Priority issues in continuing medical education show sensitivity to change in Canadian health care

The degree and scope of significant change in health care expectations, roles and delivery patterns in Canada have been widely documented. In 1988 the Sub-Committee on Research of the Standing Committee on CME [continuing medical education], Association of Canadian Medical Colleges, conducted a survey to determine whether those responsible for the CME portion of the medical school curriculum are changing their perceptions to keep pace with the changes in health care. The results were compared with those of a similar survey done in 1983. In both surveys people directly responsible for delivery of formal CME were asked to identify and rank research needs in CME. The response rates were very high. The CME issues identified in the two surveys had changed considerably, with entirely new issues being identified in 1988 and the emphasis placed on issues having changed. The identification of factors that promote or inhibit application of new knowledge by practising physicians was of lowest importance in 1983 and of primary importance in 1988, and comparison of the cost-effectiveness of CME methods was an important issue in 1983 and among the least important in 1988. The noted changes mirror developments in Canada's health care milieu.

Joint case writing: maintaining the validity and relevance of training in health care administration

The Canadian College of Health Service Executives, the personal membership professional association for senior health care managers in Canada, has developed a unique approach to enriching the quality and increasing the productivity of the academic-field relationship. This paper describes the development of the program, the need for linkages between faculty, and the field and the limitations of the case method as traditionally practiced.

Identification of functionally necessary knowledge and skills in the practice of Canadian health care management

The Canadian College of Health Service Executives (CCHSE) conducted a project in 1985-87 to identify basic competencies required in the field practice of health care management in Canada. The project derived from the College's mission to establish and promote professional standards for all health care executives in Canada. The project also addressed more specific short-term problems: to validate an existing examination purporting to measure the basic competence required for field practice of health care management in Canada; to create a data base upon which a CCHSE criterion reference test of field-based professional competence in health care administration could be created; and to provide to the training programs in Canadian health care management a detailed compilation and testing of the knowledge and skill attributes considered necessary for adequate field practice in Canadian health care administration. The project demonstrated an improved model for professional competence identification. The first step was to identify the level of professional targeted for competence assessment. Then a representative expert committee was to return to the field to examine the range of jobs done by those target individuals. This expert committee collected lists of elements from the tasks done in these target positions and then organized the elements into mutually exclusive groupings. Finally a stratified random sample of field practitioners was asked to rate the importance of these elements for competent job performance.

Physicians' participation in establishing criteria for hypertension management in the office: will patient outcomes be improved?

We designed this study to determine whether an intensive 1-day educational workshop involving family physicians in establishing essential criteria for hypertension management would significantly affect the short-term outcomes of hypertensive patients in their practices. Forty randomly selected physicians were separated into three groups: those who would be involved in establishing the criteria (15), those who would receive the criteria by mail (15) and those who would act as controls and not be aware of the criteria (10). We found no significant difference between the three groups in the number of hypertensive patients whose condition remained uncontrolled after the intervention. We conclude that physicians' participation in the establishment of standards of care for conditions such as hypertension or their awareness of such standards does not independently result in significantly better patient outcomes. Consequently, we recommend that physicians and health care planners concerned with improving outcomes not rely on any single intervention strategy when planning change.

Expectant management of abruptio placentae before 35 weeks gestation

Forty-three patients with abruptio placentae before 35 weeks of pregnancy were managed expectantly with observation or with tocolytic therapy when contractions were present. Mean time to delivery was 12.4 days. Twenty-three patients were delivered within 1 week of admission. In the remaining 20 patients, the mean time to delivery was 26.8 days. There were no intrauterine deaths. In properly selected patients with preterm gestation and low-grade abruptio it is reasonable to defer delivery. These patients must be followed closely with antepartum fetal heart rate monitoring, serial hematologic and coagulation profiles, and serial sonograms when indicated.

