Mapping motivational factors for continuous medical education: insights from general practitioners with varying levels of participating in CME

Abstract

Background:

General practitioners’ (GPs) participation in continuous medical education (CME) is crucial for patient care, GPs’ well-being and healthcare costs. Despite this, 25% of Danish GPs did not participate in CME in 2022. It is vital to understand motivational factors for engaging in CME.

Aim:

To analyze motivation for CME and differences in motivational factors among GPs with different levels of participating.

Design and setting:

A cross-sectional questionnaire informed from qualitative interviews was conducted among all 3257 GPs in Denmark in May 2023.

Method:

The response rate was 40%. Responders were categorized as ‘frequent’, ‘partial’ and ‘infrequent’ CME users. We employed descriptive statistics and logistic regression analysis to quantify predefined motivational factors. Free text comments were analyzed using systematic text condensation. We used self-determination theory as a framework in the interpretation.

Results:

Most reported motivational factors were ‘relevant medical update’ (98%) and ‘topics of interest’ (96%). Financial incentives had a minor impact across all groups. Infrequent users were less easy to motivate and were more likely to state controlled motivational factors, e.g. a duty. Frequent and partial users of CME reported more autonomous motivation, i.e. personal development, collegial togetherness and professional well-being.

Conclusions:

Relevant medical updates that enhance perceived competence in patient care are crucial for all GPs. Infrequent users seem less motivated by avoiding burnout, collegial togetherness and well-being.

Key Points

We offer five recommendations for health authorities/CME providers:

• Increase perceived competence

• Foster relatedness

• Maintain autonomy

• Test changes

• Be aware of fair remuneration.

Introduction

Continuous medical education (CME) is essential for improving patient care [1–5], supporting general practitioners’ (GPs’) well-being [6] and reducing healthcare costs [7]. Despite adequate reimbursement and a comprehensive CME program, 25% of Danish GPs did not participate in CME in 2022 [8]. A description of the Danish CME program can be found in Appendix 1.

GPs who infrequent attended CME perceived different barriers to CME participation compared to frequent and partial users [9]. Barriers for infrequent users included a lack of tradition for CME, indicating insufficient motivation [9]. Motivation is crucial for professional development excellence [10,11]. Understanding motivational factors for CME and elements influencing variations in participation is crucial, regardless of the type of CME program a country chooses.

Motivation for education

A Danish study previously found that GPs were motivated by academic interest, patient-related issues and areas where they felt less confident [6]. An older English study highlighted economic compensation as a key motivator [12], while Danish and Malaysian studies [4,6] emphasized the importance of meeting colleagues [6]. GPs were found to be motivated by both internal and external factors [6,11,13]. Internal (intrinsic) motivation was supported by work happiness, autonomy, good working conditions, professional confidence and personal traits but were diminished by burn-out and restrictive subordination [11,14]. Intrinsic motivation is positively associated with professional performance and well-being [11,15].

Self-determination theory and motivation for CME

According to self-determination theory (SDT), motivation ranges from amotivation to intrinsic motivation, encompassing a continuum of four types of extrinsic regulated motivation [14]:

Controlled extrinsic motivation (sense of obligation)

• Driven by reward and punishment (‘I have to’)

• Driven by avoiding disapproval (‘I will be looked down upon if I do not participate’)

Autonomous extrinsic motivation (sense of volition and choice)

• Driven by identified need (‘A gap in my knowledge needs to be filled’)

• Driven by alignment with personal values (‘It is a core value for me to participate’)

Intrinsic motivation is supported by perceived competence and autonomy [14]. Along with the need for relatedness, perceived competence and autonomy are crucial for moving from controlled to autonomous extrinsic motivation [14]. Motivation is clearly at stake in CME and intrinsic motivation and internalization of autonomous extrinsic motivation require the satisfaction of three basic psychological needs: need for autonomy, competence and relatedness [11].

Autonomy-supportive teaching fosters intrinsic motivation and autonomous self-regulation of learning [11]. We hypothesize that CME initiatives promoting autonomous motivation are more effective than CME driven by controlled motivation. Understanding GPs’ motivational drives and variations in motivation among different GP profiles is crucial. Our aim is to explore motivational factors influencing GPs’ participation in CME.

Research questions:

• What motivates Danish GPs to participate in CME in 2023?

