Addressing the hiatus of learning incentives for prevocational doctors: continuing medical education points for interns

Communities expect all health care professionals to maintain their knowledge and skills. While universities and specialty colleges drive learning through examinations, there are no such incentives to drive prevocational doctors, including interns, to continue learning. New accreditation standards set by the Postgraduate Medical Education Council of Queensland (PMCQ) define a number of intern education and training requirements. These requirements are mandates on hospitals to provide ongoing education programs over and above the situated learning that occurs in clinical settings. This education occurs via facility education programs (FEPs) that are facilitated by local medical education units (MEUs). There is, however, no mandate for interns to participate in FEPs, and there are no consequences if interns do not attend the FEPs offered. In addition, the Medical Board of Australia has no minimum attendance or participation requirement that affects the progression of interns to general registration.

This hiatus of learning incentives may be affecting junior doctors’ engagement in the learning opportunities provided. In 2007, an FEP evaluation conducted by the MEU of Townsville Hospital (a large regional hospital in Queensland) showed that FEP attendance was poor, even with an arbitrary setting of 80% minimum attendance. The mean attendance rate for the 32 interns was 66% (range, 51%–87%), and evaluation of attendance during previous years showed 2007 was not an atypical year (unpublished data) (Box 1). Feedback provided by interns in their 2007 end-of-term evaluations indicated that the biggest barrier to their attendance at the FEP activities was a heavy workload and a corresponding commitment to maintaining patient care. This made attendance difficult, despite these sessions occurring during “protected time” (unpublished data). This is consistent with previous research findings which have shown that junior doctors find it difficult to choose between patient care, work demands and their own professional development (PD).1

Given the lack of mandatory participation requirements, the MEU identified development of an innovative FEP as a possible means of providing incentives for interns to overcome the barriers to participation. The design brief used stated that this FEP should:

• provide flexible learning options that incorporate adult learning principles;2

• complement the situated learning that occurs in the clinical environment;3

• foster the development of learning behaviour such as self-directed4 and self-regulated learning.5

Formal ethics approval was obtained from the Townsville Human Research Ethics Committee to undertake and publish a low-risk study to address the issues identified. Design-based research methodologies6 were used, because the study focus was on the development, implementation and evaluation of a new structure for the FEP. Interns’ participation in learning activities was used to evaluate the effectiveness of this new structure.

To meet the design brief, the MEU at Townsville Hospital developed a new FEP for 2008 around a framework of four key PD domains — education sessions, skills workshops, presentations and research. The pre-existing FEP, which consisted of weekly face-to-face education sessions, had been developed by the MEU in 2007 to address components of the Australian Curriculum Framework for Junior Doctors.7 This was expanded to include skills workshops, formal presentations of professional knowledge (eg, at conferences, grand rounds or other teaching sessions) and research (eg, audits, quality assurance activities and peer-reviewed publications). In addition, an online learning portal with the potential to provide more flexible learning options was developed.

Once this framework of PD was constructed, a continuing medical education (CME) points system for interns was developed. Points were assigned by the MEU to reflect the amount of time interns would spend on each individual learning activity. A yearly minimum of 100 CME points was set as the target for interns to accrue. This equated to about 80% of the total points allocated to the 42 face-to-face education sessions offered in previous years (ie, 80% × 42 weeks × 3 points = 100.8 points). To make this target easier to achieve, interns could accrue points from any one PD domain or a combination of PD domains.

From 2008 to 2010, the incentive for interns to participate was that the concept was a flexible means of learning with the advantages of:

• providing them with expanded learning opportunities;

• allowing them to self-select relevant PD to meet their learning needs at a time that suited them;

• creating an impressive resume that could potentially give them a competitive edge for college selections.

The interns’ yearly records of participation in learning activities were converted to CME points before being collated by the MEU. An anonymous attitudinal survey, comprising mainly open-ended questions, was developed by the MEU to evaluate the 2008 FEP at the end of the year. This survey provided feedback that was used to revise the FEP, the associated learning activities and allocation of CME points for 2009, and the process was repeated in 2009 for 2010 (Box 2). Evaluations of the FEP in 2009 and 2010 were carried out using a more detailed survey, consisting of 10 questions requiring a yes or no response and three open-ended questions.

During the trial period, there was an increase in the mean number of points accrued by interns, from 114 points (range 60–168, median 113) in 2008 to 132 points (range 85–298, median 127) in 2010 (Box 3). There was a corresponding decrease in the percentage of interns who failed to accrue the required minimum — 20% in 2008 and 8% in 2010. Each year, points were accrued across all PD domains and the majority were gained through participation in education sessions (Box 3). The development of a research club in 2010 had a positive effect on interns’ use of research as a PD activity.

The FEP evaluation surveys in 2009 and 2010 revealed mixed attitudes towards the CME points system (Box 4). The majority of interns liked the flexible learning options that the system provided, but about half felt pressured to accrue points. In addition, the majority of interns felt that the PD helped them gain better knowledge and skills, helped them to develop as a clinician and contributed to their development as a professional.

When asked what they liked most about the CME points system, the interns’ most common responses were related to the flexibility of the system, the ability to monitor one’s learning and the motivation to participate in learning activities that the system provided. Other comments included themes of empowerment, appropriate learning, professionalism and being treated as a professional. When asked what they disliked most about the CME points system, interns’ comments included the pressure to accrue points, their inability to participate in activities due to work commitments, and frustration in not being able to include every aspect of non-FEP PD offered throughout the hospital.

To address a hiatus of learning incentives, a new FEP for interns based on a CME points system was implemented at Townsville Hospital from 2008 to 2010. During the trial period, the mean number of points accrued per intern increased and there was a decrease in the proportion of interns who failed to accrue the required minimum of 100 points. Interns surveyed at the end of 2009 and 2010 liked the flexibility of the system but felt pressured to accrue points.

Accruing points for participating in learning is not a new concept. It is a well accepted method of providing motivation to participate in professional learning activities.8-12 In medicine, the concept of using CME points has, to date, been restricted to medical graduates who need to accrue points to maintain specialist accreditation.8,9 Yet doctors are students of medicine from the day they enrol in medical school and throughout their entire career.13 It seems reasonable, therefore, to extend the concept of CME into the prevocational period. Many other professions require junior professionals to accumulate evidence of professional activities in the form of points,10-12 and the results of this study suggest that junior medical professionals would respond positively to such a system.

A number of studies have shown that learning contracts are an essential tool for developing learner autonomy.14-16 The FEP that was developed in this trial is a type of learning contract. The final iteration of CME point allocations (Box 2) offered the interns flexible learning options by allowing them to choose learning activities that best suited their preferred learning styles and learning needs. Education sessions provide interns with an opportunity to advance their knowledge base. Clinical skills workshops provide simulated clinical experiences that can mimic situated learning, so that learning becomes clinically relevant. Quality assurance and other research activities require self-regulated learning, whereby interns make their own decisions about what they learn, how they learn and the depth to which they understand their new knowledge.5 The new FEP used in this trial therefore provides a learning environment that adheres to the principles of adult learning.2

Although the motivational factors for interns to participate in the FEP used in this trial were not investigated, results of the trial show that interns respond well to a CME points system. As Australia moves towards a full national regulation system, the CME points system has the flexibility to be expanded to other junior doctor years and implemented in other Australian facilities to ensure that self-directed and self-regulated learning occurs across the entire prevocational continuum.

1 Intern attendance at facility education program (FEP) activities, 2000–2007*

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* Values are means and vertical bars are ranges; 2000–2006 data represent 16 interns and 2007 data represent 32 interns.