Background

Regarding physicians’ need for uninterrupted updating of their medical knowledge to provide better services to patients and guarantee professional achievements, it is highly important to pay attention to continuing professional education of doctors (1, 2). According to the law of continuing education, all the members of the Iran Medical Council need to participate in continuing medical education (CME) programs since 1996 (3). However, the limitations of face-to-face training, such as physical space restrictions, shortcomings in infrastructure, transportation problems, and limitations in providing vacancies for large groups of participants, have led many doctors to decline participation in CME courses (4). The results of studies have shown that the quality and proficiency of the educational systems are among the most important developmental concerns of governments and
decision-makers in every country. It is worth mentioning that holding educational courses alone cannot help organizations achieve their goals. In fact, CME can lead to the improvement of the quality of clinical care services only if appropriate teaching methods are used (5-7). A solution for this issue is to use novel technologies. The use of smart technology-based instruments and applications can facilitate doctors’ access to CME courses. In this regard, interactive applications based on various educational media can perform better than text-based methods for delivering educational content (8-10). Studies have noted many advantages of e-learning educational methods, such as better access of the audience to the educational content, convenience, flexibility, reduced travel costs, saving time, adaptability to different learning styles, and the possibilities of using multimedia tools, reviewing the content, providing supplementary materials, dynamic updating of scientific content, and designing interactive case presentation scenarios (9-12).

Considering the aforementioned explanations, it is necessary to apply new and user-friendly technologies with wider accessibility to deliver educational courses, including CME programs. In order to develop interactive educational applications for delivering CME courses to doctors, we first need to identify and classify the topics for which appropriate interactive applications can be designed. For this purpose, the present research aimed to scrutinize the virtual CME courses held by the Shahid Beheshti University of Medical Sciences in 1397-1399. We categorized the topics of the courses based on their educational goals, content, and methods, as well as evaluation methods, and determined the applicability of using interactive educational applications for the subjects taught.

Objectives

The present research aimed to scrutinize the virtual CME courses held by the Shahid Beheshti University of Medical Sciences in 2018-2020. We categorized the topics of the courses based on their educational goals, content, and methods, as well as evaluation methods, and determined the applicability of using interactive educational applications for the subjects taught.

Methods

This qualitative study was conducted using a directed content analysis approach (13, 14) in 2021 at the CME site of Shahid Beheshti University of Medical Sciences. In order to design and develop interactive educational applications for the CME courses of doctors, we conducted a 3-step experiment to identify topics for which appropriate interactive applications could be designed.

As required by directional content analysis, we initially performed a review of overseas and domestic literature using the keywords and phrases of continuing education courses, educational applications, continuing education topics, etc. Relevant articles authored by Iranian or foreign researchers were extracted from validated databases, according to which a number of questions were raised to be asked during semi-structured interviews. These questions covered areas such as educational goals, educational content, teaching and learning methods, evaluation methods, and type of interaction, as well as the strengths and weaknesses of the virtual CME courses (Appendix 1) (5, 15-23).

In the second step, information such as the frequency and area of the CME topics provided to general practitioners between 2018 and 2020 were extracted from the university’s CME website, and relevant educational documents and media were categorized. Then, the necessity and appropriateness of the subjects in terms of educational goals, educational content, teaching methods, and user environment were analyzed. For this purpose, 42 courses out of a total of 420 courses were chosen using the 10% sampling strategy. The researcher registered for these courses and completed them in order to be able to fill out the checklist of the research objectives. According to the study’s objectives, this checklist included the type of disease, course name, educational goals, educational content, teaching-learning methods, evaluation methods, and the user environment (interactive tools) of the applications designed.

In the third step, individual interviews were conducted with CME specialists. In addition, two focused group discussion sessions were held with the participation of ten physicians selected by purposeful and snowball sampling methods. The interviews continued until they reached data saturation. The duration of individual interviews ranged between 40 and 50 minutes, and the focus group sessions lasted 90 minutes. The criteria for selecting an interviewee included having at least two years of experience in managing or preparing and teaching a training course.

