The role of collegial interaction in continuing professional development

Barriers and Facilitators to the Implementation and Adoption of a Continuous Quality Improvement Program in Surgery: A Case Study

INTRODUCTION

As postoperative adverse events (AEs) drive worsened patient experience, longer length of stay, and increased costs of care, surgeons have long sought to engage in innovative approaches aimed at reducing AEs to improve the quality and safety of surgical care. While data-driven AE performance measurement and feedback (PMF) as a form of continuing professional development (CPD) has been presented as a possible approach to continuous quality improvement (CQI), little is known about the barriers and facilitators that influence surgeons' engagement and uptake of these CPD programs. The purpose of this knowledge translation informed CPD study was to examine surgeons' perspectives of the challenges and facilitators to participating in surgical CQI with the broader objective of enhancing future improvements of such CPD interventions.

METHODS

Using Everett Rogers diffusion of innovations framework as a sampling frame, the participants were recruited across five surgical divisions. An exploratory case study approach, including in-depth semistructured interviews, was employed. Interview transcripts were analyzed and directly coded using the Theoretical Domains Framework.

RESULTS

Directed coding yielded a total of 527 coded barriers and facilitators to behavior change pertaining to the implementation and adoption of PMF with the majority of barriers and facilitators coded in four key theoretical domains environmental context and resources, social influences, knowledge, and beliefs about consequences. A key barrier was the lack of support from the hospital necessitating surgeons' self-funding their own PMF programs. Facilitators included having a champion to drive CQI and using seminars to facilitate discussions around CQI principles and practices.

DISCUSSION

This study identified multiple barriers and facilitators to surgeons' engagement and uptake of a data-driven PMF system in surgery. A key finding of the study was the identification of the influential role of positive deviance seminars as a quality improvement and patient safety mechanism that encourages surgeon engagement in PMF systems.

Continuing Medical Education and Lifelong Learning

Continuing medical education is an ongoing process to educate clinicians and provide patients with up-to-date, evidence-based care. Since its inception, the maintenance of certification (MOC) program has changed dramatically. This article reviews the development of MOC and its integration with the 6 core competencies, including the practice-based learning and improvement cycle. The concept of lifelong learning is discussed, with specific focus on different methods for surgeons to engage in learning, including simulation, coaching, and communities of practice. In addition, the future of MOC in continuous professional development is reviewed.

Interventions to improve the well-being of medical learners in Canada: a scoping review

BACKGROUND

Medical education affects learner well-being. We explored the breadth and depth of interventions to improve the well-being of medical learners in Canada.

METHODS

We searched MEDLINE, EMBASE, CINAHL and PsycINFO from inception to July 11, 2020, using the Arksey-O'Malley, 5-stage, scoping review method. We included interventions to improve well-being across 5 wellness domains (i.e., social, mental, physical, intellectual, occupational) for medical learners in Canada, grouped as undergraduate or graduate nonmedical (i.e., health sciences) students, undergraduate medical students or postgraduate medical students (i.e., residents). We categorized interventions as targeting the individual (learner), program (i.e., in which learners are enrolled) or system (i.e., higher education or health care) levels.

RESULTS

Of 1753 studies identified, we included 65 interventions that aimed to improve well-being in 10 202 medical learners, published from 1972 through 2020; 52 (80%) were uncontrolled trials. The median year for intervention implementation was 2010 (range 1971-2018) and the median length was 3 months (range 1 h-48 mo). Most (n = 34, 52%) interventions were implemented with undergraduate medical students. Two interventions included only undergraduate, nonmedical students; none included graduate nonmedical students. Most studies (n = 51, 78%) targeted intellectual well-being, followed by occupational (n = 32, 49%) and social (n = 17, 26%) well-being. Among 19 interventions implemented for individuals, 14 (74%) were for medical students; of the 27 program-level interventions, 17 (63%) were for resident physicians. Most (n = 58, 89%) interventions reported positive well-being outcomes.

INTERPRETATION

Many Canadian medical schools address intellectual, occupational and social well-being by targeting interventions at medical learners. Important emphasis on the mental and physical well-being of medical learners in Canada warrants further exploration.