• Is there variability in motivational factors for CME among GPs with varying levels of participating in CME?

Methods

Study population

All GPs in Denmark, all eligible for CME reimbursement in May 2023 (n = 3257).

Study design

Cross-sectional questionnaire study on Danish GPs’ motivation for participation in CME. The study incorporated both qualitative and quantitative components, drawing inspiration from exploratory sequential design principles utilized in mixed methods research.

Setting

The study was conducted in Danish general practice in 2023. Danish GPs, who undergo six years of postgraduate training [16], are primary contact for patients and handle most primary care [17]. Approximately, 90% of Danes consult their GP at least once a year, and 90% of inquiries are handled in general practice.

Referrals from GPs are required for most specialist and hospital treatment [17]. Danish GPs must maintain their competencies according to the collective agreement between the Danish Association of General Practitioners (PLO) and the provider of primary care, the Danish Regions [18]. The CME program includes a voluntary part based on the GP’s individual needs analysis and a mandatory part based on a mutual needs analysis using the national curriculum of Danish family medicine as a framework [19]. There is no revalidation or recertification. Sanctions for non-participation have been discussed; they have not yet been implemented.

The CME program offers a wide range of educational formats provided by both regional and national organizations. The topics and learning objectives for the mandatory CME were determined through a national learning needs analysis involving multiple stakeholders, as detailed in Appendix 1. The inclusion criteria focused on topics relevant to all GPs in Denmark, where a collective update was deemed valuable for the primary healthcare sector [19]. Flexibility was allowed in the educational formats.

Questionnaire

Prior to developing the questionnaire, we identified all GPs in Denmark who had not used any of their reimbursement for CME in a 2-year period (n = 243) and selected 10 GPs from this group. We aimed for maximum variation in characteristics that might influence barriers to CME [20]. One of the authors (HI, a GP herself) conducted face-to face interviews in respondents’ own clinics to minimize the risk of reluctance to participate. The interviewer, supervised by one of the co-writers (NKK), chose not to use a detailed interview guide to remain open-minded. All 10 invited informants agreed to be interviewed.

The questionnaire was developed by three of the authors (HI, NKK and JS) based on the 10 interviews [20] and a literature review. The questionnaire was evaluated for construct and content validity through expert review with six reviewers (two with research experience, two educationalists and two GPs with educational insight) and a two phase pilot test (four GPs selected with variance in sex, seniority as a GP, geography and practice type (singled handed, partnership)). The questionnaire was modified in the process for clarity and comprehensibility and for content and perspective.

Initially, respondents were asked, ‘Do you use your reimbursement for CME?’. The response options included ‘frequent users’ (those who normally use all or most of their reimbursement), ‘partial users’ (those who normally use part of their reimbursement), ‘infrequent users’ (those who seldom use their reimbursement) and ‘do not know’. GPs who answered ‘do not know’ to the initial question regarding reimbursement use were excluded from the results, as reimbursement use served as our exposure variable in the study.

All groups were asked questions regarding motivational factors for CME (Supplementary Table 1). Furthermore, the respondents had the opportunity to add other motivational factors in free text.

Data collection

In May 2023, all registered GPs in Denmark received an e-mail invitation with a questionnaire investigating their motivation for participation in accredited remunerated CME. The response categories were ‘strongly agree’, ‘agree’, disagree’ and ‘strongly disagree’ for 11 predefined motivational factors, along with a free text option.

Register data from the PLO provided demographic data on sex (male/female), age (<40, 41–50, 51–60, 61–70 and >70 years), practice type (singled handed, partnership) and geography (five regions in Denmark).

Non-respondents received reminders after one and two weeks. Demographic data were collected through the questionnaire and a central database in PLO. The research group received pseudonymized data, which was transferred to a secure server.

Statistical methods

Quantitative data: Descriptive statistics were employed to examine the distribution of responses, presented as numbers and percentages, within the investigated categories ‘agree’ (comprising those who answered, ‘strongly agree’ or ‘agree’), ‘disagree’ (comprising those who answered ‘disagree’ or ‘strongly disagree’) and ‘not considered’ in relation to the questions about motivation for infrequent users vs. frequent and partial users of CME. p Values, used to assess differences in responses were calculated using the Chi-square test or Fisher’s exact test when the cell frequencies were less than five. Moreover, we performed logistic regression analysis providing odds ratios (ORs) with 95% confidence intervals (CIs) to investigate the associations between users of CME (infrequent vs. frequent/partial users) and the different aspects of motivation adjusted for sex, age, region, seniority as a GP, and practice type. All analyses were conducted using Stata version 18.0 (StataCorp, College Station, TX).

