# Continuing Medical Education for Primary Care Physicians in Israel: A Cross-Sectional Study

Authors: Pesach Shvartzman; Howard Tandeter; Daniel Vardy; Eran Matz; Anthony Heymann; Roni Peleg
Journal: Journal of Biomedical Education
 (2013)

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## Abstract

Acquiring a medical degree is only the beginning of a prolonged learning process. At some point, formal studies end, and continuing medical education (CME) may be left to personal initiative. To assess lifetime learning (LL) and CME among primary care physicians in Israel, a self-administered questionnaire, based on the Jefferson Scale of Physician Lifelong Learning (JSPLL), was mailed to 4,104 primary care physicians. A total of 979 completed the study, 53.4% males with a mean age of 51.8 ± 8.3 (range 31–79). A logistic regression model showed that male gender (OR = 1.5,P<0.05), teaching (OR = 4.5, P<0.0001), and not working in a rural clinic (OR = 0.6, P<0.01), increased the LL score. The results of the study demonstrate a need to address special subgroups that have a lower tendency to engage in LL activities. Policymakers should develop strategies to increase these physicians' interest in LL activities and the accessibility of these activities to them, including the availability of LL resources at home so physicians can get updates at their convenience.  Primary care physicians should also be encouraged to become involved in teaching of any type, as this is a facilitating factor for LL activities.


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## Body

## 1. Introduction

Acquiring a medical degree is only the beginning of a prolonged learning process. Medical schools provide the basic infrastructure of knowledge and skills. Formal studies continue during residency training and sometimes in subspecialty or fellowship programs that provide trainees with the necessary skills to perform more specific tasks. But at a certain point in time, “formal” structured studies end, and, in countries in which the recertification of physicians' skills and knowledge is not required, continuing education is left to personal initiative.Hospitals have a long tradition of continuing medical education (CME) and professional updating that are integrated into the regular work schedule. This includes staff meetings, radiology meetings, clinical-pathological meetings, and journal clubs. Community physicians usually work in solo or small group practices with a limited number of other physicians, and CME is not an integral part of their work schedule. The tradition of teaching and research in family medicine is a recent development, so it is much less established than in the hospital setting. As the focus of patient care moves to the community, the focus of CME should follow.The ways in which physicians continue to update themselves at the end of their formal studies have been described using different terms, including self-directed learning, self-educative approach, self-initiative learning, active learning, independent learning, contextual learning, CME, and distance learning. Lately, all these have been included in one terminological basket under the rubric of lifelong learning (LL) [1].Over the years, different tools have been developed to evaluate LL. In 1977, Guglielmino developed a Self-Directed Learning Readiness Scale (SDLRS) [2] that contained 58  Likert-like items such as “I love to learn.” A short version of the SDLRS, which includes only 28 items from the original scale, was prepared by Bligh in 1993 [3]. Another scale to identify predictors of self-directed learning was developed by Oddi [4] in 1986, but subsequent studies did not provide consistent support for its validity [5, 6].In 2003, Hojat et al. [1, 7]  developed a tool to measure LL for physicians that had supporting psychometric evidence. A 37-item questionnaire was developed based on a review of the literature and the results of two pilot studies. Psychometric analyses of the responses of 160 physicians identified 19 items that were included in the final version of the Jefferson Scale of Physician Lifelong Learning (JSPLL).Using this tool, we evaluated the characteristics of primary care physicians who have adopted LL as a professional principle. This information is especially important in countries like Israel where there is no legal requirement for CME or recertification, and self-initiative for LL remains the basis for assuring professional quality after formal medical studies end.


## 2. Methods

### 2.1. Setting

In Israel, a National Insurance Law was passed in 1995, which mandates the provision of health services through four Health Maintenance Organizations (HMOs). In 1970, Clalit Health Services (CHS), the largest HMO in Israel, provided primary care physicians working in community clinics with a paid work day for ongoing educational update needs. The continuing education program is provided by the universities through CME schools [8]. Each physician working for the CHS has a clause in their contract that guarantees one paid CME day a week. The other HMOs offer a paid half-day or none at all, depending on the physician's contract.  The Ministry of Health has not provided specific resources for long-term CME for physicians.


### 2.2. Study Population

The study included primary care physicians who have worked in the community setting for over two years and who work in a primary care setting for at least 15 hours per week. Primary care physicians are defined as general practitioners, pediatricians, family medicine specialists, internal medicine specialists, and geriatricians working in CHS community clinics (2,417 physicians), Maccabi Health Services (1,245 physicians), and Leumit Health Services (442 physicians).


### 2.3. Study Tool

A structured self-administered questionnaire was constructed for the participating physicians. It included the following.(1)
The JSPLL, which assesses physicians’ attitudes toward LL. The questionnaire was translated from English to Hebrew using the back-translation method [9] and was consequently culturally adapted. No validation tests were performed. It includes 19 items regarding basic elements of CME graded on a 4-point Likert scale (strongly disagree = 1, disagree = 2, agree = 3, and strongly agree = 4) [1]. The higher the score on the JSPLL, the greater the orientation toward lifelong learning. Factor analysis of the JSPLL depicts four sub-scales that are consistent with known characteristics of continuing education: (1) beliefs and motivation for professional learning, (2) educational activities, (3) recognition of educational opportunities, and (4) technical skills in searching for information [10]. The coefficient α for this tool was 0.89, and the test-retest value was 0.91 [11]. The authors concluded that the four sub-scales of the JSPLL are relevant to the various aspects of CME, as described by others [10–14].(2)
Physicians’ characteristics: age, gender, number of years in primary care, medical school, and specialty.(3)
Clinic characteristics: urban/rural, number of patients, solo practice/group practice, and number of visits/day.(4)
CME activities: specific questions regarding frequency of activities, number of papers read/week, participation in specific lectures during the past year, and other activities.


### 2.4. Data Collection

Study questionnaires were mailed to physicians with a stamped addressed envelope for a return mail. A second mailing to physicians who did not complete the questionnaire was sent out after one month. In all, study questionnaires were mailed up to three times.All participants gave their informed consent prior to participation in the study.


