The Need for Continuing Medical Education in the Kingdom of Saudi Arabia

Introduction

KS Bin Saeed, ZM Sebai, The Need for Continuing Medical Education in The Kingdom of Saudi Arabia. 1998; 18(2): 140-145

The effective and timely delivery of quality health care services to the general population has been one of the highest priorities of the Saudi government. However, this continues to be an enormous task, considering that the health manpower in the Kingdom has traditionally been composed mainly of expatriates who bring with them diverse educational and cultural backgrounds. Although this diversity has not been a hindrance in the effective provision of health care services, it is understandable that differences in cultural backgrounds among providers and receivers of care may have a serious influence on the total functioning of the entire health care system. This can be made worse by the fact that these health care providers also have widely diverging educational and professional backgrounds and, not surprisingly, have different approaches to providing care.

In the midst of the above diversities, continuing medical education (CME) may prove to. be a “unifying” force for the effective functioning of the Kingdom's health care sector. This is because CME is a lifelong process of mastering professional competence, knowledge and skills relevant to one's practice specialties. It keeps health care professionals updated about new diagnostic and therapeutic procedures. CME reinforces high-quality care practices over the course of entire careers of professionals, and has been recognized as valuable because the educational process is somehow translated into improved outcomes for patients.¹

The CME process is usually accomplished through meetings with other professionals, attending professional gatherings, such as conferences and symposia, and reading related literature, although other methods are also available. For example, primary care physicians involved in caring for diabetic patients considered their colleagues to be the second most important source of information that influenced their professional behavior.² On the other hand, a comparative study of the CME needs of physicians working in Alexandria, Egypt, and the Asir Region, Saudi Arabia, found that lectures and periodicals were the preferred educational strategy.³

Recognizing that an effective continuing medical education program can be instrumental in enhancing the performance of the health care sector, especially one with a multinational workforce, this study was conducted with the following objectives: 1) to gain an insight into the perceived needs for CME among health care professionals in the Kingdom; and 2) to examine the impact of the cost of CME on future attendance to CME activities.

MATERIAL AND METHODS

Three thousand (3000) questionnaires were sent to a random sample of health care professionals involved in the provision of health care services in different hospitals throughout the Kingdom of Saudi Arabia. These questionnaires were distributed through the Kingdom's 19 regional health affairs directorates between March and September 1995. The questionnaire did not require any identification of the respondents and was written in both Arabic and English to encourage the participation of both local and expatriate work forces of the health sector.

The first part of the questionnaire was designed to obtain some background information on the respondents. The second part focused on different items specific to CME, including the impact of CME cost. There were also open-ended questions aimed at seeking suggestions regarding the improvement of CME in the Kingdom. The following hypotheses were tested in order to achieve the objectives of this study:

Hypothesis A: There is no statistically significant difference in the perceived need for CME between each of the following:

• A₁: clinicians and non-clinicians

• A₂: health care professionals whose highest educational level is lower than a baccalaureate degree and those who obtained at least a baccalaureate degree

• A₃: Saudis and non-Saudis

• A₄: males and females

Hypothesis B: There is a statistically significant relationship between the perceived need for CME and each of the following variables:

• B₁: number of days spent on conferences the previous year

• B₂: number of days spent on seminars the previous year

• B₃: number of days spent on distance learning the previous year

• B₄: number of days spent on other forms of CME the previous year

• B₅: percentage of CME cost sponsored by the employer B₆: percentage of annual salary ready to be spent for CME.

The Statistical Analysis System (SAS) software was used in the data analysis. Multiple regression analysis was utilized to determine the impact of various factors in the perceived need for CME, which was measured as a continuous variable and defined as the number of days that health professionals indicated they needed in order to further their knowledge about the profession.

RESULTS

Two thousand and three hundred questionnaires (2300) were returned out of the 3000 that were distributed. However, there were 229 incomplete questionnaires that were deemed inappropriate for inclusion in the analysis because of the significance of the missing data. Therefore, a total of 2071 valid questionnaires were included in the analysis, for a response rate of 69%.

