The Journal ofContinuing Education in the Health Professions, Volume 15, pp. 209- 216. Printed in the U.S.A. Copyright 0 1995. The Alliance for Continuing Medical Education and the Society of Medical College Directors of Continuing Medical Education, All rights reserved.

Original Article Diary Use for Physicians to Record

Self-Directed Continuing Medical Education CRAIG CAMPBELL, MD, FRCPC Consultant, The Royal College of Physicians and Surgeons of Canada Associate Professor, Faculty of Education Medicine, The University of Ottawa Ottawa, Ontario, Canada Norman, OK

JOHN T. PARBOOSINGH, MB, ChB, FRCSC Associate Director, The Royal College of Physicians and Surgeons of Canada RS McLaughlin Chair, Medical Education The University of Ottawa Ottawa, Ontario, Canada

ROBERT D. FOX, EdD Educational Consultant, Oklahoma Research Center for Continuing Professional and Higher

University of Oklahoma

S. TUNDE GONDOCZ, MSc Program Coordinator, The Royal College of Physicians and Surgeons of Canada Ottawa, Ontario, Canada

Abstract: A pocket-size diary was offered to 4005 volunteers, physicians, and surgeons prac- ticing across Canada in 10 specialties. Volunteers were requested to keep records of their self-directed continuing medical education (SD CME) activities for a period of 10 months in 1993. At the end of this period, they were surveyed to determine use of the diary, their opinion about keeping records of SD CME activities, and their acceptance of the MOCOMP*program S philosophy. A second survey was undertaken of volunteers who had not used the diary. A total of 21 88 volunteers responded to the survey. Of those, 56.6% reported using the diary. Respondents concurred with four statements in the survey, which correlated with their reported use of the diary. A significant positive association was found with statements concerning their under- standing of what to record, identifying which keywords to enter into the diary, and whether recording SD CME activities helped them to think about the care of patients. No correlation was found between recording activities and the ability of physicians to identifL a potential impact that the SD CME activity may have on their practice. The number one reason given by those who did not complete their diaries was an abhorrence to filling in forms. Overall, the degree of compliance in using the diary was encouraging. Additionally, over two thirds of the volun- teers who used the diary reported that they would personally recommend the MOCOMP program to their colleagues. The next steps for the program include developing a software tool to enhance the educational value of a personal diary for SD CME activities.

Key Words: Continuing medical education (CME), lifelong learning, maintenance of com- petence, self-directed learning

Most physicians report that methods of self-&ected continuing medical education (SD CME), such as

reading journals and searching the medical litera- ture, are their preferred methods of CME.' These activities are reported more frequently by physi- cians in their adoption of new practices than participation in group CME activities, such as, attending conferences.2 Most mandatory CME programs, however, place a greater emphasis On

group CME activities, probably because it is easier to document physician attendance at meetings than their participation in SD CME. The Royal College

Reprint requests to: Dr. John Parboosingh, Office of Fellowship Affairs (MOCOMPM), The Royal College of Physicians and Surgeons of Canada, 774 Echo Drive, Ottawa, Ontario, Canada K l S 5N8; phone (613) 730-6243, fax (613) 730-0500. *(MOCOMPM) is an official mark and trademark of The Royal College of Physicians and Surgeons of Canada.

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Recording Self-Directed CME

of Physicians and Surgeons of Canada (RCPSC) initiated the maintenance of competence (MOCOMP) pilot project in 199 1 to assist specialist physicians and surgeons to plan and execute their CME activitie~.~ The focus of the program on SD CME required the development of a practical method for specialists to record their activities.

One purpose of record keeping in the MOCOMP program is to enable physicians to continuously review and, thereby, enhance the quality of their SD CME activities. The program requests spe- cialists to record in a diary the question or issue they address in each episode of SD CME, the methods of CME utilized (e.g., reading a journal article), and to identify the effect the CME activity may have on their practice (e.g., the intent to change their prac- tice.) Diary records, and those submitted by peers in the same specialty and in similar practice set- tings, are sent to a central office where the data are keypunched into a database. Each year, specialists in the program receive a summary of their CME activities, the topics they have addressed, the CME methods used, and the effects on their practice compared with the data submitted by their peers. We hypothesize that the opportunity for peer com- parison of SD CME activities provided by this program will set standards that will motivate the participants to continuously enhance the quality of their CME. While several authors have suggested that keeping records may be beneficial to the learn- ing process,“ there are no published reports of stud- ies that address this issue.