### 2.5. Data Analysis

Questionnaires were coded and entered in the study database using the Epidata 2.1 software. Data analysis was conducted with the SPSS 14.0 statistical software. Comparative one-way analysis was performed between different levels of LL (high versus  low) using chi-square for categorical variables and ANOVA for continuous variables withP<0.05 set as statistically significant for all analyses. A logistic regression model was constructed to predict physicians with high LL scores, controlling for clinic and patient variables.


## 2.1. Setting

In Israel, a National Insurance Law was passed in 1995, which mandates the provision of health services through four Health Maintenance Organizations (HMOs). In 1970, Clalit Health Services (CHS), the largest HMO in Israel, provided primary care physicians working in community clinics with a paid work day for ongoing educational update needs. The continuing education program is provided by the universities through CME schools [8]. Each physician working for the CHS has a clause in their contract that guarantees one paid CME day a week. The other HMOs offer a paid half-day or none at all, depending on the physician's contract.  The Ministry of Health has not provided specific resources for long-term CME for physicians.


## 2.2. Study Population

The study included primary care physicians who have worked in the community setting for over two years and who work in a primary care setting for at least 15 hours per week. Primary care physicians are defined as general practitioners, pediatricians, family medicine specialists, internal medicine specialists, and geriatricians working in CHS community clinics (2,417 physicians), Maccabi Health Services (1,245 physicians), and Leumit Health Services (442 physicians).


## 2.3. Study Tool

A structured self-administered questionnaire was constructed for the participating physicians. It included the following.(1)
The JSPLL, which assesses physicians’ attitudes toward LL. The questionnaire was translated from English to Hebrew using the back-translation method [9] and was consequently culturally adapted. No validation tests were performed. It includes 19 items regarding basic elements of CME graded on a 4-point Likert scale (strongly disagree = 1, disagree = 2, agree = 3, and strongly agree = 4) [1]. The higher the score on the JSPLL, the greater the orientation toward lifelong learning. Factor analysis of the JSPLL depicts four sub-scales that are consistent with known characteristics of continuing education: (1) beliefs and motivation for professional learning, (2) educational activities, (3) recognition of educational opportunities, and (4) technical skills in searching for information [10]. The coefficient α for this tool was 0.89, and the test-retest value was 0.91 [11]. The authors concluded that the four sub-scales of the JSPLL are relevant to the various aspects of CME, as described by others [10–14].(2)
Physicians’ characteristics: age, gender, number of years in primary care, medical school, and specialty.(3)
Clinic characteristics: urban/rural, number of patients, solo practice/group practice, and number of visits/day.(4)
CME activities: specific questions regarding frequency of activities, number of papers read/week, participation in specific lectures during the past year, and other activities.


## 2.4. Data Collection

Study questionnaires were mailed to physicians with a stamped addressed envelope for a return mail. A second mailing to physicians who did not complete the questionnaire was sent out after one month. In all, study questionnaires were mailed up to three times.All participants gave their informed consent prior to participation in the study.


## 2.5. Data Analysis

Questionnaires were coded and entered in the study database using the Epidata 2.1 software. Data analysis was conducted with the SPSS 14.0 statistical software. Comparative one-way analysis was performed between different levels of LL (high versus  low) using chi-square for categorical variables and ANOVA for continuous variables withP<0.05 set as statistically significant for all analyses. A logistic regression model was constructed to predict physicians with high LL scores, controlling for clinic and patient variables.


## 3. Results

### 3.1. Study Population

The questionnaires were mailed to 4,104 primary care physicians working at one of the three HMOs participating in the study, of whom 979 completed the questionnaire (23.9% response rate). No statistically significant differences were found between responders and nonresponders in terms of gender or years of employment at CHS. The majority of the study population was male (53.4%), with a mean age of51.8±8.3 (range 31–79), and 40.3% was born in Israel. Table 1 depicts the sociodemographic characteristics of the participating physicians.Table 1
Study population demography and physician practice characteristics (n=979).
n
%
Demographic characteristics
Age
30–50
380
41.1
%
51+
545
58.9
%
Average ± st. dv.
51.8
±
8.3
Range
31–79
925
(mis = 54)
Gender
Male
509
53.4
%
954
(mis = 25)
Country of birth
Israel
378
40.3
%
East Europe and USSR
323
34.4
%
Other
238
25.3
%
939
(mis = 40)
Physician and practice characteristics
Graduated Medical School in
Israel
344
36.5
%
Other
598
63.5
%
942
(mis = 37)
Years as a physician
1–10
47
5.3
%
11–19
178
20.0
%
20+
665
74.7
%
Average  ± st. dv.
25.5
±
8.7
Range
4–54
890
(mis = 89)
Specialists in (more than one answer could be marked)
Family physician
451
43.2
%
Pediatrician
215
20.6
%
Internal medicine
138
13.2
%
General practitioner
151
14.5
%
Geriatrician
22
2.1
%
Other
67
6.4
%
1044
Graduated specialty in
Israel
700
86.0
%
East Europe and USSR
55
6.8
%
Other
59
7.2
%
814
(mis = 14)
Years as a specialist
1–10
303
39.9
%
11–19
218
28.7
%
20+
239
31.4
%
Average  ± st. dv.
14.8
±
9.3
Range
0–51
760
(mis = 67)
Number of years in practice in primary care in Israel
1–10
226
24.5
%
11–19
397
43.1
%
20+
298
32.4
%
Average  ± st. dv.
17.4
±
8.7
Range
1–50
921
(mis = 58)
Teaching involvement
Yes
333
36.5
%
913
(mis = 66)
Academic affiliation
Yes
244
27.7
%
244
(mis = 97)
Were you a partner in planning/developing teaching programs?
Yes
234
26.0
%
900
(mis = 79)
Characteristic of main working clinic
Urban
640
66.7
%
Rural
119
12.4
%
Child health center
55
5.7
%
Other
45
4.7
%
959
(mis = 20)
Position
Head of clinic
166
17.4
%
Primary physician
713
74.7
%
Other
75
7.9
%
954
(mis = 25)
Number of population under your care (main clinic)
≤1000
238
30.3
%
1001–1500
292
37.2
%
1500+
255
32.5
%
Average  ± st. dv.
1520.5
±
1102.7
Range
50–9500
785
(mis = 194)
Other clinics you work at (more than one answer could be marked)
Urban
294
62.3
%
Rural
76
16.1
%
Child health center
8
1.7
%
Other
94
19.9
%
472
Number of hours seeing patients/week
≤30
255
27.9
%
31–45
574
62.7
%
45+
86
9.4
%
Average  ± st. dv.
34.1
±
10.5
Range
2–90
915
(mis = 64)
Average number of patients seen/day (7 hours)
≤20
114
12.7
%
21–35
309
34.3
%
36–50
356
39.5
%
51+
122
13.5
%
Average  ± st. dv.
38.8
±
14.9
Range
4–110
901
(mis = 78)Among the responders, there were more males (52.5% versus 47.0%,P=0.013), and the group was younger (49.5±8.1 versus 50.5±8.1, P=0.017). No differences were found in years of experience as a physician.Physicians were asked to rate their reading and LL practices on a scale from 1–5.The three most read sources were English journals (3.6±1.0), free websites (3.4±1.2), and Hebrew journals (3.3±1.0). The three most frequent modalities for updating activities in the past year were scientific conferences (3.5±1.2), clinical meetings in the clinic (3.4±1.5), and meetings sponsored by pharmaceutical companies (3.3±1.2).Participants were asked to note the availability of updating resources they have access to at home, at the work place, and in the medical library. The highest availability was defined as the resource being available both at home and at work. The leading resource noted was a computer with internet access (89.9%), followed by access to full-text publications (57.6%).Participants were asked to rate their attitudes regarding who should be responsible for LL. There was a strong consensus that CME activities should be funded by the HMOs and/or hospitals (4.6±0.8), that they should take place during regular working hours (4.0±1.3), and that participants might have to pay for these activities (4.8±0.7). There was a low degree of agreement that attending LL activities/CME courses should be a condition for recertification (2.8±1.4) and that physicians should be trusted to study on their own without a need for CME courses (2.8±1.2).


