Continuing Medical Education among resident physicians in Abha , Saudi Arabia : Current Practice and Existing Gaps

Background: Continuing Medical Education (CME) is concerned with the maintenance, improvement, and promotion of the health care and exhausts the physicians’ working life-span. Although international research is extensive, only a dearth of studies exists in Saudi Arabia and the Middle East. This study aims to explore CME practices of resident physicians in Abha City, south western Saudi Arabia and the existing gaps. Method: A cross-sectional questionnaire-based descriptive study conducted on residents training in various health-care facilities in Abha city. Results: Three-hundred resident physicians participated in the study (response rate of 75%). Out of them 79,7% (239) reported attending lectures and seminars for their CME needs followed by those who attended case presentations 39.7% (119). Electronic CMEs were used by a minority of residents (n = 24, 8%), and only 27.3% (n = 82,) attended journal clubs. Being busy was the main barrier against self-reading as reported by 70.7% (212) of participants, and by 51.7 % (155) for lectures and seminars, and 41.3% (124) for attending courses. There were no signicant differences in satisfaction with CME activities by gender, nationality and training level (p = 0.982, 0.924, and 0.540, respectively). Satisfaction scores with CME activities were variable across different specialties (p = 0.039). The lowest satisfaction scores were among psychiatry residents and the highest was among the restorative dentistry and surgery residents. Workshops and courses were signicantly perceived by residents as the most effective method in retention of knowledge, improving attitudes, improving clinical skills, improving managerial skills, and in proving practice behaviors. On the other hand, inter-departmental activities were signicantly perceived by residents as most effective in improving academic skills and improving departmental image. Conclusion: The participant physicians favoured contact CME activities. In consistence with global research ndings, being busy was the main barrier against CME goals attainment. Participants armed that CME activities improved their clinical practice, clinical skills and academic skills. Promotion of online learning in Saudi Arabia. Support of residents with protected time for their CME activities. Encouragement of trainees into further advice about their preference in terms of CME

graduation. A review of recerti cation examination in the US reported that examinees who had been trained long before were less successful in the examination than those who were recently trained [7]. For physicians to stay t to practice, it is thus a core professional responsibility if not an ethical and moral obligation to continue to learn throughout their career regardless of discipline, specialty, or type [8].
In 1995 a systematic review of the effect of continuing medical education strategies [9] including ninetynine studies, evaluating 160 separate interventions (apart from placebo or non-intervention controls), concluded that physician performance may be altered by many educational interventions and, to a lesser extent, so may health care outcomes. Widely-used continuing medical education delivery methods, such as conferences, have little direct impact on improving professional practice. More effective methods such as systematic practice-based interventions and outreach visits are seldom used by continuing medical education providers.
There are diverse opinions as regards continuing medical education; elicited by research in different countries and different population groups. A research from Australia focused on GPs, physicians and surgeons. It reported that modern, technology-dependent forms of CME were less common but were believed by respondents to be the best mode of delivery. The studied groups showed difference in attitudes, with physicians nding CME more enjoyable than GPs [10]. Another study on users of British Medical Journals online CME reported that younger and more recently quali ed doctors choose online CME, and their choice appears to be unrelated to workload and personal pressures [11].The consistent nding across studies from UK, Australia and South Africa is that traditional CME activities such as lectures, conferences and journal reading remain the most popular forms of CME used and all doctors found lack of time a barrier to CME activities. [10][11][12].
There are many issues facing health-related human resource development in the Kingdom of Saudi Arabia, and continuing medical education is not spared from these challenges. CME involves many actors such as providers, sponsors, participants, and regulators. Several challenges have been identi ed including a lack of transparency in the CME budget, which leads to a too close relationship between the pharmaceutical industry and physicians, as well as issues of coordination between providers, adequate assessment of needs and resources, effectiveness, and quality control [13].
In Saudi Arabia, the Saudi Commission for health specialties (SCFHS) is running different Postgraduate Programs for training of graduates in different health specialties. By the end of the training and passing the assessment modalities the candidate will get the Saudi Board certi cate which is the highest professional certi cate in general specialties awarded by the Commission. Each program will run for ve years. Similarly, the SCFHS is running CME which is de ned as educational activities, which aim to keep health practitioners abreast with the latest developments in their specialties and related elds.
In Saudi Arabia, the regulatory body that approves and accredits all CMEs, the Saudi Commission for Health Specialties (SCFHS), has ruled that all healthcare practitioners must acquire a set number of CME hours minimum 30 hours annually for successful licensing to practice as physician in the Kingdom. Resident physicians in different SCFHS post graduate training programs are exempted from CME activities for nalizing their training in the due programs. Yet, they need attending minimal CME hours to be licensed for their practice. Saudi candidates getting their postgraduate training outside the Kingdom are also required to have CME hours before licensing to practice in Saudi Arabia. CME activities are given to practicing physicians (residents, specialists and consultants) [3] Essentially, this regulation presumes that attending CME events secures the improvement of attendees' knowledge and skills [3]. However, this regulatory approach is not su cient to ensure effective learning.
There is a need to give proper attention to principles of adult learning to enable learners to be active participants in developing training programs. It is also necessary to fashion the learning activities according to learners' goals [14]. In Saudi Arabia, there have been no substantial reports on such aspects of CME [3].
Previously, the related studies have focused on quality issues in CME rather than the needs assessment of physicians who are the major stakeholders [15,16]. A key study has described the development, implementation, and evaluation of an educational program in family medicine for general practitioners in Saudi Arabia that trained about 20% of all GPs showed very promising results with signi cant improvement of knowledge [17]. However, there is dearth of information on the CME needs of the participants.
Up to the researcher's knowledge, no similar study has been conducted in Abha City, southwestern Saudi Arabia during the past decade to explore the needs and practices among resident physicians regarding their continuing education or to clarify trainees' views about different aspects of CME.

