Continuing medical education as a national strategy to improve access to primary care in Saudi Arabia

The purpose of this study was to describe the development, implementation, and evaluation of an educational program in family medicine for general practitioners in Saudi Arabia from 2009 to 2011. A continuing medical education program called Family Medicine Education (FAME) was developed with 7 modules each consisting of 12-14 hours of teaching to be delivered in 3 day blocks, over 45 days. Twenty percent (2,761) of all general practitioners participated in the FAME program. Initial assessment of the program showed significant improvement of knowledge from scores of 49% on a pre-test to 89% on post-tests. FAME program in Saudi Arabia facilitated primary care physicians’ knowledge.

Health care is free in the Kingdom of Saudi Arabia, with government-funded primary care centers being the first point of access for the citizens of Saudi Arabia, the large expatriate community, and to around 100,000 immigrants entering the country every year [1].Rural areas, as well as urban areas, are equipped with primary care centers with patient loads of around 21.5 physicians per 10,000 patients [2].Primary care physicians in Saudi Arabia, including general practitioners (GPs) and family physicians, have different postgraduate training and differ in their ability to provide primary healthcare services.The majority of primary care services in Saudi Arabia are provided by foreign-trained general practitioners with minimal to no training in family medicine.Family medicine as a career choice does not seem attractive to new doctors and only a small proportion of medical students are choosing family medicine as a career [3].As such, the current shortage of adequately trained primary health care physicians in Saudi Arabia will continue.In 1998, of 2,704 physicians in the Riyadh region, only 21.8% were from Saudi Arabia, with similar ratios across the country [4].The lack of well-trained physicians in primary care is a major threat to health care access in Saudi Arabia.Providing all GPs with 1-2 years of family medicine training or replacing all GPs with family physicians are not feasible options.As such, providing regular continuing medical education (CME) for general practitioners to upgrade and maintain their knowledge, skills, and attitudes has been considered a feasible option to improve access to good quality health care.The Centre for Postgraduate Studies in Family Medicine developed a condensed educational course called Family Medicine Education (FAME) to train general practitioners in Saudi Arabia.This paper aims to introduce the development and the evaluation of the educational program in family medicine for general practitioners in Saudi Arabia.
The project proposal was developed by the authors in 2008 as a 6-month certificate program in Family Medicine for General Practitioners, as requested by the Ministry of Health of Saudi Arabia.Programs were based on published reports from the World Health Organization and discussions with both family physicians and general practitioners in Saudi Arabia.The FAME program has been offered free of charge to all GPs by the Ministry of Health of Saudi Arabia.All GPs working in Saudi Arabia were invited to participate in this course; it was not a mandatory requirement.The initial courses and many of the subsequent courses were taught by the number of family physicians including two of the authors (SAA, ZA).The number of teachers had to be increased as the program expanded, with 54 teachers being involved in teaching in 2012.All of the teachers attended a 'train the trainer' workshop to familiarize themselves with the content and format of teaching the FAME program.Two multiple choice examinations were conducted before and after the course to assess knowledge gain.There were 30 multiple choice items to test knowledge.The questions on knowledge testing were selected from the question bank from the Postgraduate Institute of Family Medicine and had been validated earlier for use in family medicine examinations.All of the questions were piloted with family physicians and modified as needed.Statistical analysis was carried out using SPSS ver.20.0 (IBM, Armonk, NY, USA).In progress.

Content of program
The following general and specific content was chosen [5].The first 2 modules discussed an introduction to family medicine and the general concepts of family medicine, followed by 4 modules on common problems in family medicine: chronic illnesses; communicable diseases in adults and children; neurological, musculoskeletal, and mental health diseases; and gynecological diseases and obstetric care.The last module also covered professional development in family medicine (Fig. 1).The content and format were reviewed, edited, and approved by 23 family physicians.The details of the modules are described in Appendix 1.Each module of the course consists of 5 lectures, 6 small group sessions, and 4 practice cases taught over 3 full days.The course was designed to give theoretical information and practical skills on some of the main concepts of family medicine, and included the definition and scope of family medicine, communication skills, consultation and referral skills, and the clinical practice of family medicine.Each topic area starts with a lecture followed by group work, discussions, and other interactive learning activities.The small group learning sessions provided ample opportunity to give practical information that could be applied to patient care.The approximate division of the total learning time was as follows: 60% interactive small group sessions, 30% didactic lecturing, and 10% self-learning.The course was constructed to enable interactive learning with opportunities for peer learning, brainstorming, and small and large group discussions, as well as problem-based learning.Group discussions and role plays using cases were used to facilitate behavioral changes [6].

Implementation
The FAME program was started in Riyadh, the capital and the largest city in Saudi Arabia, and expanded to other areas with a vision to reach GPs in all 13 regions of the Kingdom of Saudi Arabia.During the course period, 54 trainers have trained 2,761 GPs in Saudi Arabia (Table 1

Learner evaluation
Analyzing the pre-test and post-test scores for the first 53 physicians who completed the program in 2009 showed significant improvement in knowledge, with scores improving from a mean of 49% (SD, 22%) for the pre-test results to a mean of 89% (SD, 13.5%) for the post-test results on a paired t-test (t = 15.75,P < 0.001).
FAME program in Saudai Arabia facilitated primary care physicians' knowledge acquisition.The teachers of the program attended focus group sessions in February 2012 to discuss the progress and future of the program.They discussed decentralizing the program; investing in trainers and other resources such as support staff, librarians, system administrators, textbooks, up-to-date journals and internet access; and implementing new teaching techniques with the conventional curriculum, such as practice-based small group learning and online learning.Funding to modify the program according to changing needs, offering the program for a small nominal fee, and securing research funding to evaluate the program and to analyze system changes were stressed as important considerations for the sustainability of the program.CME has been shown not only to improve physician knowledge but also to result practice changes and patient outcomes [7].Therefore, we believe that the impact of the program on patient and population health will be the more meaningful outcome, and are in the process of evaluating these factors.Serious thought should be given to the creation of continuing medical education programs based on the health-care needs of the community to improve access to primary health care.We are hoping to measure the improvement of disease management and reduction of chronic disease complications, initially, to formulate measures of health and wellness for the community in the coming years.

Module 1 .Module 2 .Module 3 .Module 5 .Module 6 .
Introduction to family medicine Definition and basic concepts of family medicine, communication skills, PHE, Referrals,Consultations, Approach to common diseases General concepts in family medicine Clinical method, Patient management, Screening, Malpractice, Ethical issues, Rational drug use, Medical records, Undifferentiated problems Common problems in family medicine: chronic disorders CHD, Hypertension, Diabetes, Obesity, Smoking, Respiratory problems Module 4. Common problems in family medicine: communicable diseases Upper respiratory tract infections, Lower respiratory tract infections, Otitis media, Urinary tract infections, Childhood infections (MMR, Chickenpox…), Vaccination, Gastroenteritis, Parasitic diseases Common problems in family medicine: Neurologic, mental, and musculoskeletal problems The management of Stroke, Headache, Musculoskeletal disorders, Depression, and Somatoform disorders in primary care Common problems in family medicine: Gynecologic and obstetric problems Preconceptional care, Pregnancy follow-up, Abnormal uterine bleeding, Dysmenorrhea, Family planning, Safe, Motherhood Module 7. Professional development in family medicine Continuous professional development, Continuous quality improvement in family medicine, Team work, Motivation Educ Eval Health Prof 2013, 10: 7 • http://dx.doi.org/10.3352/jeehp.2013.10.7 http://jeehp.orgJ