Effects of training in cardiopulmonary resuscitation on competence and patient outcome

Between 1981 and 1985 we carried out a study in two medium-sized nonteaching community hospitals to determine the rate of deterioration of knowledge and skills in cardiopulmonary resuscitation (CPR) among physicians and nurses, the accuracy of their perceptions of their knowledge and skills, the effects of practice on retention and the effect of CPR training on mortality. The participants' knowledge and skills were measured before training and immediately after, 6 months after and 12 months after training. Information on all attempts at CPR involving hospital staff was collected from medical records and from interviews with the participants. A total of 31 physicians and 54 nurses were followed during the study. Six months after training there was no difference in CPR knowledge or skills between the physicians and the nurses. In both groups CPR skills had deteriorated to near pretraining levels. By 6 months the physicians' knowledge had deteriorated to a level not significantly different from that before training. The nurses maintained a significant improvement in knowledge test scores at 12 months over those before training (p = 0.037). The physicians had an accurate perception of their knowledge but not their skills 6 months and 12 months after training, whereas the nurses did not accurately perceive either their knowledge or their skills after training. Experience with CPR did not contribute to post-training knowledge or skills in either group. There was no evidence that death rates were lower when basic life support (BLS) was begun by trained staff than when it was begun by untrained staff. The probability of survival was greater when BLS was begun within 4 minutes of arrest than when it was begun after 4 minutes, regardless of whether advanced cardiac life support was begun within 10 minutes.

Is there a problem with benzodiazepine prescribing in maritime Canada?

The benzodiazepine prescribing habits of 64 maritime doctors were studied through collection and examination of carbon copies of all prescriptions over a 22 week period. Diazepam was the most frequently prescribed anxiolytic benzodiazepine, followed by chlordiazepoxide, then oxazepam. These three drugs accounted for almost 60% of all benzodiazepine prescriptions. Triazolam and flurazepam were prescribed eight times more frequently than the other hypnotics, nitrazepam and temazepam. The number of prescriptions judged to be inappropriately excessive was small (3.3% of 7,066). Efforts by drug manufacturers, pharmaceutical sales representatives and CME providers are needed to make the practicing physician aware of the phamacokinetics of the different benzodiazepines, so that an appropriate choice of drug and frequency of daily doses can be made.

Postgraduate training route and content of subsequent practice

This study compared the practices of family medicine residency graduates with those of graduates from rotating internship programs. Proportions of medical services billed to the provincial government in each of 15 service classes formed the data base. No significant differences were observed between the groups in general, across groups for any class of medical services. Although the two groups appear to provide the same services, these results do not indicate that the two groups perform in the same manner or with the same results. Practice content, however, appears to be patient dictated rather than physician dictated. The issue is not, then, which training is better, but rather, are any of the present routes adequate.

Filing reprints: can office staff help?

Filing systems for reprints must be tailored to the individual's practice profile, to maximize usefulness as a resource for clinical problem solving. However, the clerical time involved often reduces the physician's ability to maintain such a filing system. The authors tested two hypotheses that using the International Classification of Health Problems in Primary Care (ICHPPC) nurses or receptionists could code, cross reference and file reprints after the physician has selected the articles. Contents pages of five primary care journals were given to two academic family physicians, two practicing physicians, a research assistant and two receptionists, one of whom had used ICHPPC to record patient encounters. All coders except the second receptionist, who was unfamiliar with ICHPPC, reached good agreement in coding. Filing reprints may therefore be done by trained staff for groups of physicians.

Impact of patient care appraisal on physician behaviour in the office setting

The effect of patient care appraisal on physicians' management of patients' problems was assessed. Sixteen family physicians were involved. The eight in the experimental group helped in the selection of two of the five disease conditions to be audited and in the generation of optimal criteria of care for two of the conditions. Participation in the generation of optimal criteria was followed by a significant improvement in the physicians' behaviour, but involvement in the selection of the conditions to be audited caused no change. The patient care appraisal did not lead to significant improvement of physicians' management of the conditions. In a second analysis, in which only essential criteria of care were considered, the physicians who participated in the patient care appraisal significantly improved their management of patients' problems. However, participation in the selection of the conditions and in the generation of the criteria of care had no effect on their performance. Patient care appraisal is an effective tool in continuing medical education and leads to improvement in the quality of care, provided the process focuses on essential criteria of care.