In order to test our hypothesis that by keep- ing records physicians could enhance the quality of their CME activities, we developed an instru- ment for program participants to record their SD CME. In this article, we outline the design of a diary for documentation, describe compliance by specialists with using the diary, and provide feed- back from specialists who used it in a pilot project.

Methods

During 1991 and 1992, invitations to participate in the MOCOMP pilot project were sent to all

(10,000) specialists who were certified by the RCPSC in 10 specialty fields (general surgery, orthopedic surgery, urology, rheumatology, crit- ical care, internal medicine, anesthesia, pedi- atrics, obstetrics and gynecology, and diagnostic radiology). Initially, 1937 specialists who vol- untarily registered in the program during the first 6 months were issued with customized forms to record their SD CME activities. Less than one third of the volunteers used the forms over a period of 12 months and most of them found the documentation of SD CME activities to be too time con~uming.~ During the second year of the project, a pocket-size diary was designed to replace the forms. The main advantage of the diary over the form was its portability and ease of completion. Figure 1 shows a page from a diary kept by an obstetrician who read an article and completed a literature search (CME codes 1 and 2) on “the maternal administration of folic acid to prevent fetal neural tube defects.” As a result of this CME activity, the obstetrician indi- cates his intent to modify his practice by giving folic acid to eligible patients at the time of con- ception. The keywords FOLIC ACID and NEURAL TUBE DEFECT, along with the CME methods (codes 1 and 2 ) and the intended impact on practice, will be provided in his annual pro- file of SD CME activities.8

The diary, with appropriate instructions for its completion, was sent to all 4005 specialists who had registered in the project by January 1993. In December 1993, 10 months after receiving their diaries, the registrants were requested to com- plete a mailed survey and to return their diaries. The responses were analyzed using the Statistical Package for the Social Sciences (SPSS). The dif- ferences in responses reported in this publication were compared by chi-square analysis.

A second survey was sent in February 1994 to 745 specialists who had voluntarily registered for the pilot program, but had reported in the first survey that they had not used the diary. The pur- pose of the second survey was to determine the rea- sons for their noncompliance. They were presented

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Campbell et al.

SELF-DIRECTED CME CLINICAL ISSUE OR PROBLEM under review (print and wderfine keywords):

N e w recomlnendatious for the Mse of Folicp\c;l to preveut BtD (.N~ural L b e D~fecis)

Circle code for CME method used (as many as appropriate): f Date \ a@ ’ J a n 1 9 3 AS A RESULT OF THIS CME ACTIVITY (check ONLY one): [ X ] I will modify [ ]I will wait for more [ ] I see no need to

my practice information before modify my practice modifying my practice

l h r

\ J Codes for CME method:

I . Reading articles, texts 2. CME project (literature search, audit) 3. Traineeship 7. Audiotapes, videotapes 4. Self-assessment program, quiz, test

5 . Computer learning program 6. Teaching, research, publication, presentation

8. Other

Figure 1 A page from the diary of an obstretrician in the MOCOMP program.

with 25 reasons that may have contributed to their decision not to use the diary and were asked to indi- cate on a five-point scale how much each of the reasons influenced their decision not to use the MOCOMP diary to record their SD CME activi- ties: (1) not influential; (2) slightly influential; (3) moderately influential; (4) considerably influ- ential; and ( 5 ) very influential. The higher the mean score for a reason, therefore, the more the reason was perceived by the respondents to influ- ence their decision not to keep records of their CME activities.

Results

Survey of Specialists Registered in the MOCOMP Program

A total of 2188 (54.6%) responses were received from two mailings of the survey to 4098 special- ists in the pilot program. The sociodemographic

data of the respondents and nonrespondents are described in Table 1. Reports by respondents on the use of the diary to record SD CME activities are described in Table 2: 56.6% reported using the diary to some degree, while 25.3% reported using the diary to document one half or more of the SD CME activities they had undertaken during the 10 months of the project. Significantly, more of the respondents practicing in large communities (pop- ulation of more than 500,000), compared with those from smaller communities, and more with- out a university appointment, compared with those with a university appointment, reported using the diary (Table 3). Of the respondents who reported using the diary, 1091 (92.1 %) of the 1185 indicated that they had spent less than 20 minutes each week recording SD CME activities.