### 3.2. The Jefferson Scale of Physician Lifelong Learning (JSPLL)

Table2 depicts the results of the JSPLL questionnaire regarding the LL habits of the participating physicians. Of the 979 physicians who responded, 828 completed the full questionnaire. The mean score was 57.7±7.5 (of a maximum of  76). Based on these results, three groups were identified: (1) the bottom third with a low LL activity level (score 33–54), (2) a middle activity level (54–61), and (3) an upper third with a high LL activity level (62–76).Table 2
Jefferson Scale of Physician Lifelong Learning (JSPLL) (n=979).
Please note the degree you agree with the following statements (1-strongly disagree; 4-strongly agree)
Mean
Std.
Median
n
Lifelong learning is a professional responsibility of all physicians
3.7
0.5
4
951
Rapid changes in medical science require constant updating of knowledge and development of new professional skills
3.7
0.5
4
959
I enjoy reading articles in which issues of my professional interest are discussed
3.6
0.5
4
956
I believe that I would fall behind if I stopped learning about new developments in my specialty
3.6
0.6
4
953
One of the important goals of medical school is to develop students’ lifelong learning skills
3.6
0.6
4
956
I recognize my need to constantly acquire new professional knowledge
3.5
0.6
4
957
Searching for the answer to a question is, in and by itself, rewarding
3.3
0.7
3
905
I attend educational programs whether or not CME credit is offered
3.2
0.9
3
954
I take every opportunity to gain new knowledge/skills that are important to my profession
3.2
0.7
3
956
My preferred approach in finding an answer to a question is to search the appropriate computer databases
3.2
0.8
3
953Physicians with high and low LL scores were compared. A comparison of demographic characteristics appears in Table3. The high LL group included significantly more males (50.8% versus 49.2%, P=0.03), Israeli-born physicians (54.5% versus 45.5%, P<0.01), graduates from Israeli medical schools (54.0% versus 46.0%, P<0.01), physicians involved in teaching (70.3% versus 29.7%, P<0.0001), physicians with an academic affiliation (71.4% versus 28.6%, P<0.0001), physicians who participated in the development of educational programs (74.0% versus 26.0%, P<0.001), and physicians who held a position as a clinic director (65.3% versus 34.7%, P<0.001).Table 3
Comparison of demographic and practice characteristics between physicians with high* and low** JSPLL scores (N=255 versus N=288).
JSPLL lower third scores(N=288)
JSPLL upper third scores (N=255)
Total
P value
N
%
N
%
Age
30–50
112
53.8%
96
46.2%
208
51+
153
50.7%
149
49.3%
302
Average ± st. dv.
51.87
±
8.74
51.86
±
7.65
0.993
Range
32–79
32–68
265
(mis = 23)
245
(mis = 10)
510
Gender
Male
150
49.2%
155
50.8%
305
0.031
282
(mis = 6)
248
(mis = 7)
530
Country of Birth
Israel
110
45.5%
132
54.5%
242
0.007
East Europe and USSR
89
61.4%
56
38.6%
145
Other
74
55.6%
59
44.4%
133
273
(mis = 15)
247
(mis = 8)
520
Years in Israel
≤10
7
70.0%
3
30.0%
10
10+
142
56.8%
108
43.2%
250
Average ± st. dv.
27.11
±
13.82
27.91
±
13.02
0.313
Range
6–70
8–91
149
(mis = 14)
111
(mis = 4)
260
Graduated Medical School in
Israel
108
46.0%
127
54.0%
235
0.009
Other
170
59.0%
118
41.0%
288
278
(mis = 10)
245
(mis = 10)
523
Years as a physician
1–10
14
51.9%
13
48.1%
27
11–19
48
49.5%
49
50.5%
97
20+
196
53.1%
173
46.9%
369
0.815
Average ± st. dv.
25.71
±
8.92
24.82
±
8.41
Range
5–54
6–45
258
(mis = 30)
235
(mis = 20)
493
Specialists in (more than one answer could be marked)
Family physician
132
50.8%
128
49.2%
260
0.176
Pediatrician
61
50.4%
60
49.6%
121
0.29
Internal medicine
41
51.3%
39
48.8%
80
0.41
General practitioner
43
65.2%
23
34.8%
66
0.024
Geriatrician
4
36.4%
7
63.6%
11
0.345
Other
12
29.3%
29
70.7%
41
0.001
293
286
579
Graduated specialty in
Israel
204
48.8%
214
51.2%
418
0.09
Abroad
29
61.7%
18
38.3%
47
233
(mis = 12)
232
465
Years as a specialist
1–10
86
52.8%
77
47.2%
163
0.629
11–19
66
47.8%
72
52.2%
138
20+
68
48.2%
73
51.8%
141
Average ± st. dv.
14.72
±
9.35
15.21
±
8.48
Range
1–51
1–37
220
(mis = 25)
222
(mis = 10)
442
Number of years in practice in primary care in Israel
1–10
64
54.2%
54
45.8%
118
0.426
11–19
121
57.1%
91
42.9%
212
20+
94
50.5%
92
49.5%
186
Average ± st. dv.
17.44
±
8.74
18.19
±
8.63
Range
1–50
2–40
279
(mis = 9)
237
(mis = 18)
516
Teaching involvement
Yes
65
29.7%
154
70.3%
219
<0.0001
277
(mis = 11)
242
(mis = 13)
519
Academic affiliation
Yes
46
28.6%
115
71.4%
161
<0.0001
272
(mis = 16)
233
(mis = 22)
505
Were you a partner in planning/developing teaching programs?
Yes
40
26.0%
114
74.0%
154
<0.0001
270
(mis = 18)
237
(mis = 18)
507
Position
Head of clinic
35
34.7%
66
65.3%
101
<0.0001
Primary physician
231
59.7%
156
40.3%
387
Other
14
33.3%
28
66.7%
42
280
(mis = 8)
250
(mis = 5)
530
Characteristic of main working clinic
Urban
232
57.9%
169
42.1%
401
<0.0001
Rural/kibbutz
34
45.3%
41
54.7%
75
Child health center
9
27.3%
24
72.7%
33
Other
10
35.7%
18
64.3%
28
285
(mis = 3)
252
(mis = 3)
537
Position
Head of clinic
35
34.7%
66
65.3%
101
<0.0001
Primary physician
231
59.7%
156
40.3%
387
Other
14