Qualitative data: Motivational factors from free text responses were analyzed using systematic text condensation [21,22] involving four steps:

1. Initial reading: Answers were read thoroughly to get an overall impression. Preliminary themes were generated, written down individually, and agreed upon by two of the authors (HI, NK).

2. Code grouping: Meaningful text fragments (meaning units [22]) of the chosen themes were identified and sorted into code groups.

3. Subgrouping: Each code group was reviewed and divided into subgroups if necessary. Meaning units of each individual code group and subgroups were compiled into one comprehensive artificial quotation, a condensate. Meaningful units that did not fit were either left out (statements related to barriers for CME) or placed in another code group.

4. Analytic text development: Based on the artificial quotations, an analytic text for each code group was developed and expressed in separate category headings. All data were reread to ensure final conclusions were robust. Decisions on each step in the process were made through authors’ discussions.

Results

Of the 3257 invited GPs, 1303 GPs (40%) completed the questionnaire. We analyzed data from 1244 GPs who responded to questions about motivation. Flowchart of study population can be found in Figure 1.

Figure 1.

Flowchart of study population.

Representativeness of study population

The study population was similar to the general population of GPs in terms of age, practice type and geographical regions in Denmark except from a higher proportion of female respondents (68% vs. 60%) (Supplementary Table 2).

Table 1 presents baseline characteristics of the study population stratified by use of CME. GPs in singled-handed practices and male GPs were overrepresented among infrequent users. Other demographic data were evenly distributed among the groups.

Table 1.

Baseline characteristics of the study population stratified by use of continuous medical education (CME).

	Frequent and partial users (n = 1074, 86.3%)	Infrequent users (n = 170, 13.7%)	Total (n = 1244)	p Values for differences between frequent/partial users and infrequent users
Sex				<.001
Women	744 (69.4)	95 (55.9)	839 (67.6)
Men	328 (30.6)	75 (44.1)	403 (32.5)
Age (years), mean (SD)	51.6 (7.8)	52.0 (8.7)	51.6 (8.0)	.534
Region				.425
North	91 (8.5)	18 (10.6)	109 (8.8)
Central	253 (23.6)	31 (18.2)	284 (22.8)
South	233 (21.7)	41 (24.1)	274 (22.0)
Capital	343 (31.9)	61 (35.9)	404 (32.5)
Zealand	152 (14.2)	19 (11.2)	171 (13.8)
Seniority as a general practitioner				.311
<5 years	191 (17.8)	34 (20.0)	225 (18.1)
5–15 years	490 (45.6)	84 (49.4)	574 (46.2)
15+ years	393 (36.6)	52 (30.6)	445 (35.8)
Practice type				<.001
Single handed	121 (11.3)	54 (31.8)	175 (14.1)
Partnership	953 (88.7)	116 (68.2)	1,069 (85.9)

Numbers (%) unless stated otherwise. Two general practitioners (GPs) have missing information on sex, age, region and practice type.

Quantitative data

Motivation for participating in CME

The two most reported motivational factors for participating in CME were ‘relevant medical update’ and ‘topics of interest’ stated by 98% and 96% of the GPs, respectively (Figure 2).

Figure 2.

Proportion of general practitioners answering ‘agree’ to questions on motivational factors for continuous medical education (CME).

More than half of the GPs reported the following five motivational factors: ‘enhancing patient pathways’ (77%), ‘avoiding burnout’ (70%), ‘focus on vulnerable patients’ (64%), ‘managing health resources’ (60%) and ‘avoiding overtreatment’ (53%).

‘Health policy update’, ‘Colleagues’ expectations’, ‘patients’ expectations’ and ‘well-paid CME’ were infrequently mentioned, with 35% or fewer of respondents acknowledging them. The distribution of motivational factors related to the use patterns of CME can be found in Supplementary Table 3.

Figure 3 illustrates differences in motivational factors between users of CME (frequent and partial users) vs. infrequent users.

Figure 3.

Differences in motivational factors between users CME (frequent and partial users) versus infrequent users.