The respondents concurred with four state- ments in the survey, which correlated with their reported use of the diary, as shown in Table 4. A significant positive association was observed

21 1

Recording Self-Directed CME

Table 1 Demographic Characteristics of Responders Versus Nonresponders to the MOCOMP Survey

Variable Responders (%) Nonresponders (%) p Value

Population size Academic affiliation

Full time Other*

Years in practice < 22 years 2 22 years

Practice setting””: Solo Group

Community size I500.000 > 500,000

2188

552 (25 ) 1636 (75)

1 I62 (53) 1026 (47)

991 (47) 098 (53)

310 (60) 876 (40)

1910

429 (22) 1481 (78)

980 (51) 930 (49)

888 (49) 937 (5 1 )

1084 (57) 823 (43)

.04188

NS

NS

,04937

“Specialists with part-time or clinical academic appointments and specialists with no university affiliation. ”“Missing for responders = 99. missing for nonresponders = 8 5 . ‘Missing for responders = 2. missins for nonresponders = 3.

between reported use of the diary and an under- standing of which CME activities should be recorded: 73.8% of respondents who reported using the diary to record “more than one half’ of their SD CME, compared with 47.2% of those who reported using the diary to record “less than one half” of their CME, agreed with the statement: “I understand the kinds of self-directed CME activi- ties to record in n i j diurJ%’* ( p < .00001). An equally strong positive association was observed between diary use and the level of comfort respon- dents had with identifying keywords to record in the diary: 5 1.4% of those who reported using the diary to record “more than one half” of their SD CME activities, compared with 33.1% of those who reported using the diary to record “less than one-half’ of their SD CME activities, agreed with the statement: “I feel comfortable identifying keyunrds for in! d i u v enrries” (p < .00001). Also, a significant correlation was found between use of the diary and the respondents‘ perception that keeping records of their SD CME encouraged them to reflect on their patient care: 48.3% of those who reported using the diary to record “more

than one half” of their SD CME activities, com- pared with 24.0% of respondents who reported using the diary to record “less than one half” of their SD CME activities, agreed with the statement: “entering SD CME activities in my diary helps me to think about my patient care” (p < .00001).

No correlation was found between use of the diary and ability to identify a potential impact of SD CME activities on practice: 54.8% of those who reported using the diary to record “more than one half“ of their SD CME activities, and 54.8% of respondents who reported using the diary to record “less than one half” of their SD CME activities agreed with the statement: “It is often dificult to identifi a poteiitial impact of my self-directed CME activities on my practice.” Of respondents who had used the forms in the pilot project in 1992 and who also used the diary in 1993, 82% of 59 1 reported that the diary was easier to use than the forms. Of all 2188 survey respondents, 63% showed their acceptance of the concepts embod- ied in the MOCOMP program by reporting that they “)t.ould recornmend” the MOCOMP pro- gram to their colleagues.

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Campbell et al.

Table 2 Reported Use of Diary to Record SD CME Activities (n = 2129”)

“Since receiving my diary, I have used it to record ... None Very Little Some Half Most Nearly All ... of my SD-CME activities”

923 386 280 146 290 104 43.4% 18.1% 13.2% 6.8% 13.6% 4.9%

*59 specialists did not answer this question.

Characteristics of Diary Entries

An analysis has been undertaken of the SD CME activities entered by the first 94 specialists to return their diaries. The number of SD CME activities reported in the diary by a specialist over the 10-month period varied from 1 to 8 1 with a mean of 16.4; the specialists reported spending 1 hour or less on 835 (54.3%) of the 1538 CME activities entered in their diaries; 2 to 4 hours on 482 (31.3%); and 5 or more hours on 196 (12.7%) of SD CME activities entered in the diaries. Arti- cles from specialty journals and texts were the most frequent sources of information recorded in the diaries. The participants had difficulty in identifying an outcome to their CME projects in terms of the potential impact on their clinical practice. Further information on the SD CME

entries will be published when all diaries are retrieved and their content analyzed.