33.3%
28
66.7%
42
280
(mis = 8)
250
(mis = 5)
530
Number of population under your care (main clinic)
≤1000
69
54.8%
57
45.2%
126
1001–1500
92
57.9%
67
42.1%
159
1500+
73
46.5%
84
53.5%
157
0.115
Average ± st. dv.
1433.35
±
880.15
1603.85
±
1203.89
Range
80–8000
60–9999
234
(mis = 54)
208
(mis = 47)
442
Other clinics you work at (more than one answer could be marked)
Urban
85
49.1%
88
50.9%
173
0.212
Rural/kibbutz
17
48.6%
18
51.4%
35
0.584
Child health center
0
0.0%
4
100.0%
4
0.048
Other
20
34.5%
38
65.5%
58
0.003
288
255
543
Number of hours seeing patients/week
≤30
78
49.4%
80
50.6%
158
0.566
31–45
167
54.6%
139
45.4%
306
45+
25
53.2%
22
46.8%
47
Average ± st. dv.
33.86
±
10.64
32.92
±
11.03
Range
5–65
2–60
270
(mis = 18)
241
(mis = 14)
511
Average number of patients seen/day (7 hours)
≤20
36
52.9%
32
47.1%
68
0.467
21–35
89
50.9%
86
49.1%
175
36–50
103
53.4%
90
46.6%
193
51+
44
62.0%
27
38.0%
71
Average ± st. dv.
39.86
±
15.90
37.41
±
15.16
Range
6–100
5–100
272
(mis = 16)
235
(mis = 20)
507
*High JSPLL score-upper third score (high LL activities score: 62–76).
**Low JSPLL score-bottom third score (low LL activities score: 33–54).Physicians with higher scores were significantly more likely to have rated each of the different reading sources, participated in more update meetings, and utilized each of the data sources to a greater degree (Table4).Table 4
Comparison of the updating habits of the lower and upper third respondents (N=255 versus N=288).
JSPLL bottom third scores(N=288)
JSPLL upper third scores(N=255)
P value
Mean
Std.
Median
N
Mean
Std.
Median
N
Reading update (1-not at all; 5-very much)
Professional textbooks
2.68
0.98
3
277
3.48
1.03
3
249
<0.0001
Hebrew journals
3.09
0.93
3
283
3.61
1.11
4
248
<0.0001
Foreign language journals
3.15
1.02
3
279
4.18
0.86
4
249
<0.0001
Pharmaceutical companies publications
2.63
0.97
3
277
2.82
1.1
3
240
0.039
Membership-based internet sites (exp. MD consult)
2.67
1.34
3
276
3.92
1.23
4
249
<0.0001
Nonmember-based internet sites (exp. medscape)
3.01
1.22
3
280
3.98
1.12
4
250
<0.0001
Self-learning CD
1.58
0.94
1
269
2.05
1.26
2
244
<0.0001
IMA guidelines
2.87
1.19
3
276
3.63
1.12
4
248
<0.0001
To what degree did you participate in the following updates during thepast year (1-not at all; 5-very much)
CME courses (weekly meetings)
2.93
1.78
3
275
3.3
1.79
4
240
0.021
CME minicourses
2.22
1.41
1
257
2.89
1.62
3
239
<0.0001
Scientific conferences
3
1.23
3
275
4.18
1.04
5
248
<0.0001
Clinical meetings in the clinic
2.91
1.45
3
270
3.79
1.36
4
234
<0.0001
Clinical meetings in the hospital
1.92
1.27
1
251
2.9
1.67
3
232
<0.0001
Lectures at the hospital/clinic/university
2.58
1.33
3
264
3.72
1.35
4
244
<0.0001
Pharmaceutical companies sponsored meetings
3.13
1.21
3
279
3.34
1.28
3
250
0.052
Accompanying physician (working alongside a specialist consultant)
1.89
1.33
1
247
2.29
1.66
1
212
0.001
Evaluate the frequency you utilize the following data sources when encountering a diagnostic/treatment problem (1-not at all; 5-very much)
Books
3.23
1.16
3
278
3.54
1.2
4
251
0.002
Journals
2.9
1.09
3
275
3.9
1.09
4
251
<0.0001
Computerized database
3.92
1.1
4
277
4.74
0.61
5
253
<0.0001
Colleagues at the clinic
3.23
1.23
3
272
3.58
1.24
4
248
0.001
Consultation with a specialist
3.89
1.01
4
279
4.1
0.97
4
253
0.013
Sales representative of a pharmaceutical company
1.96
1.05
2
274
1.98
1.14
2
250
0.801
Circulation from the medical management of the HMO
2.67
1.15
3
276
2.94
1.19
3
245
0.01If the updating resource was accessible both at work and at home, it was rated as highly available. For each of the updating resources, higher availability was noted for physicians in the upper third LL group. In addition, the physicians in the upper third LL group strongly agreed that CME activities should be funded by the HMOs and/or hospitals (4.68 versus 4.48,P<0.01) and that CME should be a condition for recertification (3.1 versus 2.5, P<0.0001).A logistic regression model was constructed to predict physician characteristics that correlate with higher LL scores. The independent variable was having an upper third score in the JSPLL questionnaire. The dependent variables included in the model were: male gender (OR = 1.501, 95% CI 1.044–2.159), involvement in teaching (OR = 4.460, 95% CI 3.084–6.448), and a rural clinic as the main work setting (OR = 0.601, 95% CI 0421–0.856). The number of years working in primary care in Israel, the number of patients seen, the number of hours spent seeing patients a week, and specialty status were not included in the final model. The variable, years in practice, was also not included as it had a high degree of correlation with physician age (Table5).Table 5
Logistic regression results for predicting physicians that will be in the upper third of the JSPLL questionnaire (N=979).
Variables included
Odds ratio
CI 95%
P value
Age (continuous)
1.019
0.996–1.042
0.103
Gender
Male
1.501
1.044–2.159
0.028
Female
1
Country of medical school
Israel
1.381
0.961–1.986
0.081
Abroad
1
Involved with teaching
Yes
4.46
3.084–6.448
<0.0001
No
1
Main clinic
Other
0.601
0.421–0.856
0.005
Urban
1


