Attitudes on CME among Doctors in a Sri Lankan Tertiary Care Hospital-Research Paper Sample



A 3000 Words Research paper on Attitudes on CME among Doctors in a Sri Lankan Tertiary Care Hospital




Title of the Study

Attitudes on CME among Doctors in a Sri Lankan Tertiary Care Hospital

List of Investigators

The proposed study will be carried out by the researcher (the student) and will be overseen by a supervisor. The researcher will be expected to espouse a professional approach in completing the study, including:

  • Keeping time
  • Adhering to deadlines
  • Responding to, in a timely manner, communications from the supervisor and any other member of the faculty directly or indirectly involved in the research
  • Maintaining regular and consistent communication with the supervisor and agreeing with the supervisor concerning the schedule of official supervisory meetings that is mutually acceptable

The supervisor, on the other hand, will make certain that the researcher does not have any doubt concerning what is required. Specifically, it is vital to emphasize that the proposed research will be the student’s independent work and, within the limits of the supervision, the researcher will be tasked with developing the ideas, as well as planning and managing the work.

Collaborating Institutions

The proposed study will be a single center study that will be conducted in a tertiary care hospital in Sri Lanka.

Introduction and Background


Becoming a physician or doctor requires years of experience and knowledge through formal education. However, learning often does not end with licensure and board certification that the doctor earns. Learning is lifelong and usually continues through continuous medical education, otherwise known as CME. CME plays a very important role in the advancement and prosperity of not only physicians but also all health care providers, as well. It permits practitioners to discover and learn practical ways of ameliorating patient care and to effectively direct their careers in a continuously evolving health care landscape [1]. It is worth noting that while the requirements for or adequate levels of CME tend to differ across medical disciplines and from country to country, they are nonetheless important irrespective of the scope of practice or medical specialty of the provider.

Continuing medical education permits physicians and other health care providers to keep abreast with the latest developments in their areas of specialization, improve their patient care skills, grow professionally and advance their careers, address real-life challenges encountered in the course of their practice, learn effective skills in managing medical teams, and gain membership to professional medical organizations [2]. As physicians continue to witness advancements in the medical field, it is becoming increasingly apparent that they need to be trained on the medical techniques and equipment that are shaping the future of health care. For practicing physicians, it is common for patients to come in with the knowledge of novel and emerging trends in medicine that they have heard about or researched online.

To ensure that they are abreast with patients’ instantaneous and unfettered access to medical prognoses on the Internet, physicians and other health care practitioners need to make themselves acquainted with the latest technologies and trends through CME. Overall, even though taking continuous medical education courses is regarded as a job requirement, keeping abreast with medical training and knowledge together with networking within the medical profession have been found to increase the chances of physicians advancing their medical careers. Irrespective of the position that a physician holds in a health care setting, taking an appropriate CME course should be considered a priority. Ahmed et al. [3] contend that maintaining lifelong skills and knowledge is a prerequisite for safe clinical practice. CME offers a reliable method for facilitating lifelong learning because it concentrates on the development of relationships, skills, and knowledge required to maintain the competent practice.


During the 1990s, the National Academy of Medicine, previously known as the Institute of Medicine, started documenting the consequences and implications of medical errors, the absence of coordinated care, the suboptimal standards of care and the attendant patient outcomes, as well as the rising cost of health care. This research culminated in a publication that was appropriately titled To Err is Human: Building a Safer Health System (hereafter referred to simply as “To Err is Human”), which articulated clearly the pressing need for health care strategies to reduce the occurrence of avoidable medical errors. The National Academy of Medicine followed this publication with another one in 2001 titled Crossing the Quality Chasm: A New Health System for the 21st Century (hereafter referred to as “Crossing the Quality Chasm”). This report examined in detail the need to transform the health care policy and system to ensure that it is in agreement with the expectation of quality care.

