Postal survey of approaches to learning among Ontario physicians: implications for continuing medical education

Introduction

Doctors face enormous challenges in managing the growth of knowledge throughout their careers. Medical schools have responded by developing methods to foster independent self directed lifelong learning. Regulatory bodies are also increasingly concerned with assessing continuing medical education in order to ensure the continued competence of physicians to practice.1

These forces have focused attention on the effectiveness of continuing medical education. Didactic lectures, which are a familiar part of undergraduate medical education, are not effective in changing doctors' behaviour.2 New techniques have therefore been developed to facilitate learning. 3 4 Although many physicians participate in these activities, it is not clear how effective they are for individual physicians.

Approaches to learning and the complex interaction of the environment, personal factors, and opportunities are known to affect undergraduate learning.5^–8 Knapper studied the effect of the workplace environment on learning of students in work-study programmes.9 He found that the workplace promoted a deep approach to learning (box). The achieving approach to learning (competitive and focusing on achieving high grades) found in university students was not evident in the workplace and surface approach to learning (rote memorisation, lack of understanding) divided into surface rational and surface disorganised approaches.10

Kirby et al adapted items from Ramsden and Entwistle's course perceptions questionnaire to examine variations in perceptions of the workplace climate. 7 10 11 Three factors emerged, reflecting perceptions of good supervision, choice-independence, and heavy workload (box). Items indicating that supervisors tried to understand and help employees and took their ideas seriously defined good supervision. Good supervision and choice-independence were positively associated with the deep approach and negatively associated with the surface disorganised approach to learning. Workload was strongly related to the surface disorganised approach. The questionnaires used in these studies showed Chronbach's α reliabilities for the six scales ranging from 0.71 to 0.87.10

The deep approach to learning is thought to lead to improved understanding and knowledge. 5 6 There is little empirical research to show that this is the approach used by practising physicians. If the factors that affect physicians' learning were known, providers of undergraduate and continuing medical education could improve the conditions for effective learning, including organisation of work and the development of skills for lifelong learning. In this study we examined the relations between approaches to learning at work of practising physicians and perceptions of the workplace climate to determine how these variables affect their motivation for, methods of, and perceived barriers to continuing medical education.

Participants and methods

We revised the workplace learning questionnaire for use by practising physicians (appendix).10 Because most physicians work independently, we modified the good supervision scale and relabelled it as the supportive-receptive climate scale. We piloted the questionnaire to ensure it was understandable and that items related to their intended constructs. Two items intended to measure choice-independence (“The work I am doing now will be a good preparation for career opportunities elsewhere, should I ever leave” and “The work I am doing now will definitely improve my future employment prospects”) were not relevant to most physicians. We therefore eliminated these from the final version. There were 10 items each for the approaches to learning constructs and five items per workplace climate construct apart from the choice-independence scale (three items).

We asked physicians to rate their most valued continuing medical education activities, barriers to, and motivations for continuing medical education on a five point scale ranging from “agree strongly” (5) to “disagree strongly”(1). The learning activities were categorised into consultations, independent learning (reading journals, literature searches, reading a textbook, and searching the internet), standard continuing medical education (workshops and conferences) and problem based learning. The motivations for continuing medical education were categorised as internal (“the pleasure of learning something new”), external (“the requirements of my professional college,” “fear of a lawsuit”), and professional competence (“the need to maintain my competence,” “unfamiliar patient problems”). Queen's University research ethics board approved the project.

Results

Of the 390 surveys returned, 17 were undeliverable and 27 had greater than 10% missing data, leaving 346 for analysis. The proportions of specialists, women, and younger physicians responding were slightly higher than those in the population surveyed (table 1). Specialists worked predominantly in urban settings, whereas just over half of family physicians worked in rural settings (table 2). Most physicians (208, 60%) worked 40-60 hours a week, 48 (14%) more than 60 hours a week, and 90 (26%) less than 40 hours a week.

Principal axis factor analysis indicated that the modified workplace learning questionnaires had the same factor structure as found in previous studies.14 Cronbach's α reliabilities ranged from 0.56 to 0.74 (table 3).

The mean score for the surface disorganised approach to learning (2.72) was substantially lower than the means for the surface rational or deep approaches (3.33 and 3.59; table 3). The size of the differences suggests that physicians are more likely to agree that they learn either for understanding or in an orderly or logical approach to solve a problem. They are more likely to disagree with statements about learning in a disorganised, superficial manner, overwhelmed by the task.

Family physicians, physicians from rural or remote practices, and those who had undergraduate problem based learning had higher surface disorganised learning scores than other groups (table 4). Rural and remote practice location was associated with higher workload scores.

Discussion

Most physicians take either a deep or a surface rational approach to learning at work. The deep approach indicates the intent to understand and reflect on knowledge that should affect practice behaviours. The surface rational approach may be appropriate in some situations, such as solving a pressing patient problem.10 It is a concern, however, that some physicians seem disorganised in their approach to learning at work.

The relation between perception of heavy workload and surface disorganised approaches to learning among physicians is consistent with studies in other workplace situations. 10 14 Physicians who adopt a deep approach perceive choice and independence in the workplace and a supportive-receptive atmosphere. Although we cannot determine causation from this study, studies of undergraduate students indicate that the learning environment affects the approach to learning, independent of the preferred learning style. 7 15^–17 Yet medical students with a deep approach to learning were more likely to take an intercalated degree and pursue a career in research or laboratory medicine, indicating that their approach to learning may affect the environment they choose.18

Family physicians and younger and rural hospital physicians had higher scores on the surface disorganised scale, and rural physicians scored more highly on the workload scale. Clearly, overworked young primary care physicians in isolated environments may be most vulnerable to ineffective approaches to learning at work. New British general practitioners were found to need support early in their careers to avoid stress and negative personal impact on their careers.19 Further studies are needed to determine whether changing the work environment can aid learning and support new physicians. External motivators for learning by regulatory bodies are unlikely to lead to effective learning in overloaded physicians.