SID07623

Continuous Professional Development of Medical Doctors in

Pakistan: Practices, motivation and barriers
Zarrin Seema Siddiqui
University of Western Australia

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Abstract

I n t r o d u c t i o n : Structured Continuous Professional Development (CPD) programs

for health professionals have been introduced worldwide and a need is recognized in
Pakistan especially for the medical doctors. This study explored the current
professional development practices of medical doctors in Pakistan, and identified
factors motivating and inhibiting their participation.

Methods: A cross sectional random survey with both quantitative and qualitative
items was sent to 500 medical doctors across Pakistan. The response rate was 62%.

Results: Professional reading, peer discussion and attending workshops and

conferences are the main activities undertaken by the respondents. Lack of time,
organizational culture and finances emerge as the main barriers in attending CPD
activities. Conversely, factors related to the educational activity such as relevance, cost
and incentives act as motivators for participation.

Discussion: To plan a targeted CPD program, policy makers and organizers need to
take into account the motivators and barriers identified by the respondents in this
study. Similarly there is a need for trained faculty for successful implementation,
evaluation and research regarding professional development. This faculty may design
effective educational activities based on a sound need analysis, using strategies that
cater for to the variety of learning styles and needs of participants

Keywords: Health policy, Barriers to participation, Continuous Professional

Development, motivation, Medical education, Pakistan

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Introduction

Continuous Professional Development (CPD) is defined as any activity or skill taken to

update, maintain or develop professional knowledge. 1 In the context of medical
education it is regarded as critical because biomedical knowledge is rapidly changing
and involvement of a physician in life-long learning through CPD activities is considered
to be a moral obligation. The issue has been given due consideration in many parts of
the world with introduction of mandatory and voluntary structured CPD programs
but, like many other developing countries Pakistan has still to come up with a solution.
Presently there are 100,828 doctors including 18,242 specialists registered with the
Pakistan Medical and Dental Council serving a population of more than 150 million2.
However, it is believed that the actual number of current practising doctors is less
than quoted because the Pakistan Medical and Dental Council is a licensing body that
does not maintain a record of how many doctors are actually in the active workforce.
There is currently no structured or systematic CPD program for doctors in Pakistan.
A doctor’s link with their teaching institution is lost as soon as he/she graduates or
specializes. Concerns have been raised in various forums about the deteriorating state
of medical education in the country resulting in inadequately trained doctors. 3 This
adds to the growing problem of appropriately maintaining competencies.

To plan a targeted CPD program in Pakistan this study was undertaken to identify
current professional development practices, along with what factors motivate or inhibit
doctors from participation in educational programs.

Materials and Methods:

Based on the information derived from the literature and group discussions with
practising doctors, a questionnaire with both open and closed questions was
developed. The questionnaire was mailed to medical doctors with a covering letter
explaining the purpose of the study and a self addressed stamped envelope.

Respondents were randomly selected from the database of about three thousand
medical doctors maintained at the Department of Medical Education, College of
Physicians and Surgeons Pakistan, which has a key role in the professional development
of medical doctors across Pakistan.

Responses to the closed questions were analyzed using the Statistical Package for
Social Sciences (SPSS) version 10.0 for Windows. Descriptive statistics were used to
analyse the data. Responses to open questions that explored barriers and motivation
were qualitatively analyzed. Qualitative methods of data collection and analysis are
considered to be valid means to explore attitudes and experience among a specific
professional group. 4 For the purpose of qualitative analysis, all responses to open
questions were manually examined by the author and coded into categories
accordingly.

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Results

Of 500 total distributed questionnaires 329 were returned. Twenty of the returned
questionnaires were incomplete therefore not included in the analyses. Overall this
constituted a response rate of 62%.The demographic characteristics and specialties of
the respondents have been presented elsewhere. 5 The age, sex, qualifications and
geographical area of practice suggest appropriate representation of the target group
and hence findings can be generalised.

CPD Practices during last three months

Professional reading, discussion with peers, and attending workshops and conferences
were the most common CPD activities undertaken by the respondents as shown in
Table 1. The CPD activities that were undertaken by the smallest number of doctors
were reflection, presentations, writing and research. There was no significant
difference in the types of CPD activities attended among different specialty groups.

Barriers towards CPD

Lack of time or interest in the educational activity and finances emerge as the main
barriers in attending CPD activities (Fig.1). This has also been shown in a number of
other studies that have reported time and finances as potential barriers to CPD6. In
this current study 49% of doctors were working in both the public and private sectors,
and 33% identified time as the major obstacle to their professional development.

Organisational culture was identified as a barrier for 12% of respondents. These

respondents reported have difficulty being nominated or obtaining sponsorships from
their institutions for CPD. One of the respondents even commented:

I wanted to attend a workshop on teaching medical students. Although my head

of the department granted me leave to attend yet, I was advised that whatever I
learn I should forget it then and there rather to bring it to the workplace so
what's the use if I can not apply new skills.