Aim of Study:
This study aims to explore CME practices of resident physicians in Abha City and the existing gaps.

Study Objectives
To identify the current CME practices of resident physicians.
To explore opinions of resident physicians regarding continuing medical education.
To identify barriers in CME practice among resident physicians.

Study design:
A cross-sectional survey study was conducted among male and female residents at governmental hospitals (Maternity and Children's Hospital and Aseer Central Hospital) in Abha City in 2018.
Target population and sampling: With an anticipated proportion of CME training among residents of 50% [3] and an absolute precision of 6% at 95% con dence, the minimal sample size needed for the survey was calculated to be 267 residents [18]. To account for potential nonresponse, an overall sample size of 300 residents was initially planned for the study. A list of residents was obtained that yielded 400 currently enrolled residents from all departments. All residents were invited to participate in the study using an online questionnaire. A total of 313 residents returned lled questionnaires for a response rate of 75%. Thirteen incompletely lled questionnaires were discarded, leaving a nal sample of 300 residents.

Survey tool:
This study used a self-administered questionnaire that was constructed by incorporating previous validated questionnaires obtained on request from their authors [3,19]. Besides the personal characteristics of age, gender, nationality, marital status, specialty, position, quali cation, and years of experience, the various aspects of continuing professional education were explored. The aspects of CME that were included were as follows. Current participation in CME activities: frequency of CME activity, type of activity (conference, seminar, self-reading), reasons for doing CME, satisfaction with current CME practices, preferred methods of instruction in different CME activities, and barriers to attending CME.
Resident preferences for future CME activities (time of activity, duration, evaluation methods) were also elicited.
We analyzed the total satisfaction score by adding up the ordinal responses of trainees according to the satisfaction score between 0 and 4, where strongly disagree = 0 and strongly agree = 4. Cronbach's alpha for the 8 satisfaction questions was 0.85, which indicates very good reliability and internal consistency. Obtaining all the necessary o cial approvals and research ethical committees prior to conduct the study.
Data collection and analysis: The study questionnaire was emailed to all residents working in the Asser region. Data were analyzed using the SPSS software package, version 22. Categorical data were summarized using frequencies, percent and presented using tables and bar graphs, while continuous data were summarized using median, range, arithmetic mean, and standard deviation (SD). Ch-square, student "t" test and ANOVA were used as tests of signi cance. The level of signi cance was set at p ≤ 0.05.

