional study. Br Med J 1997; 315: Dunkin MJ. A review of research on lecturing. Higher Educ Res Dev 1983; 2: Nicol F, Patterson W. Does formal approval of educational courses guarantee quality? Med Educ 1999; 33: Wilkin D, Hallam L, Doggett AM. Measures of Need and Outcome for Primary Health Care. Oxford: Oxford University Press, 1992.