Doctors working in small cities identified paucity of resources, lack of information

about activities, and limited or no CPD activities in their cities. As one female
respondent wrote:

I would like to remain in touch with what’s new happening but there are hardly
any programmes in my area and my family will never allow me to go outside the
city.

Limited resources are a significant problem in small cities. For example, there are five
qualified psychiatrists in the whole province of Baluchistan with one major library in
Bolan Medical College that does not subscribe to psychiatry journals. Therefore, it
remains a serious issue how one can expect these psychiatrists to keep in touch with
the latest advances in the field with such limitations on access and availability of
resources. Similarly some of the postgraduate training institutions are in remote areas
which still lack facilities for electronic communication.

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Some of the respondents blamed the political situation in the country as a barrier
which is justified in the context of increasing ethnic violence in some of the parts of
the country that has resulted in the death of many doctors while on the job during the
last decade.

Motivational factors towards CPD

Respondents were asked to identify the main factors they would consider if given the
opportunity to attend two educational activities. Factors related to the activity (72%)
were the main consideration followed by relevance, cost and incentive (Fig.2). A
further analysis of the factors associated with the educational activity (Fig.3) revealed
the type of activity was the main consideration. For example, a highly interactive
activity, involving discussion and active participation would be most preferable. This
was also evident in discussion of preferred learning experiences, where workshops
were the most favoured educational activity. This implies that planners should use
strategies which promote active learning rather than using didactic lectures presented
by speakers. In the case of presentations and seminars, respondents consider the
credibility of the speaker as well as his/her expertise on the subject. In addition the
organization which is conducting the activity and the likely participants has an impact
on participation.

The duration of the activity is again important because time has been repeatedly
identified as a barrier. Participants are less likely to attend any activity that involves a
whole day as this will affect their private practice and personal commitments.

Discussion

It is encouraging to know that doctors in Pakistan are engaging in a range of

professional development activities. However, in order to keep pace with changing
information and the increased demand from the public for accountability and quality
service delivery there is a need for well planned CPD activities that contribute to
further improving standards and meet the identified learning needs.)they need to be
more accountable and be able to demonstrate that they are developing professionally
to keep pace with changing information. Doctors cannot do this alone, and a whole
system and culture needs to be developed at both regional and national levels to
manage the process.7

The first issue of concern in the development of appropriate CPD is the availability of
resources. Resources fall into two categories; physical and human. Physical resources
include libraries and computer facilities. Human resources include subject experts, as
well as educational experts who can devise programs that are relevant and meet the
needs of participants. This is particularly important given that a number of
motivational factors identified in this study related to the nature of the educational
activity itself. This issue is being discussed all over the world in the field of CPD. Many
conventional continuing medical education activities cannot be shown to lead to
significant gains in knowledge, changes in performance, or improvement in health
outcomes. 8

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Active participation and adopting a problem solving approach have been two important
characteristics of effective educational strategies for CPD. Multiple studies have
demonstrated problem based learning as an effective tool for CME. 9-11 This approach
enhances effective retrieval of knowledge when similar problems are encountered in
practice, as compared to attending seminars and lectures as a passive recipient of
factual information. Therefore, it is suggested that problem based scenarios be
incorporated into discussions as part of lectures, seminars and CPD programs. This
approach has also been effectively used for a CME session on the internet and received
positive feedback. This again reinforces the effectiveness of problem based learning
along with flexibility of time. 12

Reflective practice is a continuous process of purposeful thinking about one's clinical

practice to develop understanding, insight and clinical judgment. 13 In this current
study, 55% of respondents stated that they have not used reflective skills at all during
the last three months. However, 50% reported involvement in peer discussion. Is peer
discussion not a spoken form of reflection and are respondents not aware of this
important tool for learning? Kolb's learning cycle moves around structured reflection
by identifying needs through reflecting on experiences, meeting those needs and then
during the process of applying that learning, further needs for learning are identified. 14
Thus structured reflection is a key component of self directed learning. There is a need
to inculcate among doctors reflective skills so they are able to identify their learning
needs and then design or be provided opportunities and resources to meet those
needs. Using portfolios to document CPD has been demonstrated as an effective and
efficient tool to encourage reflective practice as well as helping practitioners to plan
and implement their own CPD. 15

Lack of incentives is also identified as a barrier in the results of this study. The question
that arises is what sort of incentives may help to motivate doctors to engage in
professional development. At the national level academic promotions and employment
may be offered on the basis of evidence of participation in CPD. Provision of study
leave in all public and private hospitals could be included to provide opportunities and
incentive to participate. Similarly professional societies could mandate a certain
amount of CPD for members and publish a directory of the specialists who have been
actively engaged in the process of professional development. If this list is accessible to
the public it may then influence a person’s choice of specialist.

