J Morrison, N Johnson, A McConnachie,* A Power,+ P Redding,# D Corcoran**
General Practice and Primary Care, Division of Community Based Sciences, University of Glasgow; *Robertson Centre for Biostatistics, University of Glasgow; +Department of Medicines Management, Greater Glasgow Primary Care Division; #Department of Microbiology, Victoria Infirmary University Trust; **Department of Microbiology, Western Infirmary North Glasgow University Hospital Trust
Correspondence to: Professor Jill Morrison, General Practice and Primary Care, Division of Community Based Sciences, University of Glasgow, 1 Horselethill Road, Glasgow G12 9LX Tel: 0141 330 8330 Fax: 0141 330 8331 Email: jmm4y@clinmed.gla.ac.uk
SMJ 2005 50(3): 118-121
Abstract
Aims: To assess the feasibility and acceptability of a problem-based, peer-facilitated educational workshop about antibiotic prescribing for GPs. Method: Participants: All 39 GPs working in an average sized Local Health Care Co-operative (LHCC) in Glasgow. Intervention: Prospective collection of information about 10 prescriptions for antibiotics to assess learning needs in relation to antibiotic prescribing. Two and a half hour workshop involving problem-based group work based on the needs assessment and discussions with a consultant microbiologist, prescribing adviser and academic GP. Evaluation: Written feedback about the process of the educational intervention immediately after the workshop and outcome feedback collected after four weeks. Telephone interviews with non-participants. Results: Twenty-four GPs agreed to participate in the study. 19 of these completed the Needs Assessment and 14 of these completed the workshop. The method of learning needs assessment and the educational workshop were highly acceptable. “No time, too busy” was the main reason given for not taking part in the study. Conclusion: Some GPs are unable to participate as fully as they would like in continuing professional learning activities due to competing workload pressures. Further research is required to investigate the necessary type and balance of learning activities and the barriers to engagement to ensure the most effective use of clinician time available for continuing educational activities.
Introduction
There is considerable variation among doctors about which learning activities they prefer. Several studies report that traditional, formal approaches are most popular,1,2 and GPs have been found to value discussions with, and teaching by, hospital doctors.1,2 However, traditional approaches that are lecture dominated, involve minimal collaboration between learners and providers, and are unresponsive to learners’ needs are currently out of favour.3 Self-directed learning, which is based on experience and draws on the principles and features of adult learning is in vogue. Adults like their learning activities to be problem centred and relevant to their practice with immediately applicable outcomes.4 Recognising that professionals’ practice is characterised by “complexities, uncertainties and competing values”,5 it has been suggested that peers and colleagues could act as educators in a coaching role, explaining how and why they would act in a given situation.6 Peer education is more effective when the message is delivered by local opinion leaders, relevant to the doctors’ own practice and they have the opportunity to voice their concerns.7
It is generally agreed that accurate assessment of learning need is the first step in planning effective continuing professional development activities8. However this process is poorly understood, difficult to do well and often inadequately carried out9. In addition, methods such as portfolio-based learning which emphasize identifying and addressing individual educational needs, may not produce the general shifts in clinician behaviour that are required to address important public health problems.
A change in the antibiotic prescribing behaviour of doctors is needed at a global level. Eighty-five to 90% of antibiotics are used in the community10 and there are growing concerns about cost, increasing workload for self-limiting conditions and the rising prevalence of antibiotic resistance.11 Above average prescribing for acute respiratory illness is associated with increased consultation rates7 while large-scale reduction in prescribing patterns is associated with reduced antibiotic resistance.11
This study aimed to assess the feasibility and acceptability of a problem-based, peer-facilitated educational workshop about antibiotic prescribing. It also evaluated a method of notional educational needs assessment and attempted to involve all GPs in a single local health care co-operative (LHCC – the current organisational structure for general practice in Scotland) in an educational activity. A potential strength of LHCCs is that they provide a context with particular opportunities for professional co-operation around identified health issues.
The methods of learning described in this study are quite similar to those used in Canada’s Practice Based Small Group Learning Programme described by MacVicar in 2003.12 He stated that there was “much for us in the UK to learn from it”. The Canadian model evolved from a problem based learning (PBL) approach initially at McMaster University, Hamilton, Ontario which has a PBL medical curriculum. Our study was based in Glasgow which also has a PBL undergraduate medical curriculum and we were interested in how this method could be used in continuing professional development.
Method
Ethics approval for the study was obtained from Greater Glasgow Primary Care Local Research Ethics Committee. A single LHCC of about the average size for Glasgow (60,100 patients) was selected and members of the research team attended a routine LHCC management meeting attended by all available LHCC members and discussed the study. Permission was given to approach GPs in the LHCC to ask them to participate in the study and a list of GPs working in the LHCC was obtained.