Results from the logistic regression analysis indicated lower odds of answering agree to all questions regarding motivation for infrequent users compared with partial and frequent users; however, no significant differences were found for ‘avoid overtreatment’, and ‘patients’ expectations’, and borderline significant associations were found for ‘focus on vulnerable patients’, and ‘managing health care resources’ (Table 2). Differences between GPs who participate in CME and those who rarely do were mainly indicated in terms of ‘relevant medical update’, ‘avoiding burnout’, ‘colleagues’ expectations’ and ‘well-paid CME’. In all cases, infrequent users indicated less agreement.

Table 2.

Odds ratios (ORs) with 95% confidence intervals (CIs) for the odds of answering ‘agree’ to questions on motivation for continuous medical education (CME), comparing infrequent users to often and partial users.

	OR (95% CI)
Relevant medical update	0.31 (0.10–0.97)
Topics of interest	0.45 (0.21–0.98)
Enhance patient pathways	0.49 (0.32–0.75)
Avoid burnout	0.41 (0.28–0.59)
Focus on vulnerable patients	0.59 (0.47–1.02)
Managing healthcare resources	0.69 (0.47–1.00)
Avoid overtreatment	0.82 (0.56–1.20)
Health policy update	0.60 (0.40–0.88)
Colleagues’ expectations	0.40 (0.24–0.65)
Patients’ expectations	0.94 (0.59–1.49)
Well paid CME	0.24 (0.10–0.57)

All analyses are adjusted for sex, age, region, seniority as a general practitioner, and practice type. Significant findings are marked in italics.

Qualitative data

To provide a comprehensive overview, GPs were given the opportunity to include motivational factors as free-text comments. Out of 1244 GPs, 247 (22%) provided free-text comments. Among infrequent users, 22 cited free text comments (13%). Free text comments were categorized into five main categories, listed by frequency:

• 1. Relatedness/collegial togetherness

Majority of comments highlighted the importance of meeting colleagues, exchanging experiences and gaining new inspiration.

One learns a lot from the inter-collegial conversations during courses. It is crucial for courses to allow space for these discussions on how others manage the many challenges they face. (frequent user)

Meeting colleagues with different perspectives on illness and health and testing my own views in the field lower the risk of being unconsciously incompetent. (Partial user)

No comments from infrequent users in this category.

• 2. Perceived competence/professional confidence

Many GPs, regardless of user type, were motivated by the need to stay professionally updated for the benefit of their patients.

• 3. Personal development and wellbeing

Comments indicated that personal development and well-being increased job satisfaction and confidence.

To develop personally, as a doctor, and as a leader. (frequent user)

To learn something about myself and my reactions on difficult, complex patients. (partial user)

No comments from infrequent users in this category.

• 4. Break from clinical work

GPs from all user types valued the opportunity to step away from clinical routines and return with renewed energy.

It is a sanctuary, a time for contemplation, which we otherwise do not have in everyday life. (frequent user)

An opportunity to be away from clinic and engage with medical work in another way. Provides new ideas, fresh air, and renewed energy. (partial user)

Breathing space from patients. (infrequent user)

Mandatory/a duty

Fewest comments, mostly from infrequent users, indicated participation as a duty.

It is a duty and also rewarding to acquire new knowledge and return inspired to practice. (frequent user)

A duty to update end to develop professionally. (partial user)

Because I must. (infrequent user)

Discussion

Main findings

‘Relevant medical update’ (98%) and ‘topics of interest’ (96%) were the most reported motivational factors for all user types, highlighting the importance of perceived competence in patient care. Despite being more frequently reported among frequent and partial users, well-paid CME had minor impact on motivation across all user groups. ‘Avoiding burnout’ was the fourth most common motivational factor overall but had minor impact on infrequent users.

The qualitative data found that infrequent users were more likely to report controlled regulated extrinsic motivation (Mandatory/a duty) than frequent and partial users. While frequent and partial users reported autonomous regulated motivation (personal development, collegial togetherness and well-being) more often than infrequent users.