## 3.1. Study Population

The questionnaires were mailed to 4,104 primary care physicians working at one of the three HMOs participating in the study, of whom 979 completed the questionnaire (23.9% response rate). No statistically significant differences were found between responders and nonresponders in terms of gender or years of employment at CHS. The majority of the study population was male (53.4%), with a mean age of51.8±8.3 (range 31–79), and 40.3% was born in Israel. Table 1 depicts the sociodemographic characteristics of the participating physicians.Table 1
Study population demography and physician practice characteristics (n=979).
n
%
Demographic characteristics
Age
30–50
380
41.1
%
51+
545
58.9
%
Average ± st. dv.
51.8
±
8.3
Range
31–79
925
(mis = 54)
Gender
Male
509
53.4
%
954
(mis = 25)
Country of birth
Israel
378
40.3
%
East Europe and USSR
323
34.4
%
Other
238
25.3
%
939
(mis = 40)
Physician and practice characteristics
Graduated Medical School in
Israel
344
36.5
%
Other
598
63.5
%
942
(mis = 37)
Years as a physician
1–10
47
5.3
%
11–19
178
20.0
%
20+
665
74.7
%
Average  ± st. dv.
25.5
±
8.7
Range
4–54
890
(mis = 89)
Specialists in (more than one answer could be marked)
Family physician
451
43.2
%
Pediatrician
215
20.6
%
Internal medicine
138
13.2
%
General practitioner
151
14.5
%
Geriatrician
22
2.1
%
Other
67
6.4
%
1044
Graduated specialty in
Israel
700
86.0
%
East Europe and USSR
55
6.8
%
Other
59
7.2
%
814
(mis = 14)
Years as a specialist
1–10
303
39.9
%
11–19
218
28.7
%
20+
239
31.4
%
Average  ± st. dv.
14.8
±
9.3
Range
0–51
760
(mis = 67)
Number of years in practice in primary care in Israel
1–10
226
24.5
%
11–19
397
43.1
%
20+
298
32.4
%
Average  ± st. dv.
17.4
±
8.7
Range
1–50
921
(mis = 58)
Teaching involvement
Yes
333
36.5
%
913
(mis = 66)
Academic affiliation
Yes
244
27.7
%
244
(mis = 97)
Were you a partner in planning/developing teaching programs?
Yes
234
26.0
%
900
(mis = 79)
Characteristic of main working clinic
Urban
640
66.7
%
Rural
119
12.4
%
Child health center
55
5.7
%
Other
45
4.7
%
959
(mis = 20)
Position
Head of clinic
166
17.4
%
Primary physician
713
74.7
%
Other
75
7.9
%
954
(mis = 25)
Number of population under your care (main clinic)
≤1000
238
30.3
%
1001–1500
292
37.2
%
1500+
255
32.5
%
Average  ± st. dv.
1520.5
±
1102.7
Range
50–9500
785
(mis = 194)
Other clinics you work at (more than one answer could be marked)
Urban
294
62.3
%
Rural
76
16.1
%
Child health center
8
1.7
%
Other
94
19.9
%
472
Number of hours seeing patients/week
≤30
255
27.9
%
31–45
574
62.7
%
45+
86
9.4
%
Average  ± st. dv.
34.1
±
10.5
Range
2–90
915
(mis = 64)
Average number of patients seen/day (7 hours)
≤20
114
12.7
%
21–35
309
34.3
%
36–50
356
39.5
%
51+
122
13.5
%
Average  ± st. dv.
38.8
±
14.9
Range
4–110
901
(mis = 78)Among the responders, there were more males (52.5% versus 47.0%,P=0.013), and the group was younger (49.5±8.1 versus 50.5±8.1, P=0.017). No differences were found in years of experience as a physician.Physicians were asked to rate their reading and LL practices on a scale from 1–5.The three most read sources were English journals (3.6±1.0), free websites (3.4±1.2), and Hebrew journals (3.3±1.0). The three most frequent modalities for updating activities in the past year were scientific conferences (3.5±1.2), clinical meetings in the clinic (3.4±1.5), and meetings sponsored by pharmaceutical companies (3.3±1.2).Participants were asked to note the availability of updating resources they have access to at home, at the work place, and in the medical library. The highest availability was defined as the resource being available both at home and at work. The leading resource noted was a computer with internet access (89.9%), followed by access to full-text publications (57.6%).Participants were asked to rate their attitudes regarding who should be responsible for LL. There was a strong consensus that CME activities should be funded by the HMOs and/or hospitals (4.6±0.8), that they should take place during regular working hours (4.0±1.3), and that participants might have to pay for these activities (4.8±0.7). There was a low degree of agreement that attending LL activities/CME courses should be a condition for recertification (2.8±1.4) and that physicians should be trusted to study on their own without a need for CME courses (2.8±1.2).