All GPs in the LHCC were contacted in writing with information about the study and asked to complete and return a form indicating whether they were willing or not willing to participate. If they were not willing to take part in the study they were asked to indicate if they would be willing to participate in a brief telephone interview to explain their response. Non-responders received two further mailings and contact was attempted by telephone and in person.
GPs who did not wish to participate in the educational intervention but were willing to discuss their reasons for this response, participated in a brief telephone interview with the principal investigator. They were asked why they had not agreed to participate. Prompts were used and covered time pressures, lack of interest, already participating in another study, no perceived problems with antibiotic prescribing, unsuitable dates for meeting, too many forms to fill in, did not need PGEA points, insufficient incentive, attitude to team offering session, and no wish to take part in LHCC based learning.
Postgraduate Education Allowance (PGEA) approval was obtained for both the needs assessment and the workshop. On completion of both parts of the intervention, attending GPs received one PGEA point for Service Management and one point for Disease Management. Later recruitment drives included examples of positive comments given by earlier participants about the educational intervention in the letters of invitation.
Learning needs assessment
GP’s who agreed to participate in the educational intervention were asked to prospectively complete one A4 sized form for each one of 10 consecutive prescriptions they wrote for an antibiotic. Information given on the forms by GPs included: date and time of prescription; gender and age of patient; presenting complaint; drug, dose and duration of treatment prescribed; bacteriological investigations performed; rationale for prescribing; and the use of any guidelines. We excluded antibiotic treatment for gynaecological infections as this often resulted from swabs taken at specialised clinics. Finally, the respondent was asked to reflect on, and describe, any difficulty they had in deciding to prescribe the antibiotic. The forms were returned to the research team prior to the educational workshop.
Educational workshop
A total of 11 different dates spread over six months, with some workshops in the afternoon and others in the early evening, were offered to GPs. All workshops were held in the Department of General Practice which was less than two miles from the health centres and surgeries involved. Refreshments were provided. GPs who were unable to attend the arranged dates were contacted and asked to identify other suitable dates for them and individual workshops were offered. In some cases, GP’s were contacted four times and offered alternative dates between June and November 2002.
During the educational workshop which lasted two and a half hours, GP ’s were presented with a preliminary evaluation of the Needs Assessment (further information about this is available in the final report of the study to the Chief Scientist Office13). They were also shown the LHCC prescribing rates for commonly used antibiotics compared with the Health Board average. This was followed by three periods of group work involving case based discussion.
The three cases were developed from the reports of areas where the participants had experienced difficulty in making a decision about prescribing antibiotics. These three areas were otitis media, lower respiratory tract infection and urinary tract infection. The GPs in the study team (JM and AP) constructed the cases using the information provided on the Needs Assessment forms and their own clinical experience so that the cases reflected real clinical experience as far as possible (example of scenario in Appendix 1). The participants were provided with journal articles, local guidelines and web based materials which they could use to inform their decisions about how they would manage each case. Each period of group work was followed by a discussion on the groups’ views about the case with a consultant microbiologist, prescribing adviser and academic GP.
Evaluation
At the end of the workshop, GP’s were asked to complete an evaluation form to assess: the acceptability of the method of needs assessment and the educational workshop; whether they gained new knowledge about antibiotic prescribing as a result of the intervention; and whether they thought it would result in changes in their antibiotic prescribing practice.
Follow up
A single A4 laminated sheet detailing the key learning points from the workshops was produced and sent to all GPs who participated in the study four weeks after the workshop. They were also asked to complete a brief questionnaire about whether the key points raised from the antibiotic workshop were useful and whether as a result they believed they had changed their practice.
Results
Participation articipation in the study Of the 39 GPs in the LHCC, 24(62%) agreed to participate in the study. Seven GPs declined to participate and three of these agreed to a brief telephone interview to explain why they didn’t want to be involved in the study. The remaining eight GPs in the LHCC did not respond despite three written reminders and attempts at personal contact.
Of the 26 GPs who agreed to participate in the study, 19 completed the Needs Assessment and 14 of these completed the workshop. (Figure 1) The research assistant spoke to the 12 GPs who did not complete the study despite agreeing to participate in it. Although they wished to participate, they were unable to identify convenient time and cited pressure of work as a cause of this difficulty.