For conducting the individual interviews, the time and place were arranged with the interviewee. Written informed consent was obtained to audio-record the interview, and after each interview, the recorded file was transcribed verbatim. Next, the recorded file was matched with the transcribed text. Every interview (either individual or focus group) was then summarized, coded, and finally categorized with regard to the objectives of the interview. Duplicated categories were identified in subsequent interviews. Finally, themes, categories, and their frequencies of mentioning were extracted and organized in seven dimensions (Table 1).

The data gathered during the literature review, reviewing documents and checklists related to courses, individual interviews, and focus group sessions were analyzed using MAXQDA software version 2010 (VERBI Software GmbH, Germany).

In order to ensure the reliability and accuracy of the qualitative data, the criteria of Lincoln and Guba, including reliability, verifiability, and transferability (15), were utilized. Credibility was achieved by
long-term communication with the participants and prolonged engagement with the data through conducting in-depth interviews, as well as by reviewing the interview texts by the participants. Reliability was achieved via peer-reviewing by external reviewers. For this purpose, the texts of some of the interviews, along with the codes, categories, and themes extracted, were provided to three experts in the field of qualitative research (who were not members of this study’s research team) to be verified.

Table 1. Themes Derived from Individual Interviews and Focus-group Sessions

For transferability, a complete description was provided for the background of the research, the process of participant selection, and the procedures used for data collection and analysis. Verifiability was confirmed through an audit trail for the research process and decisions.

Results

Four professors in the field of medical education participated in individual interviews, two of whom (50%) were full professors; one was an associate professor (25%), and the other was an assistant professor (25%). Two of the professors were male (50%), and the mean age of the participants was 49 ± 8 years.

In focus group sessions, 20 general practitioners participated, 55% (n=11) of whom were male and 45% (n=9) were female, and the means of age and work experience were (mean ± SD) 38 ± 5 and (mean ± SD)
7 ± 2 years, respectively.

The analysis and recapitulation of nine domestic articles and eight foreign articles revealed that online CME programs delivered via e-learning platforms were largely effective. The topics chosen for the courses were largely suited to the interests of the audience. The physicians preferred the afternoon and before dinner as the best time for participation in these courses, and most of them used mobile phones, and fewer used iPads to participate in the courses. Most of the doctors had a sincere commitment to accomplish the courses. Also, the quality of voice and the style of presentation were directly associated with the enthusiasm of doctors to attend the courses.

The review of the documents showed that a total of 546 face-to-face and virtual CME courses, some of which are still ongoing, were held by the Shahid Beheshti University of Medical Sciences over the two years under investigation. Out of these, 420 courses were completely virtual; 362 courses were held by clinical departments, and 58 courses were held by basic science departments (Tables 2 and 3).

In this study, 42 courses were selected by statistical sampling to investigate the trends and goals of the virtual CME courses held at the Shahid Beheshti University of Medical Sciences. Among the 420 virtual courses, according to statistical calculations, we projected three scenarios of 10% sampling for different situations, which led to the suggestion of sample sizes of 42, 80, and 59. According to our analyses, we selected the first scenario (i.e., the 10% sampling method that required a sample size of 42) (Appendix 2).

The reviewing of the documents showed that the educational goals of the courses had been defined at lower Bloom cognitive levels (i.e., knowledge, perception, and application). Only a few courses defined educational goals at the analytic level, and there were no courses focusing on higher-level objectives such as evaluation and synthesis. Objectives either were not mentioned or were verbally explained for some courses, indicating a low focus on educational goals (Table 4).

Reviewing the educational content of the CME courses revealed that most of them employed non-interactive lecture-based teaching using slides, and in most of them, the images and diagrams were fixed and inactive. Some of the courses included videos, but interactive tools such as Storyline had been employed uncommonly (Table 4).

Investigating the teaching and learning methods demonstrated that they were not diverse, and the most common methods included non-interactive lecturing, case studies, and questioning without the instructor’s feedback. Some of the courses used problem-oriented methods by presenting a scenario, and at the end of some courses, a summary or conclusion was provided. In addition, some courses employed samples, key concepts, and content organization methods (Table 4).

Regarding the type of evaluation in the CME courses examined, all courses used the same evaluation method, which was based on the final exam.