## 3.2. The Jefferson Scale of Physician Lifelong Learning (JSPLL)

Table2 depicts the results of the JSPLL questionnaire regarding the LL habits of the participating physicians. Of the 979 physicians who responded, 828 completed the full questionnaire. The mean score was 57.7±7.5 (of a maximum of  76). Based on these results, three groups were identified: (1) the bottom third with a low LL activity level (score 33–54), (2) a middle activity level (54–61), and (3) an upper third with a high LL activity level (62–76).Table 2
Jefferson Scale of Physician Lifelong Learning (JSPLL) (n=979).
Please note the degree you agree with the following statements (1-strongly disagree; 4-strongly agree)
Mean
Std.
Median
n
Lifelong learning is a professional responsibility of all physicians
3.7
0.5
4
951
Rapid changes in medical science require constant updating of knowledge and development of new professional skills
3.7
0.5
4
959
I enjoy reading articles in which issues of my professional interest are discussed
3.6
0.5
4
956
I believe that I would fall behind if I stopped learning about new developments in my specialty
3.6
0.6
4
953
One of the important goals of medical school is to develop students’ lifelong learning skills
3.6
0.6
4
956
I recognize my need to constantly acquire new professional knowledge
3.5
0.6
4
957
Searching for the answer to a question is, in and by itself, rewarding
3.3
0.7
3
905
I attend educational programs whether or not CME credit is offered
3.2
0.9
3
954
I take every opportunity to gain new knowledge/skills that are important to my profession
3.2
0.7
3
956
My preferred approach in finding an answer to a question is to search the appropriate computer databases
3.2
0.8
3
953Physicians with high and low LL scores were compared. A comparison of demographic characteristics appears in Table3. The high LL group included significantly more males (50.8% versus 49.2%, P=0.03), Israeli-born physicians (54.5% versus 45.5%, P<0.01), graduates from Israeli medical schools (54.0% versus 46.0%, P<0.01), physicians involved in teaching (70.3% versus 29.7%, P<0.0001), physicians with an academic affiliation (71.4% versus 28.6%, P<0.0001), physicians who participated in the development of educational programs (74.0% versus 26.0%, P<0.001), and physicians who held a position as a clinic director (65.3% versus 34.7%, P<0.001).Table 3
Comparison of demographic and practice characteristics between physicians with high* and low** JSPLL scores (N=255 versus N=288).
JSPLL lower third scores(N=288)
JSPLL upper third scores (N=255)
Total
P value
N
%
N
%
Age
30–50
112
53.8%
96
46.2%
208
51+
153
50.7%
149
49.3%
302
Average ± st. dv.
51.87
±
8.74
51.86
±
7.65
0.993
Range
32–79
32–68
265
(mis = 23)
245
(mis = 10)
510
Gender
Male
150
49.2%
155
50.8%
305
0.031
282
(mis = 6)
248
(mis = 7)
530
Country of Birth
Israel
110
45.5%
132
54.5%
242
0.007
East Europe and USSR
89
61.4%
56
38.6%
145
Other
74
55.6%
59
44.4%
133
273
(mis = 15)
247
(mis = 8)
520
Years in Israel
≤10
7
70.0%
3
30.0%
10
10+
142
56.8%
108
43.2%
250
Average ± st. dv.
27.11
±
13.82
27.91
±
13.02
0.313
Range
6–70
8–91
149
(mis = 14)
111
(mis = 4)
260
Graduated Medical School in
Israel
108
46.0%
127
54.0%
235
0.009
Other
170
59.0%
118
41.0%
288
278
(mis = 10)
245
(mis = 10)
523
Years as a physician
1–10
14
51.9%
13
48.1%
27
11–19
48
49.5%
49
50.5%
97
20+
196
53.1%
173
46.9%
369
0.815
Average ± st. dv.
25.71
±
8.92
24.82
±
8.41
Range
5–54
6–45
258
(mis = 30)
235
(mis = 20)
493
Specialists in (more than one answer could be marked)
Family physician
132
50.8%
128
49.2%
260
0.176
Pediatrician
61
50.4%
60
49.6%
121
0.29
Internal medicine
41
51.3%
39
48.8%
80
0.41
General practitioner
43
65.2%
23
34.8%
66
0.024
Geriatrician
4
36.4%
7
63.6%
11
0.345
Other
12
29.3%
29
70.7%
41
0.001
293
286
579
Graduated specialty in
Israel
204
48.8%
214
51.2%
418
0.09
Abroad
29
61.7%
18
38.3%
47
233
(mis = 12)
232
465
Years as a specialist
1–10
86
52.8%
77
47.2%
163
0.629
11–19
66
47.8%
72
52.2%
138
20+
68
48.2%
73
51.8%
141
Average ± st. dv.
14.72
±
9.35
15.21
±
8.48
Range
1–51
1–37
220
(mis = 25)
222
(mis = 10)
442
Number of years in practice in primary care in Israel
1–10
64
54.2%
54
45.8%
118
0.426
11–19
121
57.1%
91
42.9%
212
20+
94
50.5%
92
49.5%
186
Average ± st. dv.
17.44
±
8.74
18.19
±
8.63
Range
1–50
2–40
279
(mis = 9)
237
(mis = 18)
516
Teaching involvement
Yes
65
29.7%
154
70.3%
219
<0.0001
277
(mis = 11)
242
(mis = 13)
519
Academic affiliation
Yes
46
28.6%
115
71.4%
161
<0.0001
272
(mis = 16)
233
(mis = 22)
505
Were you a partner in planning/developing teaching programs?
Yes
40
26.0%
114
74.0%
154
<0.0001
270
(mis = 18)
237
(mis = 18)
507
Position
Head of clinic
35
34.7%
66
65.3%
101
<0.0001
Primary physician
231
59.7%
156
40.3%
387
Other
14
33.3%
28
66.7%
42
280
(mis = 8)
250
(mis = 5)
530
Characteristic of main working clinic
Urban
232
57.9%
169
42.1%
401
<0.0001
Rural/kibbutz
34
45.3%
41
54.7%
75
Child health center
9
27.3%
24
72.7%
33
Other
10
35.7%
18
64.3%
28
285
(mis = 3)
252
(mis = 3)
537
Position
Head of clinic
35
34.7%
66
65.3%
101
<0.0001
Primary physician
231
59.7%
156
40.3%
387
Other
14