All three GPs who completed a telephone interview indicated that “no time, too busy” was the main reason for not taking part in the study. All three also stated that they did not need PGEA points but indicated that they liked the team offering the session, they felt that they had problems with their antibiotic prescribing and they were interested in the issue. They also stated that they wished to take part in LHCC based educational initiatives although one GP said he did not feel that the LHCC was working well at present. Two out of the three GPs were already participating in another study and the other stated that their attendance on a formal course of postgraduate study limited time for other educational activities. Two thought the dates and times were unsuitable and two thought there were too many forms to fill in. Two thought that there was insufficient incentive to take part in the study and one suggested that locum cover would have been a suitable incentive. One GP stated that the issue had “not been identified as an LHCC learning need” and that “national priorities needed to coincide with LHCC priorities”.
Learning needs assessment
A total of 182 forms were returned by the 19 GPs who agreed to participate in the study. Sixteen of the GPs completed all 10 forms. One GP completed nine forms, one completed eight forms and a third completed five forms.
Evaluation
All 14 GPs who attended the workshops completed an evaluation form. This simple evaluation suggests that both the method of learning needs assessment and the educational workshop were highly acceptable to those who participated in both. (Table I) The free comments given on the forms were generally extremely positive. These included comments such as “interesting and interactive”, “very friendly, open discussion” and “plenty of opportunities to discuss anxieties”, “well-organised”, “easy to participate”, “stimulating” and “I felt I put in more input than normal”.
Follow up
Eleven of the 14 attendees at the workshop completed the follow-up questionnaire. All 11 of them replied that they found the key points produced from the workshop useful and all said that they had implemented suggestions from the workshop. Examples of the changes made to practice included: increasing the dose of amoxycillin (six respondents); using short courses of antibiotics for uncomplicated urinary tract infections (five respondents); avoiding antibiotics in some respiratory tract infections; and prescribing less ciprofloxacin.
Discussion
It was not feasible, using the methods employed, to recruit all GPs in an LHCC into this study. We made very intensive efforts to recruit all of them into the study by offering a wide range of dates and times for meetings, by letter, by personal contact with GPs and by gaining PGEA approval for the intervention. Evidence from the telephone interviews suggests that it may have been possible to recruit a few more GPs into the study by paying locum fees for attendance. The main difficulty, however, for GPs would appear to be workload pressures which leave little time for extra educational activities.
This study was carried out during 2002 and these pressures may be even greater at present due to the requirements of the new General Medical Services (GMS) contract.14 There are no specific incentives within the new GMS contract relating to antibiotic prescribing and it is likely that this specific educational intervention would be less attractive now to GPs than interventions linked to incentives within the new GMS contract. There was some evidence that GPs were already undertaking postgraduate education activities based on their own and their practice’s needs assessment and that these were given priority in allocating time to educational activities. There was also a little evidence that the LHCC was not the correct structure for implementing an educational intervention. Anecdotal feedback from participants and a little evidence from the telephone interviews suggested that participants did not recognise the LHCC as a specific learning organisation.
The method of learning needs assessment used was feasible and highly acceptable to GPs. It enabled the educational workshop to be structured to address their learning needs and had advantages over methods of assessment that simply ask GPs to identify their learning needs because evidence about areas of difficulty in prescribing was prospectively collected. The structure of the workshop was also based on evidence from educational research and mainly involved interactive, problem based, group work with short periods of discussion. The educational intervention was therefore found to be highly acceptable to participants. It was, however, very labour intensive in terms of the time commitments of the facilitators, particularly in view of the low number of GPs who attended.
There is a growing trend for continuing professional learning activities to address the individual’s personal development plan.9 There is evidence that adults learn best when the learning activity addresses a personally identified learning need.13 However, activities designed to meet learning needs identified by individuals or teams may fail to ensure the broader learning that is required to address the public health agenda. In this case, antibiotic use is a public health concern due to increasing problems of antibiotic resistance.10 It is also a concern due to the cost and workload implications of patients expecting antibiotic treatment for minor illness.11 Public Health issues such as this can be addressed by educational interventions but if these issues are not included in personal or practice learning plans then insufficient time may be allocated to them to make a difference.
The General Medical Council has stated that “maintaining and improving one’s practice requires involvement in different types of activity ”.15 While going some way to addressing these concerns, this raises further questions about the necessary type and balance of educational activities.
Short-term follow-up suggested that the workshops had influenced the antibiotic prescribing practice of the GPs who had attended. However, longer follow-up and harder evidence about changes in prescribing practices would be required to prove that the workshop had effected a sustained change in antibiotic prescribing practice.
A recent Dutch study demonstrated a reduction in antibiotic prescribing for respiratory tract symptoms after a “multiple intervention” aimed at established “peer review groups” in Primary Care.16 Given our experience, it is unlikely that a similar intervention would work in Scotland at the present time.
ACKNOWLEDGEMENTS: We would like to thank the GPs who participated in this study and Prof. TS Murray for advice. This study was funded by a small grant from the Chief Scientist Office of the Scottish Executive Health Department (Grant Number CZG/4/57).
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