Table 1 shows the sociodemographic profile of the respondents in this study. It can be seen from this table that nurses accounted for almost half of all respondents (48.4%). Doctors comprised only 14.5% of all respondents; more than half were general practitioners, while the others were either specialists or consultants. Half of the respondents had a diploma (50.0%) and more than one-third (36.2%) had a baccalaureate degree. Less than 10% of all respondents completed higher education and there were also some (3.7%) who finished lower than baccalaureate degree. More than two-thirds of the respondents were non-Saudi (67.2%), and more than half of all respondents (53.2%) were female.

Table 1. Frequency distribution of sociodemographic variables in the CME study, Saudi Arabia, 1995.

The CME-specific variables included in the study are shown in Table 2. On the average, respondents indicated that they needed 12.8 days for CME every year but the actual average time spent on the different forms of CME was only 4.6 days. Out of all respondents, 22.5% indicated that they needed 11-20 days for CME annually, 16.9% required 1-10 days and 6.9% perceived that they needed at least 30 days for CME each year.

Table 2. Frequency distribution and mean of CME-related variables in the CME study, Saudi Arabia, 1995.

Many respondents (36.2%) did not indicate their CME requirements in terms of days per year. It is rather unlikely that this means that those respondents did not need CME. This probably means that they did not really understand the concept of CME and consequently, could not understand its importance.

Respondents spent an average of less than two days in conferences in 1994. This very low figure is mainly due to the fact that almost two-thirds of the respondents (65.7%) did not attend any conference at all during that year.

Almost one-third of all respondents (30.1%) were able to spend between 1 to 10 days in conferences; 3.2% spent a total of 11-20 days in conferences and only 1% spent a total of more than 20 days attending conferences.

As can also be seen from Table 2, respondents spent an average of 0.9 of a day attending seminars, and more than two-thirds of all respondents did not attend any seminar at all in the year before this study was conducted. However, almost one-fifth (18.8%) of those who completed the questionnaire indicated that they were able to spend 1-10 days on seminars. This indicates that very few (3%) were able to attend seminars for a total of more than 10 days.

Distance learning was the least utilized method of CME among the respondents surveyed; an average of only 0.6 of a day was spent on distance learning. More than 90% of all respondents did not spend any time at all on distance learning. Some (8.5%) spent at most 10 days for distance learning and less than 1% of all respondents had more than 10 days of distance learning.

An average of 1.4 days was spent on other forms of CME in 1994, mainly on lectures. The majority of the respondents (82.9%) did not even spend time on these informal ways of obtaining CME. Only 10.9% of all respondents spent as much as 10 days on this educational activity and a little over 6% spent a total of more than 10 days on it.

On the whole, more than two-fifths (42.4%) did not spend any time on CME during that year, and 41.5% spent a total of less than 10 days. Some (13.3%) were able to spend a total of 11-20 days on CME and there were a few (2.8%) who even spent a total of more than 20 days.

With regards to the influence of cost on attendance in CME activities, almost three-quarters of the respondents indicated that they would attend CME only if the cost were fully covered by the employer. Only 17.7% were willing to attend CME courses even if they had to pay as little as 24% of the cost. Almost 6% indicated that they were willing to shoulder as much as 50% of CME costs, and 2.2% indicated their willingness to pay as much as 75% of the cost incurred in attending CME activities.

In terms of personal expenditure on CME, while the vast majority of respondents indicated that they were not ready to bear the expenses from their own pockets, 17% of all respondents were willing to invest as much as 10% of their annual salary for CME; while less than 5% indicated that they were ready to spend more than 10% of their yearly income on CME.

Table 3 shows the results of the multiple regression analysis of the factors affecting the perceived need for continuing medical education. Ten variables were included in the analysis: profession (Prof); highest educational degree (Educ); nationality (Nat); sex (Sex); number of days spent on conferences (Conf); number of days spent on seminars (Sem); number of days spent on distant learning (DL); number of days spent on other forms of CME (Others); percentage of CME cost sponsored by the employer (CO); and percentage of annual salary ready to be spent for CME (AS). Except for the highest educational attainment, all the other variables were statistically significant at P<0.001. The overall F-value was also statistically significant at P<0.001.

Table 3. Multiple regression analysis of factors affecting the perceived number of days needed for CME, Saudi Arabia, 1995 (N=2071).