Results
The present study included a total of 300 residents. Figure 1 shows the CME activities undertaken by the study participants in the previous year. During this period, 239 (79.7%) of the participants reported attending lectures and seminars for their CME needs. There were 102 who attended workshops (34%), whereas 89 (29.7%) reported attending group discussions and 119 (39.7%) reported attendance at case presentations. Electronic CMEs were used by a minority (n = 24, 8%), and only 82 (27.3%) attended journal clubs. There were 131 (43.7%) who attended conferences. Residents usually engage in more than one modality of CME activities. Table 1 shows that the study included 176 (58.7%) males and 124 (41.3%) females among the participating residents, most of whom were Saudis (n = 289, 96.3%). Half of all residents were married. By specialty, 24.3% were residents in family medicine, 21.3% in internal medicine, and 12.7% in pediatrics.
Other specialties, namely obstetrics and gynecology, ENT, and dermatology, made up approximately 5%, and orthopedics, preventive medicine, and general surgery about 4% of study participants each. Lower gures were shown for ophthalmology (3.7%), radiology (3.3%), and psychiatry (2%), while emergency medicine, restorative dentistry, and urology each made up less than 2% of the residents. By the level of residency, there were 89 residents (29.7%) in rst year (R1); almost equal numbers of R2 and R3, 75 and 74 (25% and 24.7% respectively); 44 (14.7%) R4; and only 7 (2.3%) were R5. Table 1 shows also the average total satisfaction scores. There were no signi cant differences between males and females regarding satisfaction with CME activities scores (p = 0.9816). Similarly, no signi cant differences in scores were found by nationality and marital status. Satisfaction scores with CME activities were variable across specialties (p = 0.039). The lowest satisfaction scores were among psychiatry residents and the highest was among the restorative dentistry and surgery residents. There were no signi cant differences in satisfaction scores by training level (p = 0.54). α "using student t test" β "using ANOVA" Table 2 describes the residents' beliefs about continuous medical education as assessed by their level of agreement with various statements. To the statement, "I believe that my CME needs are currently satis ed," 42.3% of the residents agreed, compared to 24.3% who disagreed. To the statement, "I believe that my medical school education encouraged me to be an independent self-learner," 49.4% agreed and 24.3% were neutral. More than two-thirds (68.7%) agreed that "I believe that CME activities should be organized on a national level." To the statement, "CME activities keep me up-to-date," a majority (65%) agreed and 8% disagreed. Some (68.7%) agreed that "CME activities help me to improve my practice," in contrast to 8.3% who disagreed. A majority (65%) agreed with the statement, "CME activities affect my professional con dence," compared to 26.7% who were neutral. As to the statement "CME activities offer new learning opportunities," 65.3% agreed and 7.7% disagreed or strongly disagreed, respectively. "CME activities provide su cient scopes for questions and discussions" was agreed to by 57.7%, while 10.7% disagreed.  workshops and courses were signi cantly most effective compared to the other two methods in retention of knowledge, improving attitudes, improving clinical skills, improving managerial skills, and in proving practice behaviors. On the other hand, inter-departmental activities were signi cantly most effective compared to the other two methods in improving academic skills and improving departmental image.   Table 4 shows participants' preferred methods of instruction in the CME activities during the past one year. The highest frequency of residents preferred that lectures should take place in the form of a conference/symposium (n = 111, 37%). For demonstration-type CME activities, residents preferred that it should take place in workshops (n = 119, 39.7%), while for hands-on practice, most residents preferred that it should take place in workshops (n = 162, 54%). Similarly, for small group CME seminar practice, the highest frequency of residents preferred workshops (n = 108, 36%). However, for live-casepresentation CMEs, residents equally preferred workshops and conferences (n = 88, 29.3%; 89, 29.7%, respectively), while for simulation CMEs, workshops were the preference of 40.7% (123) of the residents. For distance learning CMEs and electronic meeting CMEs, the highest frequency of residents preferred conferences (n = 119, 39.7%; n = 134, 44.7%, respectively). Table 4: Residents' preferred methods (n=300) of instruction in the CME activities during the past one year Table 5 shows the frequency distribution of respondents by their preferred CME resources, frequency of CME activity, and reasons for using different CME activities and barriers. The most prevalent self-reading method was reading medical books (n = 230, 76.7%), followed by online websites for self-reading (n = 196, 65.3%). One out of each ve residents reported reading medical journals, which was lower than the 30.3% who reported using social media for self-reading purposes. When asked how often they read, the highest frequency of residents (n = 128, 42.7%) reported weekly self-reading, compared to 116 (38.7%) who reported daily self-reading. The reasons for using self-reading as a CME method were ease of time management (n = 208, 69.3%), ease of place (n = 104, 34.7%), price (n = 54, 18%), subject (n = 86, 28.7%), and reputation of provider (n = 13, 4.3%). Barriers to self-reading were reported as being busy (n = 212, 70.7%), lack of interest (n = 31, 10.3%), lack of provision (n = 26, 8.7%), lack of suitability (n = 15, 5%), and high cost (n = 26, 8.7%). Another method of CME was attending lectures and seminars, for which 106 residents (35.3%) reported attendance at conferences, 74 (24.7%) live casts, 195 (65.0%) presentations, and 19 (6.3%) used distance learning. In terms of the frequency of lectures and seminars for CME activities among residents, the highest frequency of residents (n = 130, 43.3%) reported weekly attendance, compared to 46 (15.3%) who reported daily use of lectures and seminars for CME needs. Also, 88 (29.3%) reported monthly attendance, while 57 (19%) reported rarely attending lectures or seminars. As for why they chose lectures and seminars as a CME method, time was reported by 125 residents (41.7%), place by 134 (44.7%), price by 37 (12.3%), subject by 49 (16.3%), speaker certi cation by 26 (8.7%), and the reputation of the provider by 14 (4.7%). Barriers to using lectures and seminars for CME activities as reported by residents were being busy by 155 (51.7%), lack of interest by 50 (16.7%), lack of provision by 50 (16.7%), lack of availability by 67 (22.3%), lack of suitability by 18 (6%), and high cost by 37 (12.3%).
