Continuing professional development in occupational medicine for general practitioners

Occupational Medicine Advance Access published March 13, 2009 Occupational Medicine doi:10.1093/occmed/kqp013 Continuing professional development in occupational medicine for general practitioners Kevan Thorley, Susan Turner, Louise Hussey and Raymond Agius Background The Health and Occupation Reporting (THOR) network for general practitioners (GPs) offers free online continuing professional development (CPD) to contributing GPs. Use of this resource by members is relatively low. Non-uptake is most frequently attributed to lack of time. The primary aim was to assess the effects of changes made to educational material, available online to GPs participating in THOR-GP, 1 year after a needs assessment which informed the changes. The secondary aim, developed from the findings of the original study, was to compare contributing GPs who undertake work in occupational medicine, with those who do not, in terms of uptake of the educational material and of educational need. GPs participating in THOR-GP, who responded to a questionnaire to assess their use of THOR-GP s website for CPD, were sent a follow-up questionnaire 1 year after the original survey. Both questionnaires comprised scales derived from the syllabus for the Diploma of the Faculty of Occupational Medicine and questions about attitudes to CPD in occupational medicine. No change was found in uptake of or rating of components of the website, following modification. Responders worked on average seven sessions per week in general practice and 1.5 sessions in occupational medicine. GPs working in occupational medicine reported greater confidence in some subject areas than GPs not currently working in occupational medicine and were also more likely to engage in CPD activity within the specialty of occupational medicine. Undertaking work in occupational medicine increases confidence in the subject and stimulates the use of related educational facilities. Continuing medical education; continuing professional development; e-learning; general practitioners; occupational medicine; web-based learning. Aim Methods Results Conclusion Key words Introduction Online learning has the potential to fulfil the needs of general practitioners (GPs) who practise occupational medicine in the UK, but despite the rapid growth of the Internet as a source of continuing professional development (CPD) or perhaps because of its recent rapid growth, web-based learning remains poorly evaluated [1]. The Health and Occupation Reporting (THOR) network, based at the University of Manchester s Occupational and Environmental Health Research Group (OEHRG), comprises a range of clinical specialists and occupational physicians reporting schemes for work-related ill-health. THOR-GP is a scheme in which Occupational and Environmental Health Research Group, University of Manchester, 4th Floor, C Block, Humanities Devas Street, Oxford Road, Manchester M13 9PL, UK. Correspondence to: Raymond Agius, Occupational and Environmental Health Research Group, University of Manchester, 4th Floor, C Block, Humanities Devas Street, Oxford Road, Manchester M13 9PL, UK. Tel: 144 1512755531; fax: 144 1512755506; e-mail: kevan.thorley@manchester.ac.uk GPs report cases of work-related ill-health seen in a general practice setting. Participating GPs are given educational information and resources, including free CPD material on occupational medicine topics via a website [2]. The uptake of the resource is low and lack of time is the most frequently cited reason for non-use [3]. Lack of time has also been given as a reason for non-use of Internet resources by primary care staff in Nottingham and Rotherham [4]. Although protected time is recommended for e-learning in health care organizations, such protected time may not be available to GPs (despite e-learning being perceived as a time-saving method) [5,6]. Designers of educational resources should identify the needs of users (or potential users) and adapt the content and design of material in order to meet the needs of the group and of individual learners. This should result in a continuous process so that a learning cycle may then be initiated and maintained. Feedback from the first cycle of appraisal on THOR- GP s web-based CPD material has been analysed and acted upon [3]. For example, the website was modified Ó The Author 2009. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Page 2 of 5 OCCUPATIONAL MEDICINE using topic headings that were more clearly defined, the amount of text on the first web page was substantially reduced and links to other sites were introduced in order to extend the range of information available to users. In addition, diagnostic categories of cases reported by THOR- GP reporters were linked to relevant educational material on the site, in order to make the act of reporting a case in itself an interactive learning experience. One strategy successfully used to increase participation in online learning is the use of e-mail reminders [7]. The OEHRG maintains regular contact with THOR-GP reporters and as a result of the findings of the first survey, reminders are now sent in regular e-mails and THOR-GP quarterly reports to encourage contributors use of the available e- learning resources. The present study is based on a second cycle of feedback, aiming to assess the effects of changes made to the site and strategies described above. A secondary aim developed from the results of the first survey is to compare contributing GPs who undertake work in occupational medicine, with those