Both reports brought to the fore the disquieting frequency of occurrence of medical errors that impacted negatively on not only the safety of patients but also the quality of patient care [4]. They also challenged nurses, physicians, and other stakeholders in the health care industry to come up with and implement a roadmap for the delivery of health care in a manner that is equitable, safe, patient-centered, and efficient. Most recently, educational leaders from across the various health care disciplines (including dentistry, public health, nursing, pharmacy, medicine, and osteopathic medicine) came together to discuss the prospects of collaboration through inter-professional practice [5]. This meeting led to a report that highlighted the need and framework for inter-professional practice. Balmer [6] observes that to address the concerns raised by the “To Err is Human” and “Crossing the Quality Chasm” reports, which advocated for the need to improve the quality of care and patient outcomes, CME was recommended as a way of addressing the challenge of providing safe and effective patient-centric care.

Historically, CME has been viewed as a way of reinforcing the knowledge of physician and other practitioners in the health care environment within their unique areas of practice or specialization. While physicians continue to engage in CME activities, whether these actually ameliorate their knowledge and whether exposure and instructional techniques are superior to single experiences are issues that continue to attract intense debates. CME is regarded as a permanent commitment by physicians to provide safe and patient-centered care, and despite the protracted history of engaging in continuing medical education by physicians and other medical practitioners, the outcomes are not ideal.

A Review of the Literature

CME is considered an important element for professional development and improving the clinical performance of doctors, thereby ultimately impacting on the quality of health care and patient outcomes [6]. Given the current state of health care that is characterized by an increase in the physicians in the tertiary care system in developing countries such as Sri Lanka, it is imperative to consider doctors’ meta-cognition in their role as learners if they are to be engaged effectively in the learning process. According to VanNieuwenborg et al. [7], the current society is largely knowledge-based and, therefore, most actualizations within the health care industry demand that doctors constantly develop and improve their skills. The main objective of CME programs is to enable specialist physicians to improve their skills and knowledge through avenues such as symposiums, workshops, formal courses, and conferences. Nevertheless, specialist practices have been changing in the recent years, including an increase in medical interdisciplinary collaboration, innovation in diagnostic and therapeutic methods, and the transformation of conventional, non-interventional areas of expertise into interventional specialties.

In view of the above, Ahmed et al. [8] note that because most traditional CME approaches that are meant to address the changes as mentioned above are yet to be validated, such programs may be ineffective in reducing the gap between the extant clinical practice and the best possible evidence-based practice. The authors further emphasize that CME is an important element of continuous professional development, or CPD, which addresses a variety of skills, such as management, training, education, audit, communication, as well as team building. Continuous professional development and continuing medical education are usually used interchangeably. A perfect CME program must make certain that the doctor’s knowledge, psychomotor skills, clinical outcomes, and overall performance reflect the latest state of knowledge to ensure safe clinical practice because these factors play a critical role in ensuring competence and superior clinical performance.

A direct relationship exists between the knowledge of physicians, their psychomotor skills, and clinical outcomes [9]. Doctors who receive their certification through knowledge testing have been found to register lower rates of morbidity and mortality compared to those who have not undergone certification [10, 11]. A study by Norcini et al. [12] also found that the mortality rate for patients who were attended to by a certified cardiologist after a heart attack was 19 percent lower compared to those who were attended to by an uncertified cardiologist. This points to the fact that providing the latest knowledge, irrespective of the medium, constitutes an important aspect of an effective CME program. Continuing medical education has been found to offer both long- and short-term benefits. Nevertheless, Ahmed et al. [13] caution that research on multiple techniques of CME instruction has hitherto been befuddled by duplication in certain fields of knowledge, thereby occasioning imprecise results.

New teaching media can be employed to counteract the effects of the said duplication. Consequently, it is evident from the literature that CME programs should embrace multiple instructional methods whenever feasible. It is worth noting that the level of competence in a physician’s clinical skills is directly related to their clinical knowledge. According to Ahmed et al. [14], clinical skills are often classified according to psychomotor skills (physical examination or procedural techniques) and the capacity to apply knowledge (cognitive skills). Continuing medical education has been demonstrated to be effective in ameliorating the clinical skills of doctors. The evidence that exists in the literature suggests that CME techniques can be valuable with regard to teaching clinical skills to tertiary care doctors [15]. However, evidence on the effectiveness of continuous medical education methods in the training of hospital specialists remains scant.