Attending courses as a CME activity was reported by 186 (62%) residents, 115 (38.3%) residents reported attending workshops, while group discussions were reported by 83 (27.7%). In terms of the frequency of attending CME courses, the highest frequency of residents (n = 134, 44.7%) reported rare attendance, compared to 81 (27%) who reported monthly attending CME courses. However, 66 (22%) reported weekly attendance and 23 (7.7%) daily. In terms of the reason for choosing courses as a CME method, time was reported by 122 (40.7%), place by 112 (37.3%), price by 39 (13%), subject by 73 (24.3%), speaker certi cation by 36 (12%), and reputation of provider by 23 (7.7%). Barriers to attending courses were; being busy (n = 124, 41.3%), lack of interest (n = 36, 12%), lack of provision (n = 87, 29%), lack of availability (n = 101, 33.7%), lack of suitability (n = 15, 5%), and high cost (n = 46, 15.3%). Figure 2 shows residents' preferences regarding various aspects of CME activities. The preferred duration for CME activities for the majority of participating residents (n = 153, 51%) was one to two days, followed by 137 (45.7%) who preferred three to seven days. The majority (n = 194, 64.7%) preferred that CMEs should take place on a workday, compared to 106 (35.3%) who preferred a non-workday. Mornings were preferred by most participants (n = 216, 72%), with only 45 (15%) preferring afternoons and 43 (14.3%) evenings. Regarding method of evaluation, the highest frequency of residents (n = 135, 45%) preferred a questionnaire evaluation for CME activities, compared to 114 (38%) who preferred group discussion and 55 (18.3%) who preferred verbal assessment. Discussion CME, Continuing Medical Education, constitutes a wide range of educational activities that aim for the maintenance, development, and improvement of the knowledge, skills, and professional performance that enable practicing clinicians to provide safe and e cacious clinical services. Lifelong learning remains an indispensable element in enhancing clinical knowledge and professional behavior among practicing clinicians [20], as clinical experience over the years does not necessarily yield higher levels of skills, professional behavior, or knowledge [21,22]. This study is unique in exploring various aspects of CME activities utilized by resident trainees in Abha City in Saudi Arabia, as well as their opinions of the effectiveness of CME activities and the barriers that hinder accessing them.
This study found that the most popular CME activity among the participating residents was lectures and seminars. Lectures are not just popular in our sample of trainees, but also remain the main source for CME. Around the world, studies exploring physicians' CME preferences agreed with our study ndings [6,23]. Also, a recent exploratory study from Saudi Arabia con rmed that the majority of healthcare professionals preferred symposia and short courses [3]. Indeed, lectures are famous as one of the most common forms of dispensing knowledge among clinicians and have been found to have a positive impact on knowledge and skills, though they have very little performance-improving effect [6]. The least popular CME activity was electronic activities. These are non-contact CME activities, which could be one of the reasons for their unpopularity among trainees [24]. Research has found that the more interaction there is between the adult learner and the educator, the greater the satisfaction with the learning method [23]. Electronic CME activities have certain sophisticated requirements, such as access to smart devices and software and the ability to afford extensive data connectivity costs [25]. Electronic CME activities have many advantages, such as exibility and individualized learning format [24,26], and trainees should be encouraged to make effective use of them. Notably, some studies did not nd substantial differences between didactic lectures and online teaching methods in improving diagnostic skills among physicians [27,28].
In the current study, the resident physicians did not show much inclination towards using live casts, or electronic conferencing, particularly for workshops, courses or inter departmental activities. This is an interesting nding, considering that internet penetration rate in KSA at 93.3%, is among the highest globally [29]. This highlights under-usage of an effective resource friendly learning method, which has shown to improve knowledge, attitude and practice of physicians [30].This trend has been reported earlier by students from a university in Najran, Saudi Arabia, who reported that 97% of them have computer and internet access, yet 73% opted for conventional learning methods. [31] One of the main ndings of this study is that the main barrier against attending all forms of CME was being busy, although it was higher for self-reading than contact CME like attending lectures and seminar courses. Our ndings are a stark reminder of the reality of how busy clinical services are nowadays. No matter how motivated a clinician is, time pressures can hamper their CME goals attainment. This nding has been con rmed across national and international studies [32], and indeed little has changed in the past two decades, as a study in the same region some 20 years ago revealed that physicians had little time allocated for CME practice [33]. Time constraints were the second most common reason for not attending CME activities in a Pakistani sample of physicians [34]. The problem of a lack of protected time, we suspect, must have increased in recent times. Contrary to our ndings, a recent study from the Eastern Region of Saudi Arabia found that lack of postgraduate education and dissatisfaction with CME activities were the main reported barriers to physicians' accessing CME activities [25]. Interestingly, that study found that high case load is an impetus for physicians to gain extra knowledge and skills and engage in CME more frequently [35].
Another reassuring nding in this paper that almost half of the participants a rmed that conferences improved their clinical practice and academic skills. Also, two out of every three residents con rmed that workshops and courses improved their clinical skills. This overall improvement in clinical skills as an effect of engaging in CME has been well established in several educational papers [36][37][38][39] and is consistent with the results of the current study. The results of our study are grounds for cautious optimism and point to improvements in physicians' satisfaction with CMEs over that reported in the last decade [19].
This study did not establish any background factors exerting a signi cant impact on satisfaction with CMEs, which agrees with the results of another study [40]. It is reassuring that gender was not a determining factor in satisfaction with CME activities. Only few differences were observed between training specialties, and it was worrying that psychiatric trainees were the least satis ed among the participants. Many surveys indicate that dental health professionals are in general more satis ed with CME activities than other health-care workers [39]. This could explain the differences in satisfaction scores between trainees in restorative dentistry and other medical trainees.
This study provided some much-needed answers. While it was comprehensive in assessing the CME practices and needs of the residents, it is limited by the fact that the study concerns resident physicians of one region and its results are not generalizable to all of KSA. Other limit to our study was involved all resident physicians at governmental care hospitals in Abha City which trained hospitals and all residents were considered as trainees' physician.
Limitations of the study were mostly related to being performed in a local region of Saudi Arabia.
Generalization of the present study should be performed with some caution.