The results of the multiple regression analysis yielded the following model for the study:

Perceived need for CME=7.63+4.54(Prof)0.41(Educ) +10.00(Nat)+3.77(Sex)+0.36(Conf)+0.55(Sem)+0.63 (DL)+0.47(Others)+0.04(CO+0.41(AS)

DISCUSSION

The results of this study show a big difference between the indicated need for continuing medical education and the amount of time actually spent on it. Although the indicated average number of days needed for CME per year was 12.8 days, the average total time actually spent was only 4.6 days, indicating a discrepancy of more than eight days. The time actually spent on CME by the respondents of this study was much lower than the average two weeks that U.S. medical staff spend on continuing education.⁴

Distance learning, although hardly utilized by the sample in this study, may be useful considering that there are many professionals who are involved in the provision of care in the remote areas of the Kingdom where CME activities may not likely be conducted formally. There can be significant unmet specific demands for CME among both rural and urban doctors, but the case is more critical for rural doctors, mainly because of distance and geographic isolation. Therefore, in remote areas, the most feasible method of CME for health care providers may be distance learning.

It can be seen from the results of the multiple regression analysis that all variables have a positive effect on the perceived need for CME. However, the regression model has an R² of only 21%, meaning that these variables combined account for only 21% of the variation in the perceived need for CME. Nonetheless, the model gives an indication of the relative influence of the variables included in this study on the perceived need for CME. For example, among the different forms of CME that were considered in the study, there is little variation on their effect on the perceived need for CME.

Results of the multiple regression analysis show that profession had a statistically significant relationship with perceived need for CME. Thus, we reject hypothesis A₁. This means that those in the clinical profession (general practitioners, specialists, consultants, dentists) felt that they required more time for CME compared to those in the non-clinical profession (β=4.54).

However, educational attainment was not statistically significant in determining the perceived number of days needed for CME (β=0.41), which leads us to accept hypothesis A₂. This means that there is no statistically significant difference in the perceived need for CME between those whose highest educational attainment was lower than a baccalaureate degree and those who had at least a college degree. Thus, in terms of the level of education, respondents did not significantly vary in their perceived need for CME.

With regards to nationality, the results show that there was a statistically significant difference between Saudis and non-Saudis in their perceived need for CME (β=10.00). Therefore, we reject hypothesis A₃. This means that Saudis perceived that they needed more time for CME compared to non-Saudis. With regards to sex, there was also a statistically significant difference in the perceived need for CME between males and females (β=3.77), so we also reject hypothesis A₄. Male respondents indicated that they needed more time for CME compared to their female counterparts. This is an interesting departure from the results of an earlier study, where females indicated the need for significantly more training than men.⁵

All the factors relating to the number of days spent on different forms of CME had statistically significant positive coefficients: conferences (β=0.36); seminars (β=0.55); distance learning (β=0.63); other forms of CME (β=0.47). These results validate hypotheses B₁, B₂, B₃, and B₄ that there is a statistically significant relationship between the perceived need for CME and the number of days spent the previous years on each of these different forms of CME. This means that the more time the respondents spent attending CME activities during the previous year, the more they felt the need for CME. This can be an indication of their appreciation of the importance of CME, particularly in carrying out their profession.

As for the financial factors (percentage of CME cost sponsored by the employing organization and percentage of annual salary ready to be spent for CME), both have statistically significant positive coefficients (β=0.47 and β =0.04, respectively), leading us to the acceptance of both hypotheses B₅ and B₆. This means that the greater the percentage of CME cost sponsored by the organization, the more the respondents perceived the need for CME. Furthermore, the more ready the respondents were to spend their own financial resources, the more indication there is for their perceived need for CME. However, it should also be noted that a percentage increase in the annual salary that would be readily spent for CME would have a greater impact on the perceived need for CME than a percentage increase in the CME cost that would be sponsored by the employer.