Survey of Specialists Who Did Not Use the Diary to Record Their SD CME

The second survey was mailed to 745 specialists who reported in the first survey that they had not used the diary to keep records of any of their CME activities. Five hundred and nineteen (69.7%) specialists responded. The mean score (SD) and rank order in which the respondents placed the 25 reasons for not using the diary are shown in Table 5. Abhorrence of filling in forms and the perception that record keeping would be time consuming were given as the reasons that most influenced their failure to respond. The fear of

Table 3 Reported Use of the MOCOMP Diary by Survey Respondents to Record SD CME: Frequency Distribution by University Affiliation and Size of Community in which They Practice

Diary Used to Record SD CME

Chi-square DF

p Value

Academic affiliation Full time 264 (49.4) Other* 942 (59.1)

Community population > 500,000 756 (59.4) 5 500,000 449 (52.6)

270 (50.6) 14.69 653 (40.9) 1

p = .00013

5 17 (40.6) 405 (47.4)

9.38 1

p = .00219 *Specialists with part-time or clinical academic appointments and specialists with no university affiliation.

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Table 4 Correlation between the Respondents’ Reported Use of Diary and Their Concurrence with Statements from the Survey

Proportion of SD CME Recorded in Diary

Less than More than Chi-square DF One Half One Half One Half p Value

“I understand the kinds of SD CME activities I should record in my diary. ”

Disagree Not sure Agree

“ I feel comfortable identtfiing keycords for euch of my diary entries.”

Disagree Not sure Agree

“Entering SD CME items in my diary helps me to think about my patient care.

Disagree Not sure Agree

“It is ofen difficult to identifv a potential impact of m y SD CME activities in my practice.”

Disagree Not sure Agree

n = 646 (5%) n = 145 (96) n = 393 (%)

152 (23.5) 23 (15.8) 34 (8.6) 189 (29.3) 37 (25.5) 69 (17.5) 305 (47.2) 85 (58.6) 290 (73.8)

n = 643 n = 146

230 (35.8) 30 (20.5) 76 (19.4) 200 (31.1) 41 (28.1) 114 (29.2) 213 (33.1) 75 ( 5 1.4) 201 (51.4)

n = 642 n = 146 n = 393

310 (48.3) 55 (37.7) 108 (27.5) 178 (27.7) 31 (21.2) 95 (24.2) 154 (24.0) 60 (41.1) 190 (48.3)

n = 646 n = 146 n = 392

192 (29.7) 44 (30.1) 105 (26.8) 100 (15.5) 26 (17.8) 72 (18.4) 354 (54.8) 76 (52.1) 215 (54.8)

74.48 4

< .00001

n = 391

50.55 4

< .00001

73.69 4

< .00001

2.35 4

,67237

Respondents are categorized by the proportion of SD CME they reported recording in the diary and their responses to four statements.

discovering that they participate in less CME than their colleagues was given as least influen- tial in their decision not to comply. In fact, 188 (36.2%) respondents indicated their intent to keep diary records in 1994.

Discussion

The literature on how physicians learn and make changes in their practices supports our decision to place SD CME activities at the center of a strat- egy to support the lifelong learning activities of specialists in Canada. The independent pursuit of learning promoted by the MOCOMP program is

supported by theoretical models of how physi- cians learn from practice9 and by qualitative stud- ies of how physicians learn and make changes in their clinical practice.IO The subject of intentional self-education of adults is being studied with increasing interest. While several professional bodies in Europe require their members to keep diaries as evidence of their continued education activities,” we are not aware of its use specifically to enhance the quality of independent learning. The value of keeping records may encourage learners to “conceptualize their learning in fresh new ways,’‘‘ and the process of recording may allow “an individual ... to reflect upon what is being

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Campbell et al.

Table 5 Reasons for Not Participating in MOCOMP Pilot Project: Presented in Rank Order of Mean Influence Score and Standard Deviation

Rank Statement Mean SD

I 2 3 4 5 6 7 8 9

10

11 12 13

14 15 16 17

18 19 20 21 22 23 24

Because I hate filling in forms Because I forget to record my CME regularly Because it would take too long to keep records of the journals I read Because recording my CME would take time away from other activities Because I want to participate but I have not as yet made it a priority Because MOCOMP is another bureaucratic invasion into my life Because teaching in an academic center keeps me up to date Because I do not think recording my CME will benefit my patients Because I need objective evidence that participation in the MOCOMP program will improve the quality of care I provide Because I feel no pressure from external agencies (e.g., hospital) to record my CME Because the MOCOMP program is voluntary Because I see no need to record the impact of my CME on my practice Because I believe a mandatory system of CME (e.g., 50 hours per year) is preferable to the MOCOMP program Because I am waiting for a computer version of the MOCOMP diary Because I feel all specialists should be recertified at intervals by examination Because MOCOMP is opening the door to mandatory CME Because I prefer to wait until the MOCOMP program is fully established before I register Because I can’t afford the time to participate in CME Because I am not adequately compensated for my participation in CME Because the topics my peers have reviewed in the past year are of no interest to me Because I am concerned that my CME records might not be kept confidential Because, compared with my peers, I have fewer opportunities to participate in CME Because I find the MOCOMP program threatening Because my MOCOMP profile may show me that I do less CME than my peers