Table 2. The Titles and Frequencies of Virtual Learning Courses Held in the Context of the Continuing Clinical Medical Education Program for General Practitioners at Shahid Beheshti University of Medical Sciences from 2018 to 2020

Table 3. The Titles and Frequencies of Virtual Learning Courses Held in the Context of the Continuing Non-clinical Medical Education Program for General Practitioners at Shahid Beheshti University of Medical Sciences from 2018 to 2020

The questions were answered on multiple random choice scales, requiring a minimum score of 70 out of 100 to pass the exam. The duration of the test was 30 minutes, and the maximum number of retesting was three times for each participant (Table 4).

Regarding the utilization of tools and software in the courses, most of the educational content had been presented in the form of videos and audio slides in the software environment, equipped with adequate and appropriate tools for changing the size of the window, moving forward, and backward, pausing, as well as tools such as eraser, lighter, outline, search, adjusting the volume and timeline, and note-making (Table 4). Table 4 summarizes five examples of the courses, but all 42 courses can be analyzed based on the criteria provided in this table.

The results of the third step of the study
(a recapitulation of focus group sessions) showed that 40% of the content was about diseases such as
COVID-19, cancers, eye diseases, and diabetes, and 30% of the courses were held virtually, enabling access to the course at any time and in any location. One advantage of virtual courses is their flexibility, allowing the participation of different professional groups, but a noteworthy drawback can be the lack of adequate interaction between the instructor and learners (Appendix 3).

The data from the interviews were organized into seven dimensions, including objectives, content, teaching methods, evaluation, type of interaction, strengths, and weaknesses. The views and concerns of the interviewees about the topics covered in CME courses were also outlined, and the themes intertwined with their needs and concerns were extracted to obtain more comprehensive findings (Appendix 4).

According to the main objective of the study, the CME courses were categorized based on their subjects to assess the applicability of interactive educational applications, the results of which have been shown schematically in Appendix 4.

Table 4. The Results of Analysis of 42 Virtual Clinical/Basic Science Continuing Medical Education Courses Provided to General Practitioners

Discussion

Based on the results of the present study, CME courses had good accessibility, but their educational goals were mostly at low Bloom cognitive levels, and they mostly contained non-interactive content. In most cases, the teaching method chosen was through lecturing, while it was expected to use more interactive methods. Evaluations were objective and summative, while formative evaluation should be considered more frequently. In addition, educational platforms lacked appropriate graphical efficiency and user-friendly tools, which need to be improved.

The results of studies have confirmed that continuing education programs held online and via e-learning instruments are somehow more effective than traditional programs; nevertheless, the transformation of Iran’s education system in parallel with technological advances takes place slowly due to the lack of the infrastructure required, as well as due to cultural barriers. The preferences of the audience, including duration, type of presentation, and evaluation methods, are deterministic in choosing the topics and features of CME courses, encouraging participants to favor virtual courses. This finding was in line with the report of Atai and Siamian, who investigated the role of virtual learning in holding CME courses during the COVID-19 pandemic (16). However, our observation was opposed to the results of a study by Wang et al., who investigated the effectiveness of e-learning in CME among healthcare workers in China (17) and asserted that virtual learning was effective among healthcare staff but not for general practitioners, which could be due to the poor quality of educational content or choosing topics unmatched with the needs of the audience.

According to the results obtained, the educational content presented in virtual courses is longer available compared to that presented in face-to-face training courses, so physicians can register and complete these courses when they need to. This flexibility causes doctors to be more enthusiastic about virtual rather than in-person CME courses. This finding was consistent with the results of Sadeghi-Tabar et al., who investigated various dimensions and components of CME based on blended learning (18).

The results of the present research showed that in most CME courses, general topics were offered to medical professionals, while specialized and challenging topics were avoided.

This can be probably due to the lack of appropriate software and hardware infrastructure and the unavailability of a user-friendly management platform allowing for constructive communication with the audience. This finding was in line with the results of Atai et al. (19), who studied the effectiveness of conventional CME methods.