who do not, in terms of uptake of the educational material and of educational need. Methods The second feedback cycle involved a questionnaire surveytothosethor-gpreporterswhorespondedto the first survey [3]. In May 2007, postal questionnaires were sent to 169 GPs (of the 213 in the original study), and the questionnaire was also made available on THOR- GP s website for completion online. The second questionnaire was identical to that used in the first feedback cycle, except that questions on GPs age and gender were replaced by those asking about workload (namely sessional work in general practice and/or occupational medicine) and whether their practice was a training practice. The main section of the questionnaire investigated two areas: the educational needs of participating GPs and awareness and use of the CPD material provided on the website. Sources of material used for the questionnaire design were the syllabus for the Diploma in Occupational Medicine (DOccMed) from the Faculty of Occupational Medicine (FOM) [8], the content headings of the CPD material available on the OEHRG website and feedback sections of the BMJlearning and Doctors.net websites. The questionnaire comprised yes/no answers, free text and a five-point scale for questions relating to training and educational needs and effectiveness of the website. For training needs, the scale applied a score from 1 no training needed to 5 I definitely need more training. Non-responders were sent postal reminders at 1 month and 2 months after the first mailshot. Completed questionnaires were returned by post to the OEHRG, and data were extracted and analysed using a standard statistical software package (SPSS 15.0 for Windows). Multicentre Research Ethics Committee approval has been given for THOR and THOR-GP (reference number MREC 02/9/72). Results In the year since sending out the first questionnaire, 23 of the original 213 responders had been removed from THOR-GP because of non-participation, 1 GP was on sabbatical and another was absent from the practice on health grounds, 2 had retired and 17 had withdrawn from the scheme. The second questionnaire was therefore sent to 169 THOR-GP contributors. The response rate after sending two reminders was 83%. Twenty-seven per cent of responders reported that they currently did no work in occupational medicine. Those currently undertaking work in occupational medicine spent 18% of their working week in occupational medicine and 82% in GP work. The mean number of occupational health (OH) sessions per week was 1.5 and of GP sessions 7. Almost half the doctors who responded (47%) worked in training practices. However, working in a training practice was not associated with CPD activity in occupational medicine or with having confidence in subject areas within the DOccMed syllabus. Twenty-three per cent of responders said that they had looked at the educational material on the THOR-GP website, compared with 22% of those responding to the first questionnaire. There was no association between sessional work in occupational medicine and use of the website or use of e-learning material in general. However, working sessions in occupational medicine was strongly associated with other educational activities such as reading occupational medicine journals, attending courses on occupational medicine topics and attending meetings relating to occupational medicine (Table 1). There was no statistical difference between the mean scores for the self-assessment of educational needs from the first questionnaire and those of the second using paired t-tests. However, mean scores were lower (indicating higher levels of confidence) from the second questionnaire for all subject areas, with the exception of one, namely OH services, the OH team, functions and management. Confidence in this single area of the syllabus was strongly associated with responders undertaking sessional work in occupational medicine (Mann Whitney U-test 1447, P 5 0.02), and GPs not currently working in occupational medicine were significantly less confident than those who were working at least one session per week in the specialty (Table 2). Table 3 shows the change in reasons given by responders for not using the educational material available on THOR-GP s website. Lack of time remained the most frequently given reason (58%). However, 71% of

K. THORLEY ET AL.: CPD IN OM FOR GPs Page 3 of 5 Table 1. Association between CPD activity and working in OM CPD activity Number of GPs not working in OM Number of GPs working in OM Total number of GPs Chi squared P-value Do not Use THOR-GP website 28 78 106 Use THOR-GP website 10 22 32 Total 38 100 138 0.3 NS Do not read OM journals 21 25 46 Read OM journals 16 75 91 Total 37 100 137 12.2,0.001 Do not attend OM courses 32 59 91 Attend OM courses 5 41 46 Total 37 100 137 9.1,0.01 Do not attend OM meetings 32 62 94 Attend OM meetings 5 38 43 Total 37 100 137 7.5,0.01 Do not use e-learning 22 55 77 Use e-learning 15 45 60 Total 37 100 137 0.2 NS Do not use other sources a 36 93 129 Use other sources a 1 7 8 Total 37 100 137 0.9 NS OM, occupational medicine; NS, not significant. a Material such as in-house training. Table 2. Association between work in occupational medicine (OM) and self-rating of confidence in two areas of the DOccMed syllabus Core area of syllabus Definition and scope of occupational medicine Confidence self-rating score Number of GPs not working in OM Number of GPs working in OM Total 0 1 0 1 1 10 32 42 2 9 44 53 3 14 16 30 4 2 8 10 5 2 0 2 Total 38 100 138 OH services, the OH team, functions and management 0 1 0 1 1 6 22 28 2 