3.743 3.526 3.429 3.179 2.792 2.701 2.492 2.341 2.23 1

2.182

2.169 2.090 2.010

1.711 1.627 1.602 1.580

1.535 1.428 1.333 1.326 1.251 1.217 1.122

1.363 1.414 1.396 1.535 1.480 1.483 1.550 1.439 1.426

1.274

1.282 1.337 1.287

1.184 1.079 1.036 1.008

1.114 0.948 0.75 1 0.818 0.723 0.629 0.455

learned.”5 While these quotations indicate the views of leading professionals, there are no defin- itive studies in support of our hypothesis that keeping records of SD CME activities enhances the process of learning, motivates the learner to undertake further projects, or encourages changes in behavior and improves patient care practices. The first step towards testing our hypothesis was to develop a method of record keeping that is acceptable to the majority of specialists. The MOCOMP diary proved to be an initial step in encouraging physicians to record their continuing professional activities.

The results of our survey showed that a sig- nificant number of those who used the diary agreed that it helped them to reflect on their patient care activities. There was no agreement among diary users that the use of the diary enhanced ability to identify the potential effect of SD CME activities on their practice. For a profession that has never been required or requested to record their SD CME activ- ities, the degree of compliance in using the diary (itself a major change in the lives of specialists) was, however, encouraging. Over two thirds of the vol- unteers who used the diary reported that they would personally recommend the MOCOMP program to

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Recording Self-Directed CME

their colleagues. Our results suggest that special- 2.

ists who use the diary regularly understood that the goal was to provide them with a personal tool to enhance their CME, whle those who did not seemed to misunderstand this basic philosophy of the pro- gram. The latter expressed a general objection to “form filling.” which is most often undertaken by practitioners to satisfy the requirements of an exter- nal agency with little benefit to themselves. Further, their fear that keeping records would be time con- suming was not borne out by the experiences of those who used the diary. Of the responders. 90% estimated that it took less than 20 minutes each week to keep records of their SD CME activities.

The first version of the MOCOMP diary used in the pilot program was limited in the amount of information requested on each CME item. Also, the process of data collection and the generation of the physician’s annual CME profile from a central database was labor intensive and imprac- tical. A computer version of the diary (PCDiary),

to store, sort, and retrieve a personal database of SD CME activities. Diary files will be transmitted and peer data accessed by a bulletin board system.

computer diary use on physician learning and practice behaviors. The impact of this program on

impact on patient care activities are the objec- tives of continuing research in this important area.

3.

4.

s.

6.

currently under testing. will enable the specialist 7.

A study is in progress that examines the effect of

physician learning, adoption of innovations. and

8.

9.

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Parboosingh JT, Gondocz ST. The Maintenance of Competence Program of The Royal College of Physicians and Surgeons of Canada JAMA 1993; 270:1093.

Feldman DH. Beyond universals in cognitive development. Norwood, NJ: Ablex, 1980.

Lukinsky J. Reflective withdrawal through journal writing. In: J Mezirow et al. Fostering critical reflection in adulthood: a guide to transformative and emancipatory learning. San Francisco: Jossey-Bass, 1990.

Mocker DW, Spear GE. Lifelong learning: formal, nonformal, informal, and self-directed. Information series no. 241. ERIC Clearinghouse on Adult, Career, and Vocational Education. Columbus, OH: National Center for Resexch in Vocational Education. Ohio State University, 1982.

Clark AJ, Campbell C, Gondocz ST. The CME activities of specialists in the MOCOMP program. Ann R Coll Physicians Surg Can

Parboosingh J , Gondocz ST, Lai A. The annu- al MOCOMP profile. Ann R Coll Physicians Surg Can 1993; 26(5):44-47.

Schon DA. The reflective practitioner: how professionals think in action. New York: Basic Books, 1983.

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