In a study by Fani et al., the challenges of virtual medical education were investigated, and the results suggested that virtual training methods might not be applicable to specialized and practical topics (20). This finding opposed the results of the present study, and this difference could be related to the type of educational content. On the other side, simulation and gamification can provide a safe and stress-free environment to facilitate learning and reinforce traditional education (21).

In most CME courses analyzed, there was no clear mention of the objectives, which is an important part of the courses. These courses mostly focus on low-level cognitive objectives. Experts, however, presume such goals to be the best for virtual CME courses if these courses address diseases and their treatments. Consistently, the results of Ammenwerth et al. approved this observation (22).

Our analysis showed that the educational content in the CME courses was mostly presented through audio slides and podcasts. This is while educational videos seem to be more effective for learners. In addition, the use of diverse content, such as simulators and educational games, can help exert deeper learning effects.
Micro-educational content, despite having narrower objectives, can also help the audience learn more deeply. The results of studies by De Gagne et al. (23, 24), Gawlik et al. (25), Sozmen et al. (26), and Thillainadesan et al. (27) were also in line with our findings.

Overall, conventional teaching-learning methods more commonly use non-interactive techniques such as lectures. Although methods such as presenting clinical cases and scenarios and problem-solving techniques are also used, these methods use less interactive content. Experts suggested the use of not only non-simultaneous teaching methods but also simultaneous techniques such as reverse classes, which was consistent with the results of studies by Hradetzky et al. (3), Atai et al. (19), and Xiberta et al. (28).

In terms of interactions, the CME courses analyzed had low levels of interactions. This interaction was more focused on the engagement of the learner with the educational content through the tools offered by the applications used to present the course. However, less attention was paid to other types of interactions, including the interaction of learners with the professors and their peers, as well as providing constructive feedback. Consistently, Momtazmanesh et al. (5), Longhini et al. (10), and Yeh et al. (29) reported similar findings; however, our observation opposed the results of Tehrani et al., who assessed the perception of university professors from virtual learning and highlighted the low levels of interactions, inadequate motivations, and inefficient support in virtual learning (30), which can be due to the fact that the audience of virtual learning in the recent study were students.

Regarding evaluation, most CME courses were focused on multiple-choice final exams. Experts suggest using formative evaluation methods, such as taking a pre-test and using case-oriented methods, as well as paying attention to cheating prevention strategies. This observation agreed with the results of Cheong and Hsu (31), Ebrahimi et al. (32), and Eskanderzadeh et al. (33).

The strengths of the CME course held included the diversity of courses and their wide accessibility to learners. The most prominent limitation of these courses included the lack of effective interactions between learners and instructors.

Nowadays, most CME courses are held virtually, and clinical courses generally outnumber courses related to basic sciences. There is a need to revise the design of educational plans and reinforce technical infrastructure. The objectives of the courses were mainly at low and middle cognitive levels, with less attention being paid to higher cognitive levels, such as criticism, evaluation, or synthesis.

The use of e-learning tools can augment the active role of the learner, leading to more comprehensive learning. Therefore, it is suggested to renew technical infrastructure and empower instructors by familiarizing them with the fundamentals of designing virtual courses and technological infrastructures so that they can develop motivational, educational content.

One of the limitations we faced during conducting interviews and focus-group sessions was the poor cooperation of doctors due to their busy schedules. Also, parts of the research coincided with the COVID-19 outbreak that made accessibility to the audience difficult, requiring extensive efforts and prolonged time for making arrangements.

Conclusion

According to the results of the present study, the design and development of interactive applications can help deliver effective CME courses only if these applications are designed based on learners’ requirements and possess suitable pedagogical features. These applications can obviate the drawbacks of the conventional methods used to deliver CME courses (e.g., low to medium cognitive levels) and allow for holding higher-level courses. On the other hand, the smart platforms of these applications enable effective education at skill-based and motivational levels. Moreover, because learners are offered numerous complex and multifaceted choices, they are expected to master problem-solving and decision-making skills through receiving feedback. Finally, these applications provide accessibility to educational courses anywhere and anytime, making them applicable for learners who cannot attend them. Moreover, the attractive learning environment encourages learners to actively participate in the course and experience more satisfaction and deeper and more meaningful learning.