Do family physicians differ from specialists? A particular care in continuing medical education patterns

This study contrasts specialists with family physicians in use, preference for and perceived effectiveness of different CME methods. Results indicate that FPs differ substantially from specialists in their CME choices. CME providers can utilize the patterns reported here in designing continuing education programs to match more specifically the learning habits of their clients. Individual physicians can also plan their CME choices in the light of these differences.

Computerization of undergraduate medical curriculum content

A method is reported for the computerized storage and retrieval of informative summaries of the didactic portion of the first 3 years of the medical undergraduate curriculum utilizing the MICOM word processor and SORT 200 program with disc storage. Each lecture, small group session, laboratory or clinical experience summary is assigned a page of computer memory and is coded in the header line for various indices describing the session format, location, audiovisual usage, teacher and other demographics. The second line contains the lecture title and its situation within the teaching block. A summary of the teaching session follows. This was compiled and distilled from summaries prepared by the individual teachers, lecture handouts and the personal notes of the two medical students who divided the lectures equally between themselves and prepared individual summaries which were then exchanged. The resulting composite summary was returned to the teacher for comment and/or modification before entry onto the MICOM word processor. The SORT 2000 program permits search, selection and retrieval of the content of each teaching session from the data contained in the header line or any word, word segment or phase occurring in the summary. Reproduction of the data discs facilitates multiple access and allows each department or teaching block to review the complete curriculum quickly, identify redundancies and more fully integrate new or existing material.

Physicians' and nurses' retention of knowledge and skill after training in cardiopulmonary resuscitation

Physicians and nurses in a community hospital who successfully completed the standard 1-day training program in basic life support cardiopulmonary resuscitation (CPR) were retested 6 and 12 months after training. Their perceptions of their knowledge of and skill in CPR were recorded along with an account of the roles they had taken in CPR incidents. The physicians and nurses initially had the same level of knowledge of CPR, but the physicians learned significantly more and retained it longer. After training, the nurses participated much more in CPR incidents, limiting themselves to basic life support functions. The physicians' participation, however, remained at about the same level and was limited to advanced life support functions. By 12 months after training the scores in both groups were similar to the pretraining scores, which suggests that practice with feedback is necessary during the 1-year period before retraining and recertification. It may be that the two groups require different training programs.

Physician practice profiles for CME: four investigations into sampling methods

Sampling physicians' patient contacts to produce a practice profile forms the basis of three present individualized CME programs. The practical and statistical adequacy of these sampling procedures was examined and found to be seriously lacking. Samples were compared to a 6-month continuously coded data base on 16 family physicians. Following analysis of the 6-month data base for significant sources of variance, two new sampling procedures were proposed and tested against a 12-month continuously coded data base. Results indicate both practical acceptability and adequate representation by these two sampling procedures.

Patterns of intellectual deficit in Huntington's disease

The study investigated patterns of intellectual deficit in 13 patients with recently diagnosed Huntington's disease (mean duration of 2.3 years) and 46 offspring "at risk" for the illness using the Wechsler Adult Intelligence Scale (WAIS). The results support the idea that certain cognitive skills remain relatively intact at early stages of the disease while other skills are impaired. A consistent pattern of impairment was observed in the patient group which included the Arithmetic, Digit Span, Digit Symbol, and Picture Arrangement subtests. The most striking result was a demonstration of significantly increased variability among the "at risk" population of the Digit Span and Picture Arrangement subtests. These findings suggest that the WAIS may be a useful adjunct to neurological diagnosis for longitudinal monitoring of intellectual changes even at very early stages of the illness.

The content of family practice: do we need more studies?

Having an accurate job description of family physicians is important to a number of audiences. There is a tendency to produce another content profile of family practice in response to every specific request for an accurate job description, rather than examining the existing profiles. We analyzed the amount of similarity and therefore redundancy in currently available profiles of family practice. Our findings indicate remarkable consistency across profile studies. We conclude that there is no need to continue producing profiles of family practice unless something significant occurs in the medical environment to suggest there might be a change in the profile.