9 45 54 3 13 22 35 4 5 11 16 5 4 0 4 Total 38 100 138 responders to the first questionnaire reported lack of time as a reason for non-uptake. Sixteen responders to the second questionnaire gave specific examples of their educational needs which might be addressed in future by the website for THOR-GP Table 3. Reasons for not using the educational material on THOR- GP s website Reason a reporters. Only two specified OH law (which was the most frequently suggested topic in the first questionnaire), two asked for a general update and two for information about hand arm vibration syndrome. Discussion First questionnaire, number of responders (%) (n 5 166) Did not have 119 (72) 58 (42) the time Not working in 30 (18) 18 (13) occupational medicine CPD in occupational 31 (19) 32 (23) medicine is not a priority Unaware of the 60 (36) 47 (34) material available Unable to access the 9 (5) 3 (2) site (THOR-GP s website) Other reasons 9 (5) 2 (1.5) Second questionnaire, number of responders (%) (n 5 137) a Note that more than one response is permitted for each reason cited in this table. Although the response rate to both questionnaires was relatively high (75% for the first questionnaire and 83% for

Page 4 of 5 OCCUPATIONAL MEDICINE the second), the number of doctors no longer involved in THOR-GP resulted in a smaller population of participants available to respond to the second questionnaire. GPs in this study represent 7% of all GPs practising occupational medicine in the UK, assuming an estimated denominator of 3000 practitioners[9]. However, the sample is drawn from a group of GPs who may be seen as well motivated and enthusiastic since they are contributing to a national reporting network and have achieved a minimum standard of education in occupational medicine. The high percentage of responders who are GPs in training practices supports this view about the motivation of participants. A proportion (27%) of this sample of doctors was not currently practising occupational medicine, though trained and qualified in this specialty. Confidence in some areas of the syllabus was higher for GPs who were carrying out some sessional work in occupational medicine, suggesting that practice reinforces theoretical training. It is disappointing to find that the rate of use of the free CPD material in occupational medicine available on THOR-GP s website remains low (22%) 1 year after intervention to improve accessibility and content of the site along with evidence-based methods to raise awareness of the resource including e-mail reminders. Completion of the first questionnaire might itself have been expected to raise awareness. Lack of time remained the most frequently given reason for non-uptake. Undertaking sessional work in occupational medicine appears to provide the stimulus to engage in traditional CPD, journal reading, meetings and courses and to increase confidence in some areas of the syllabus, but not to affect the use of e-learning including THOR-GP s online resource. The University of Manchester s web-based package is currently the only interactive source of CPD specifically developed for use by GPs practising occupational medicine [10]. The Department for Work and Pensions (DWP) produces web-based CPD material for GPs which is designed to address limited educational needs, related specifically to sickness absence certification [11]. The FOM encourages all those working in occupational medicine (specialists and non-specialists) to participate in its CPD scheme consisting of approved courses, meetings and conferences, and some written material available from the FOM s website [8]. Net-Teaching Work-Related Medicine (NetWoRM) is an interactive web-based system for undergraduate teaching in occupational medicine based on clinical and practical aspects and uses case histories and information on the theory and practice of occupational medicine; this material has been shared between universities within Europe. NetWoRM is also being developed for use in specialist occupational medicine postgraduate training [12]. Reminder systems are among few strategies with a demonstrable evidence base that have been found to be effective in producing changes in the performance of doctors [13 15]. Our e-mail reminder system did not result in an increase in use of the website. However, linking diagnostic categories of cases reported by participants to relevant educational material on the site will attempt to increase awareness and relevance to participants and increase the interactive element of the resource. The problem of lack of protected time for CPD for GPs remains. The industries served by GPs in occupational medicine are unknown within this survey, but may be within the private sector, for National Health Services Trusts, or for the DWP. Even public sector work may be done under private contract, with doctors working as single-handed practitioners or for independent providers, and there may be potential problems for these doctors to access and undertake CPD and appraisal in occupational medicine [16]. Similar problems may also beset single-handed GPs working in primary care, and peer support methods of education (such as interprofessional learning sets and clinical supervision) have been advocated to help mitigate the problem of isolation of GPs [17]. This isolation added to the anomalous status of GPs working in occupational medicine may be a reflection of the position of OH services as a whole, as highlighted in the recent Black Report, which calls for integration of some OH services into the NHS and for a network of GPs interested in health and work to