33.3%
28
66.7%
42
280
(mis = 8)
250
(mis = 5)
530
Number of population under your care (main clinic)
≤1000
69
54.8%
57
45.2%
126
1001–1500
92
57.9%
67
42.1%
159
1500+
73
46.5%
84
53.5%
157
0.115
Average ± st. dv.
1433.35
±
880.15
1603.85
±
1203.89
Range
80–8000
60–9999
234
(mis = 54)
208
(mis = 47)
442
Other clinics you work at (more than one answer could be marked)
Urban
85
49.1%
88
50.9%
173
0.212
Rural/kibbutz
17
48.6%
18
51.4%
35
0.584
Child health center
0
0.0%
4
100.0%
4
0.048
Other
20
34.5%
38
65.5%
58
0.003
288
255
543
Number of hours seeing patients/week
≤30
78
49.4%
80
50.6%
158
0.566
31–45
167
54.6%
139
45.4%
306
45+
25
53.2%
22
46.8%
47
Average ± st. dv.
33.86
±
10.64
32.92
±
11.03
Range
5–65
2–60
270
(mis = 18)
241
(mis = 14)
511
Average number of patients seen/day (7 hours)
≤20
36
52.9%
32
47.1%
68
0.467
21–35
89
50.9%
86
49.1%
175
36–50
103
53.4%
90
46.6%
193
51+
44
62.0%
27
38.0%
71
Average ± st. dv.
39.86
±
15.90
37.41
±
15.16
Range
6–100
5–100
272
(mis = 16)
235
(mis = 20)
507
*High JSPLL score-upper third score (high LL activities score: 62–76).
**Low JSPLL score-bottom third score (low LL activities score: 33–54).Physicians with higher scores were significantly more likely to have rated each of the different reading sources, participated in more update meetings, and utilized each of the data sources to a greater degree (Table4).Table 4
Comparison of the updating habits of the lower and upper third respondents (N=255 versus N=288).
JSPLL bottom third scores(N=288)
JSPLL upper third scores(N=255)
P value
Mean
Std.
Median
N
Mean
Std.
Median
N
Reading update (1-not at all; 5-very much)
Professional textbooks
2.68
0.98
3
277
3.48
1.03
3
249
<0.0001
Hebrew journals
3.09
0.93
3
283
3.61
1.11
4
248
<0.0001
Foreign language journals
3.15
1.02
3
279
4.18
0.86
4
249
<0.0001
Pharmaceutical companies publications
2.63
0.97
3
277
2.82
1.1
3
240
0.039
Membership-based internet sites (exp. MD consult)
2.67
1.34
3
276
3.92
1.23
4
249
<0.0001
Nonmember-based internet sites (exp. medscape)
3.01
1.22
3
280
3.98
1.12
4
250
<0.0001
Self-learning CD
1.58
0.94
1
269
2.05
1.26
2
244
<0.0001
IMA guidelines
2.87
1.19
3
276
3.63
1.12
4
248
<0.0001
To what degree did you participate in the following updates during thepast year (1-not at all; 5-very much)
CME courses (weekly meetings)
2.93
1.78
3
275
3.3
1.79
4
240
0.021
CME minicourses
2.22
1.41
1
257
2.89
1.62
3
239
<0.0001
Scientific conferences
3
1.23
3
275
4.18
1.04
5
248
<0.0001
Clinical meetings in the clinic
2.91
1.45
3
270
3.79
1.36
4
234
<0.0001
Clinical meetings in the hospital
1.92
1.27
1
251
2.9
1.67
3
232
<0.0001
Lectures at the hospital/clinic/university
2.58
1.33
3
264
3.72
1.35
4
244
<0.0001
Pharmaceutical companies sponsored meetings
3.13
1.21
3
279
3.34
1.28
3
250
0.052
Accompanying physician (working alongside a specialist consultant)
1.89
1.33
1
247
2.29
1.66
1
212
0.001
Evaluate the frequency you utilize the following data sources when encountering a diagnostic/treatment problem (1-not at all; 5-very much)
Books
3.23
1.16
3
278
3.54
1.2
4
251
0.002
Journals
2.9
1.09
3
275
3.9
1.09
4
251
<0.0001
Computerized database
3.92
1.1
4
277
4.74
0.61
5
253
<0.0001
Colleagues at the clinic
3.23
1.23
3
272
3.58
1.24
4
248
0.001
Consultation with a specialist
3.89
1.01
4
279
4.1
0.97
4
253
0.013
Sales representative of a pharmaceutical company
1.96
1.05
2
274
1.98
1.14
2
250
0.801
Circulation from the medical management of the HMO
2.67
1.15
3
276
2.94
1.19
3
245
0.01If the updating resource was accessible both at work and at home, it was rated as highly available. For each of the updating resources, higher availability was noted for physicians in the upper third LL group. In addition, the physicians in the upper third LL group strongly agreed that CME activities should be funded by the HMOs and/or hospitals (4.68 versus 4.48,P<0.01) and that CME should be a condition for recertification (3.1 versus 2.5, P<0.0001).A logistic regression model was constructed to predict physician characteristics that correlate with higher LL scores. The independent variable was having an upper third score in the JSPLL questionnaire. The dependent variables included in the model were: male gender (OR = 1.501, 95% CI 1.044–2.159), involvement in teaching (OR = 4.460, 95% CI 3.084–6.448), and a rural clinic as the main work setting (OR = 0.601, 95% CI 0421–0.856). The number of years working in primary care in Israel, the number of patients seen, the number of hours spent seeing patients a week, and specialty status were not included in the final model. The variable, years in practice, was also not included as it had a high degree of correlation with physician age (Table5).Table 5
Logistic regression results for predicting physicians that will be in the upper third of the JSPLL questionnaire (N=979).
Variables included
Odds ratio
CI 95%
P value
Age (continuous)
1.019
0.996–1.042
0.103
Gender
Male
1.501
1.044–2.159
0.028
Female
1
Country of medical school
Israel
1.381
0.961–1.986
0.081
Abroad
1
Involved with teaching
Yes
4.46
3.084–6.448
<0.0001
No
1
Main clinic
Other
0.601
0.421–0.856
0.005
Urban
1