The justification for the Research

Medical research plays an important role in improving patient outcomes and, therefore, there is a moral obligation to not only pursue it but also involve oneself and contribute to it. People benefit from being part of the society in general, and from living in a world where scientific research is conducted and the benefits of the said research employed for the betterment of the world. In light of the above considerations, the moral obligations to carry out the proposed study are clear. The principal objective of CME is to maintain and improve clinical competence and performance. The leaning objectives of continuing medical education are usually broad and range from the acquisition of knowledge to a change in the attitudes of physicians.

An improvement in academic knowledge ought not to be the principal goal of CME, and only when the skills and knowledge that have been acquired are capable of providing an opportunity for a positive change in practice will continued education be meaningful and beneficial. Given that CME has been established to play an important role in ameliorating patient outcomes, improving the efficiency and overall quality of the health care system, and reducing the cost of health care administration, the proposed study has practical implications for improving the care delivery and enhancing patient outcomes in the Sri Lankan health care system. The study is particularly important because there is currently no system to revalidate the registration of doctors in Sri Lanka and, therefore, CME not widely used.

Objectives of the Proposed Research

General Objective

  • To explore the attitudes of Sri Lankan tertiary care doctors towards continuous medical education

Specific Objectives

  • To examine how best CME practices can meet the learning needs of tertiary care doctors
  • To look at the barriers that the doctors face in completing continuing medical education and how these barriers can be overcome

The Proposed Methods

Study Design

The proposed study will utilize a quantitative cross-sectional survey that will be designed to investigate the attitudes of Sri Lankan tertiary care doctors towards CME practices and the factors that promote or hinder their participation in these programs.

The Study Period

The proposed study will be written within a period of 1 year and will be submitted at the end of the master’s program.

The Study Population

The sample will be drawn from a tertiary care hospital with approximately 150 doctors. Doctors who are on leave, whether maternity, long-term medical leave or study leave will be excluded from the study.

Sample Size Calculation

The formula for sample size calculation has been calculated from KP Suresh and S Chandrashekara [1], who present a way for calculating sample size estimation for proportion in survey type of studies. The formula for sample size is –

N = [Z2α/2 * p(1-p) * D]/E2,

Where p is the prevalence or proportion of event of interest in this study,

E is the margin of error, which is to be determined by the researcher,

Z α/2 is the standard normal variate (1.96 for 5% level of significance, 2.58 for 1% level of significance),

D is the design effect, which represents the sampling design used in the survey type of study.

The design effect for a simple random sampling is usually 1. For cluster random sampling, it varies from 1.5 to 2. D will have a higher value for purposive, convenience, or judgement sampling.

We would be conducting this study at 5% level of significance. So, the value of Z α/2 will be 1.96. The margin of error in this case has been taken at 5%. We lack any previous study about the proportion determination of doctors with positive attitude towards CME. So, we have taken p as 90%, being on the safer side. As the sample chosen is from a tertiary care hospital, the sample is not likely to be simple random. It represents more of a cluster random sample. So, we would take the value of D as 1.5.

Calculating the sample size, we get

N = [1.962 * 0.9 * (1-0.9) * 1.5]/0.052 = 208

Now, since we have taken the expected proportion as 90%, we will adjust the final adjusted sample size, with a non-response rate of 10%.

Hence, the adjusted sample size will be 208/(1-0.10) = 208/0.90 = 231.


The survey form (including both questionnaires and statement type structure) would be provided to the doctors of the tertiary care hospital, which would consist of demographic details and questions about respondents’ attitudes towards CME and determination of current CME activities. Most of the questions in the form have used a standard graded response. In the demographic details, only the age and year of qualification would be kept in open-format question, while other details such as medical specialty would be kept in closed-format questions.

The Likert scale used for the response would be – 1 = Strongly Agree (or Completely Yes), 2 = Agree (or Partially Yes), 3 = Disagree (or Partially No), 4 = Strongly Disagree (or Completely No).