Comparison with other studies

Medical updates on patient-related issues provide perceived competence. Our finding that medical updates in patient related topics are a key motivational factor aligns with other studies [6,12,13]. Our findings also highlight the importance of togetherness and autonomy for GPs motivation as stated in SDT [11]. This is supported by studies which have shown that the exchange of experiences among colleagues, preventing burnout and supporting GP well-being are important for CME [6,13,23]. Our data show differences among frequent and infrequent users. Infrequent users, cite more extrinsic motivation and less relatedness or collegial togetherness as motivational factors. We have not identified studies conforming or refuting these findings related to varying levels of CME participation.

A recent Danish study [24] found money to be a less important motivational factor, similar to our results, but Denmark already has a generous reimbursement system, and it is uncertain whether economic compensation would play a bigger role in countries with less economic incentives. It differs from an older UK study [12] which highlighted financial incentives, for health promotion and service management sessions.

Methodological considerations

All GPs in Denmark were invited to participate in the survey, achieving response-rate of 40% which was comparable to other studies [25,26] but could entail selection bias. The study population was representative of the GP population in Denmark except for a higher proportion of female GPs (68% vs. 60%). While self-reported data can introduce bias, the proportion of GPs identifying as infrequent users of CME matched the annual report from Association of General Practitioners [8].

The questionnaire was developed using qualitative data, consulting the literature and validated through expert review and pilot testing. We consider this a strength. The questionnaire was developed based on insights from qualitative interviews with 10 infrequent users of CME focusing on barriers. Therefore, the design did not fully explore the GPs’ views on motivation, nor the attitudes among frequent users. It gave rise to reflexive considerations that three of the researchers are GPs with experience in the Danish CME system. To address this, two researchers independently assessed the free-text comments using Malterud’s systematic text condensation method [21,22], without knowing the respondents’ user status. Only after categorizing the comments did the researchers determine whether the responses came from frequent, partial or infrequent users. Since both frequent, partial and infrequent users made free text comments, which expressed different patterns, we found that free text comments add understanding to our quantitative results. However, minor bias due to our perspective, content insight and experience cannot be entirely excluded despite our deliberate attempt to minimize it. The data are collected from Danish GPs, whose CME program is based on professional integrity without revalidation or recertification, with CME activities reimbursed up to approximately €6500 per year. Caution is needed when generalizing these findings to GPs in other countries, though motivational factors may be similar across borders. It is likely that well-paid CME is less important as a motivational factor in a country with good remuneration. Future research should explore these similarities and differences.

Implications

Health authorities should address factors important for internal motivation: need for autonomy, competence and relatedness. While external factors like mandatory requirements and reimbursements [14] may be more accessible for CME organizers, SDT provide us with a nuanced understanding of external motivation and show a possibility of internalizing external towards internal motivation with the right approach.

Our recommendation for CME organizers is to:

• Increase perceived competence: Focus on applied learning in topics relevant for GPs.

• Foster relatedness: Especially important when planning internet-based CME or similar.

• Maintain autonomy: Avoid reducing autonomy when standardizing CME.

• Test changes: Evaluate the impact of changes.

• Be aware of fair remuneration: While important, simply increasing payments is unlikely to significantly enhance motivation.

Further research should explore GPs’ preferences for learning frameworks and the impact of mandatory CME on intrinsic motivation.

Conclusions

Relevant medical updates that enhance perceived competence in patient care are crucial for all GPs.

Infrequent users are less motivated by avoiding burnout and more likely to cite controlled extrinsic motivation (Mandatory/a duty), while frequent and partial users report autonomous motivation (personal development, collegial togetherness, well-being) more often. Well-paid CME may have minor impact on motivation especially for frequent and partial users.

We offer five recommendations for health authorities/CME providers: keep focus on increasing perceived competence. Foster relatedness, especially when planning internet-based or similar CME. Avoid reducing autonomy when standardizing CME. Test changes to evaluate the impact. While fair remuneration is important, simply increasing remuneration is unlikely to significantly enhance motivation.

Funding Statement

HI had funding from Research Unit of General Practice and the General Practice Fund (Grant ID: 991307).

Ethical approval

All methods were conducted in accordance with relevant guidelines and regulations. The project has been ethically approved by SDU (University of Southern Denmark) Research and Innovation Organisation, RIO (record number 11.659). The National Scientific Ethical Committee has been asked (record number 20222000-47) but according to the Danish legislation (Scientific Ethical Committees Act § 14/1 + 2), the project needs no approval from the National Scientific Ethical Committee.

Disclosure statement

No potential conflict of interest was reported by the author(s).