be a source of growing expertise at a regional and local level [18]. Such a network exists already in THOR-GP, and further development of CPD for these practitioners should provide an important component of national policy. Internet use among doctors is growing rapidly; it is believed that.85% of physicians use the web and it has been estimated that the number of web-based continuing medical education (CME) activities increased by 700% between 1998 and 2003 [19]. Despite this, few studies assess the effectiveness of learning outcomes of web-based CME. The majority of evaluative research on this topic is based on participation satisfaction data [20]. In one recent study, web-based CME was shown to produce objectively measured changes in behaviour, as well as sustained knowledge gains that are comparable or superior to those resulting from traditional methods [19]. An evaluation of learning outcomes that assessed knowledge before and after completion of a range of web-based CME courses found that the majority of courses demonstrated significant changes in knowledge and confidence, as well as self-reported retrospective changes in practice [21]. It would appear that substantial resources are required to provide an e-learning facility for occupational medicine practitioners in order to attract regular participation. Research into the factors which motivate doctors to use webbased learning may help to address the problems of low uptake of resources. It is possible that resources which are available free of charge may be less highly valued than those requiring fees for use; however, BMJlearning and Doctors.net have provided free sources of CPD with

K. THORLEY ET AL.: CPD IN OM FOR GPs Page 5 of 5 considerable success. The question of the effect of mandatory systems of CPD in revalidation and licensing also requires investigation. Key points A website offering free CPD material in occupational medicine to GP participants in a national research project has a low rate of use by the members of the scheme. Lack of time was the most frequently cited reason for non-uptake. Further research is required into ways of encouraging GPs to use web-based CPD material. Funding Health & Safety Executive with core academic support from the Higher Education Funding Council for England. Conflicts of interest None declared. References 1. Curran VR, Fleet L. A review of evaluation outcomes of web-based continuing medical education. Med Educ 2005;39:561 567. 2. The Health and Occupation Reporting Network. http:// www.medicine.manchester.ac.uk/coeh/thorgp/ (2 February 2009, date last accessed). 3. Thorley KJ, Hussey L, Turner S, Zarin N, Agius R. CPD for GPs using the THOR-GP website. Occup Med (Lond) 2007;57:575 580. 4. Doney L, Barlow H, West J. Use of libraries and electronic information resources by primary care staff: outcomes from a survey. Health Info Libr J 2005;22:182 188. 5. McKimm J, Jollie C, Cantillon P. ABC of learning and teaching: web based learning. Br Med Assoc 2003;326:870 873. 6. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. J Am Med Assoc 1995;274:1836 1837. 7. Abdolrasulinia M, Collins BC, Casebeer L et al. Using email reminders to engage physicians in an Internet-based CME intervention. BMC Med Educ 2004;4:17. 8. Faculty of Occupational Medicine. Diploma in Occupational Medicine Examination Regulations, Syllabus and Guidance Notes for Candidates and Teaching Centres. London: Faculty of Occupational Medicine of the Royal College of Physicians, 2003. 9. Smith NAL. Occupational medicine and the general practitioner. Occup Med (Lond) 2005;55:77 78. 10. Donnelly AB, Agius RM. The distance learning courses in occupational medicine 20 years onwards. Occup Med (Lond) 2005;55:319 323. 11. Department of Work and Pensions Corporate Medical Group Online learning for Medical Practitioners. www.dwp.gov.uk/ medical/ (2 February 2009, date last accessed). 12. Kolb S, Reichert J, Hege I et al. European dissemination of a web- and case-based learning system for occupational medicine: NetWoRM Europe. Int Arch Occup Environ Health 2007;80:553 557. 13. Cherry NM, Meyer JD, Chen Y, Holt DL, McDonald JC. The reported incidence of work-related musculoskeletal disease in the UK: MOSS 1997 2000. Occup Med (Lond) 2001;51:450 455. 14. Agius RM, Bagnall G. Development and evaluation of the use of the Internet as an educational tool in occupational and environmental health and medicine. Occup Med (Lond) 1998;48:337 343. 15. Burgess G, Holt A, Agius RM. Preference of distance learning methods among post-graduate occupational physicians and hygienists. Occup Med (Lond) 2005;55:312 318. 16. Thorley KJ. Appraisal of general practitioners practising occupational medicine. What happens and what do they think about it? Educ Primary Care 2008;19:376 381. 17. Lord J. Future of primary healthcare education: current problems and potential solutions. Postgrad Med J 2003;79:553 560. 18. Black C. Working for a healthier tomorrow. Report to the Secretary of State for Health and the secretary of state for work and pensions. TSO, London, 2008. 19. Fordis M, King J, Ballantyne C et al. Comparison of the instructional efficacy of Internet-based CME with live interactive CME workshops: a randomised controlled trial. JAm Med Assoc 2005;294:1043 1051. 20. Kriplani S, Cooper HP, Weinberg AD, Laufman L. Computer-assisted self-directed learning: the future of continuing medical education. J Contin Educ Health Prof 1997; 17:114 120. 21. Curran V, Lockyer J, Sargeant J, Fleet L. Evaluation of learning outcomes in web-based continuing medical education. Acad Med 2006;81(Suppl):30 34.