The suggestions of respondents indicate that there is much to be desired in the conduct of CME activities in the Kingdom. These suggestions varied from the financial to the administrative aspects of conducting CME. Some respondents believed that the Ministry of Health (MOH) should sponsor free CME for all members of the health care team (medical and paramedical staff, nursing staff and administrators of health care facilities), while others indicated that attendance in CME activities should be made compulsory for all professionals in the health sector. Others even suggested that attendance in CME activities be made a prerequisite for promotion among Saudis, and for the renewal of contract among expatriates. However, it has been found that CME would not be effective if participants were just compelled to attend and were not allowed to choose their own preferred areas.⁶

Many respondents also suggested that conferences and seminars should be held more often, with each conference or seminar conducted continuously for up to 15 days. This indicates that the conference format is still the most widespread and popular method of CME. Respondents also suggested that participation should be encouraged by providing clear English translation of those lectures or sessions which are conducted mainly in Arabic. With this, new information technologies such as computers and telecommunications may prove useful in CME.

Probably the most significant suggestion was that CME activities should have clinical and practical bases and that both contents and methods used should be determined by existing needs. This point should be taken seriously by future planners of CME because good quality CME demands that the content of the program should be based on the real needs of the prospective participants rather than the needs perceived by those who will provide it. Thus, the challenge to those involved in providing CME is the improvement of its activities in a way that new information about certain issues related to the provision of health care are presented in a practical and timely manner to the concerned health care professionals.

In view of the above, needs assessment may have to be an important prerequisite in planning for CME. Needs assessment ideally involves the testing of health care professionals to determine deficiencies in knowledge, skills and orientation that affect their proficiency in providing care. This may be a time-consuming and expensive prerequisite, but can be the most significant determining factor in the success or failure of any CME undertaking.

It can also be seen from the results of this study that while the vast majority of the respondents indicated varying degrees of need for CME, most were not willing to spend their own financial resources for CME activities. Almost two-thirds of the respondents indicated that they needed CME and yet more respondents indicated that they were willing to attend CME activities only if all the related costs incurred would be fully paid by their employer. However, an even greater proportion (78.7%) indicated that they were not ready to spend any amount from their salary for CME activities. These results are consistent with the findings of an earlier study, wherein respondents indicated that one of the greatest barriers to attending CME activities was the loss of income.⁵

Results of this study suggest that financial considerations may have contributed to the discrepancy between the perceived need for CME and the amount of time actually spent attending various forms of CME. Apparently, although the majority of the respondents seemed convinced that they needed CME, it does not seem to be a priority if they have to commit their personal financial resources to it. The need could not be converted into reality if their financial capability does not warrant meeting this need. And if the organization they were working for did not appreciate the importance of CME or have limited financial resources that could be allocated for CME, then it is understandable that the amount of time spent for CME will be much less than the perceived need.

CONCLUSION

The findings of this study indicate that continuing medical education in the Kingdom should be given more attention. Considering the documented positive effects of CME, especially on the quality of patient care and cost reduction, the results of this study may indicate serious implications for both. If those directly responsible for providing health care to patients continue to spend very little time on CME activities, there is a probability that the quality of the care they provide might be seriously compromised. This calls for hospital administrators to seriously consider the possibility of allocating more financial and other resources to the promotion of CME. The hospital management should also find means and ways to effectively encourage the staff to participate in CME activities.

Continuing medical education activities should be rationally planned and systematically evaluated, since such activities could have a profound impact on the manner in which medicine is practiced and on the outcome of patient care. As more and more hospitals and health care organizations pay more serious attention to quality and outcome of care, it may also be worth considering the possibility of linking quality assurance with CME. There is also the possibility that, eventually, CME may prove to be one of the best quality assurance tools.

If CME is to be an integral part of the Kingdom's entire health care system, at the core of the framework of the national priorities of health care delivery, then this will require the allocation of greater financial resources. This is essential for the development of a truly effective CME system.

This study emphasizes the importance of, and need for, continuing medical education. Thus, it is recommended that a more comprehensive study be conducted in the future to include the specific areas where CME is most needed and the forms of CME which might be most effective. Considering the low R² of the regression model, future studies should also consider other factors that are likely to influence the need for CME.

It is further recommended that a Saudi Arabian Accreditation Council for CME be established. This body will be responsible for accrediting all CME activities conducted within the Kingdom. Knowing that CME activities are accredited may also be one effective way of encouraging health care professionals to participate in these activities.