Conclusions
In conclusion, resident physicians mostly attended conferences, lectures and seminars and to a lesser extent workshops and group discussions for their CME needs. Electronic CMEs were used by a minority of them. They reported workshops and courses most effective in retention of knowledge, improving attitudes, improving clinical skills, improving managerial skills, and in proving practice behaviors. The reported barriers to CME were being busy, lack of provision, lack of suitability and high cost. Based on the ndings of this study, it is recommended that online learning be promoted as a CME format for trainees and practicing clinicians in Saudi Arabia. There should be support of residents and clinicians through provision of protected time for their CME activities outside their daily clinical commitments. Future research should focus on the effects of various forms of CME on clinical effectiveness as well as the professionalism and communication skills of physicians.

Declarations
Ethics approval and consent to participate: Informed consent was obtained from all residents prior to data collection as written consent. All the selected respondents were given assurance of con dentiality that the information gathered will be used exclusively for research purposes. This study was approved by the Institutional Review Board of the College of Medicine; King Khalid university (KKU) (Reference #: REC: 2018/05/72).
All necessary o cial approvals to conduct this study were obtained. Consent for publication: Not applicable.
Availability of data and materials: The data that support the ndings of the current study are available from the corresponding author on reasonable request.
Competing interests: The authors declare that they have no competing interests Funding: None Authors' contributions SA, NM and AM were the main authors of the manuscript. AF planned the study. NM and AF contributed to the data analysis and manuscript writing with assistant and supervision of SA. MA, AA and AM assisted in nal analyses and writing the manuscript in nal proof article. All authors approved submission of the nal manuscript. Figure 1 Distribution of CME activity taken by the residents in the previous year Residents' preferences regarding various aspects of CME activities

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. ISSMSTROBEChecklistCME.pdf questionnairesurveytool.doc