The survey form is as follows: –

  1. Do you take audit seriously?
  2. Do you feel forced into CME?
  3. Do colleges take CME too seriously according to you?
  4. I find I learn best from a lecture rather than a practice.
  5. Time is your biggest barrier in performing CME.
  6. Does CME help in solving unfamiliar patient problems?
  7. I like CME only when an expert is brought in that lecture.
  8. Do you think journals are irrelevant to your CME needs?
  9. Would you have stopped if there was no pressure to undertake CME?
  10. An Internet search on solving patient care issues is the best CME for a doctor.
  11. Would you rather spend your time doing things other than CME?
  12. I enjoy learning new things from CME.
  13. Do you fear a lawsuit if you do not undertake CME?
  14. Targeted face-to-face workshop is the best CME.
  15. I feel dinner meetings with an expert speaker as a waste of time.
  16. Conferences are good for social content and promotion, but not CMEs.
  17. I do not feel the urge to undertake CME for maintaining competence.
  18. Do you like reading journals?
  19. I do audit only if it is enforced by the college.
  20. CD-ROMs are better than books for me.

The responses for these questions are to be given on the Likert scale from 1 to 4. The responses will then be grouped average-wise and specialty-wise for further analysis.


1. Warden, GL. Redesigning continuing education in the health professions. Washington National Academies Press; 2010. 297 p.

2. Cruess, RL, Cruess, SR, Steinert, Y, editors. Teaching medical professionalism: Supporting the development of a professional identity. Cambridge: Cambridge University Press; 2016. 293 p.

3. Ahmed, K, Wang, TT, Ashrafian, H, Layer, GT, Darzi, A, Athanasiou, T. The effectiveness of continuing medical education for specialist recertification. Canadian Urological Association Journal. 2013 Jan; 7: 266-72.

4. Balmer, JT. The transformation of continuing medical education (CME) in the United States. Advances in Medical Education and Practice. 2013 Jan; 4: 171-82.

5. Interprofessional Education Collaborative Expert Panel, American Association of Colleges of Pharmacy, American Association of Colleges of Osteopathic Medicine. Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington: Interprofessional Education Collaborative; 2011. 47 p.

6. Anwar, H, Batty, H. Continuing medical education strategy for primary health care physicians in Oman: Lessons to be learned. Oman Medical Journal. 2007 Jan; 22(3): 33-5.

7. VanNieuwenborg, L, Goossens, M, De, LJ, Schoenmakers, B. Continuing medical education for general practitioners: a practice format. Postgraduate Medical Journal. 2016 Jan.; 92(1086): 217-222.

8. Ahmed, K, Wang, TT, Ashrafian, H, Layer, GT, Darzi, A, Athanasiou, T. The effectiveness of continuing medical education for specialist recertification. Canadian Urological Association Journal. 2013 Jan; 7: 266-72.

9. Tollefson, J. Clinical psychomotor skills: Assessment tools for nurses, 5-point body assessment scale. South Melbourne: Cengage Learning Australia; 2019. 404 p.

10. Prystowsky JB, Bordage G, Feinglass JM. Patient outcomes for segmental colon resection according to the surgeon’s training, certification, and experience. Surgery. 2002 Jan; 132:663-70.

11. Rutledge R, Oller DW, Meyer AA, et al. A statewide, population-based time-series analysis of the outcome of ruptured abdominal aortic aneurysm. Ann Surg. 1996 Jan; 223: 492-502.

12. Norcini JJ, Lipner RS, Kimball HR. Certifying examination performance and patient outcomes following acute myocardial infarction. Medical Education. 2002 Jan; 36: 853-9.

13. Ahmed, K, Wang, TT, Ashrafian, H, Layer, GT, Darzi, A, Athanasiou, T. The effectiveness of continuing medical education for specialist recertification. Canadian Urological Association Journal. 2013 Jan; 7: 266-72.

14. Ahmed, K, Wang, TT, Ashrafian, H, Layer, GT, Darzi, A, Athanasiou, T. The effectiveness of continuing medical education for specialist recertification. Canadian Urological Association Journal. 2013 Jan; 7: 266-72.

15. Niles, N. Basics of the US health care system. Boston: Jones & Bartlett Learning; 2011. 443 p.

16. Charan, J,Biswas, T. How to calculate sample size for different study designs in medical research?. Ind Journ of Psy Med. 2013 Jan; 35(2): 121-126.

17. Charan, J,Biswas, T. How to calculate sample size for different study designs in medical research?. Ind Journ of Psy Med. 2013 Jan; 35(2): 121-12

18. KP Suresh and S. Chandrashekara, 2012 Apr, Sample size estimation and power analysis for clinical research studies, US National Library of Medicine


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