Lack of time is one major barrier repeatedly mentioned in many of the open-ended
responses. Short educational activities were favoured due to the lack of time and so
this was an important motivator for a doctor to attend. Barriers identified by women
respondents were lack of time due to family commitments, as well as the venue
especially when they have to travel to cities distant from their work or home.

For women doctors in Pakistan it is a common scenario to get married after

graduation and leave the profession to have children and fulfil family commitments
even if there is a reluctance to do so. This may involve a gap of many years away from
practice. Currently there is no system in place to check the competence of doctors,
male or female that takes an extended break from their professional career before
deciding to resume professional practice. This is a concern as basic skills acquired

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during undergraduate education can deteriorate after years in practice,16 so one can
assume that for those not practicing at all the situation will be worse. This is an issue
of major concern that could be in some ways be addressed through CPD.

A possible solution to this crucial element in professional development will then be to

explore ways for flexible delivery options. These options might include established
formats as well as evolving new formats that incorporate provision for synchronous
and asynchronous learning. With the advent of information and communication
technology, options such as teleconferencing and video satellites are a possibility,
However, in resource poor countries or regional areas where such technologies are
not readily available participation in CPD activities via these mediums would be
restricted to people practising in major cities. In these instances, CD ROMs and
distance-learning packages developed in accordance with the principles of instructional
design would offer better alternatives.

Finally the time has come to initiate programs aimed towards maintaining and
improving competence of health professionals. A sound CPD program for doctors may
be the first step in this direction and mark the beginning of a new era in medical
education in Pakistan.

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References

1. Guly HR. Continuing Professional Development for doctors in accident and

emergency. J Accid Emerg Med 2000;17:12-14
2. Pakistan Medical and Dental Council 2006.Statistics. URL
http://www.pmdc.org.pk/stat.htm accessed online 10th May 2006.
3. Naqvi AS. Problems of medical education in Pakistan. JPMA 1997;47:267 – 269.
4. Kitzinger J. Introducing focus groups. BMJ 1995; 311: 299 – 302.
5. Siddiqui ZS, Secombe M, Peterson R. Continuous Professional Development: a
framework for medical doctors in Pakistan. JPMA 2003; 53: 290 -294
6. Rothenberg E, Wolk M, Scheidt S, Schwartz M, Aarons B, Pierson RN Jr. Continuing
medical education in New York County : physician attitudes and practices Journal of
Medical Education 1982;57:541-549
7. Grant J, Chambers E. The Good CPD Guide: A Practical Guide to Managed CPD.
London: Joint Centre for Education in Medicine;1999
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systematic review of continuing medical education strategies. JAMA 1995; 274:700-
705.
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Doucet MD, Purdy RA, Kaufman DM, Langille DB. Comparison of problem-based
learning and lecture format in continuing medical education on headache diagnosis
and management. Medical Education 1998;32:6 590-6
10. Premi J, Sharon S, Harwi K, Lamb S, Wakefiel J, William J. Practice based small group
CME. Acad Med 1994; 69:800-2.
11. Tamblyn RM, Barrows HS . Bedside Clinics in Neurology: An alternative format for
the One-Day Course in Continuing Medical Education JAMA 1980; 243: 1448 - 1450
12. Sargeant JM, Purdy RA, Allen MJ, Nadkarni S, Watton L, O’Brien P. You’ve got Mail:
Distance Education: Evaluation of a CME Problem based Learning Internet
Discussion, Acad Med 2000;75: 10 S50 – 52.
13. Rooda LA, Nardi DA. A curriculum self study of writing assignments and reflective
practice in nursing education. J Nurs Educ 1999;38:333-335.
14. Kolb DA. Experiential Learning. Chicago: Prentice Hall;1984
15. Mathers NJ, Challis MC, Howe AC, Field NJ. Portfolios in continuing medical
educationeffective and efficient? Med Educ 1999; 33: 521-530
16. Ward J. Continuing Medical Education:Part 1.Med J Aust 1988;148:20-22.

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Table 1: Current CPD Practices of Respondents

Number of
Respondents
Participated (%)
Reading Professional Journals 280 (90.6)
Peer discussion 264 (85.4)
Attending Workshops/ Conferences 238 (77)
Active role in Profession 206 (70)
Planning for effective teaching 214 (69.3)
Searching on line 201 (65)
CME Coursework 177 (57.3)
Writing & Research 165 (53.4)
Presentation by respondent 151 (49)
Reflection 137 (44.5)

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Lack of
Resources Information
7% 5%
Distance
Time
7%
33%

Organisational
12%

Finances
Lack of interest
16%
20%

Figure 1: Barriers towards attending educational activities.

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Incentives Cost
Relevance 1% 4%
23%

Activity
72%

Figure 2: Motivation to attend educational activities

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Resource
Venue material
8% 2% Type
33%

Speaker
23%

Organization Duration
14% Participants 15%
5%

Figure 3: Factors associated with educational activity

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