## 4. Discussion

Hospitals have a long tradition of CME activities that are an integral part of the regular working schedule, while primary care physicians work in solo or group practices, and CME activities are usually not included in their regular working hours. Thus, it is important to understand which CME activities are available in the primary care setting.Since the response rate in our study was only 23.9%, it might be assumed that the study sample does not represent the study population. The response rate may have been higher among physicians who do participate in CME (and may represent particular age and gender groupings), so that the rate of CME activity may be even lower among those who did not participate. If so, the need for remedial action is even greater. Nevertheless, a study population of 979 physicians, who come from three of the four HMOs in Israel, can provide, at the least, a partial picture of attitudes towards LL among primary care physicians in Israel.Defining the characteristics of those who have a stronger propensity for LL does not necessarily lead to a course of action that would increase this inclination in others.  In many countries, women take most of the responsibility for and burden of raising children and caring for the family [15]. This could lead to a conflict between home and work among female physicians [16] and affect both their interest and opportunity to take part in LL activities. Thus, ways should be sought to encourage female physicians to participate in relevant CME activities and develop LL habits.A large number of Israeli students study outside of Israel. In many cases, they are likely to have lower LL scores, so this group should also be encouraged, through incentives, to develop LL skills and habits through remedial programs within residency programs.In a study from Israel, an outcome-based CME program addressed and tried to solve the singular needs of practicing immigrant physicians [17]. This type of program could also lead to increased LL activity.Factors associated with higher LL scores included involvement in teaching, having an academic affiliation, and/or holding a position as a clinic director. However, these factors are often inherent characteristics that are not fostered by training programs. Still, encouraging physicians to engage in academic activities can lead to positive outcomes. HMOs should encourage physicians' access to university academic departments. It might also be beneficial to identify factors that encourage LL in rural practices and try to adopt them like in urban settings.The degree of availability of various update modalities is also important. Physicians with high LL scores had greater accessibility to each of the update modalities both at home and at work. It is not surprising that the availability of CME resources and the allocation of time for LL activities during working hours were associated with higher LL activity. Policymakers should find ways to increase accessibility to free LL activities at home and at work in order to enhance LL options.In a Cochrane review on the effects of CME meetings and workshops on professional practice and health care outcomes [18], the authors concluded that educational meetings alone or combined with other interventions can improve professional practice and the achievement of treatment goals by patients. Studies in medical education have focused primarily on whether continuing education activities are effective in creating a change in the treatment approaches of physicians and improving the health outcomes of patients. A review paper that compared the effect of formal CME teaching (lectures, presentations, and printed materials) with interactive CME programs showed that formal methods had little to no effect, while interactive programs had a medium to high effect [19]. In our study the three most frequent formats for LL were scientific conferences, clinical meetings in the clinic, and meetings sponsored by pharmaceutical companies. Of these, the latter should be the one of greatest concern to us. The current literature on the relationship between the pharmaceutical industry and the medical profession is remarkably consistent [20]. Doctors (and medical students) are influenced by contact with industry, but they incorrectly believe that they are immune to its effects or that they are capable of identifying and averting the danger of any inappropriate bias and influence [21, 22]. Therefore, policy makers should look for ways to allocate funds for CME activities, with the aim of “protecting” physicians from their tendency to depend on pharmaceutical companies for funding.


## 5. Conclusions

Davis et al. [23] suggested that leaders in medical education and related fields should identify high-priority research topics in CME research with the aim of expanding the scope of CME and conducting rigorous scientific studies on the process and effectiveness of CME. Successful research on this topic could provide us with ways to improve all aspects of CME. The results of such research could help policymakers formulate ways  to increase physician participation in LL activities and maintain or improve their knowledge, skills, and attitudes even if a long time has passed from the conclusion of their formal medical studies. Further studies should be performed on the contribution of CME to clinical outcomes.



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