Optimization of transmural care by implementation of an online expert panel to assess treatment strategy in patients suffering from colorectal cancer liver metastases: A prospective analysis

INTRODUCTION

Centralization of oncological care results in a growing demand for specialized consultations and referrals. Improved telemedicine solutions are needed to facilitate access to specialist care and select patients eligible for referral. The purpose of this quality improvement initiative was to optimize transmural care for patients suffering from colorectal cancer liver metastases through implementation of an online expert panel.

METHODS

A digital communication platform was developed to share medical data, including high-quality diagnostic imaging of patients suffering from colorectal cancer liver metastases. Feasibility of local treatment strategies was assessed by a panel of liver specialists to select patients for referral. After implementation, an observational cohort study was conducted to evaluate quality improvement in transmural care using revised Standards for Quality Improvement Reporting Excellence guidelines.

RESULTS

From September 2016-September 2018, eight hospitals were connected to the platform, covering a population of 3 m. In total, 123 cases were assessed, of which 54 (43.9%) were prevented from needless physical referral. Assessment of treatment strategy by an online expert panel significantly reduced the average lead time during multidisciplinary team meetings from 3.73 min to 2.12 min per patient (p < 0.01).

CONCLUSIONS

Implementation of an online expert panel is an innovative, accessible and user-friendly way to provide cancer-specific expertise to regional hospitals. E-consultation of such panels may result in more efficient multidisciplinary team meetings and prevent fragile patients from needless referral. Sustainability of these panels however is subject to structural financial compensation, so a cost-effectiveness analysis is warranted.

An Examination of Self-Reported Assessment Activities Documented by Specialist Physicians for Maintenance of Certification

INTRODUCTION

Specialists in a Maintenance of Certification program are required to participate in assessment activities, such as chart audit, simulation, knowledge assessment, and multisource feedback. This study examined data from five different specialties to identify variation in participation in assessment activities, examine differences in the learning stimulated by assessment, assess the frequency and type of planned changes, and assess the association between learning, discussion, and planned changes.

METHODS

E-portfolio data were categorized and analyzed descriptively. Chi-squared tests examined associations.

RESULTS

A total of 2854 anatomical pathologists, cardiologists, gastroenterologists, ophthalmologists, and orthopedic surgeons provided data about 6063 assessment activities. Although there were differences in the role that learning played by discipline and assessment type, the most common activities documented across all specialties were self-assessment programs (n = 2122), feedback on teaching (n = 1078), personal practice assessments which the physician did themselves (n = 751), annual reviews (n = 682), and reviews by third parties (n = 661). Learning occurred for 93% of the activities and was associated with change. For 2126 activities, there were planned changes. Activities in which there was a discussion with a peer or supervisor were more likely to result in a change.

CONCLUSIONS AND DISCUSSION

Although specialists engaged in many types of assessment activities to meet the Maintenance of Certification program requirements, there was variability in how assessment stimulated learning and planned changes. It seems that peer discussion may be an important component in fostering practice change and forming plans for improvement which bears further study.

Collective intelligence in medical decision-making: a systematic scoping review

BACKGROUND

Collective intelligence, facilitated by information technology or manual techniques, refers to the collective insight of groups working on a task and has the potential to generate more accurate information or decisions than individuals can make alone. This concept is gaining traction in healthcare and has potential in enhancing diagnostic accuracy. We aim to characterize the current state of research with respect to collective intelligence in medical decision-making and describe a framework for diverse studies in this topic.

METHODS

For this systematic scoping review, we conducted a systematic search for published literature using PubMed, Embase, Web of Science, and CINAHL on August 8, 2017. We included studies that combined the insights of two or more medical experts to make decisions related to patient care. Studies that examined medical decisions such as diagnosis, treatment, and management in the context of an actual or theoretical patient case were included. We include studies of complex medical decision-making rather than identification of a visual finding, as in radiology or pathology. We differentiate between medical decisions, in which synthesis of multiple types of information is required over time, and studies of radiological scans or pathological specimens, in which objective identification of a visual finding is performed. Two reviewers performed article screening, data extraction, and final inclusion for analysis.

RESULTS

Of 3303 original articles, 15 were included. Each study examined the medical decisions of two or more individuals; however, studies were heterogeneous in their methods and outcomes. We present a framework to characterize these diverse studies, and future investigations, based on how they operationalize collective intelligence for medical decision-making: 1) how the initial decision task was completed (group vs. individual), 2) how opinions were synthesized (information technology vs. manual vs. in-person), and 3) the availability of collective intelligence to participants.

DISCUSSION

Collective intelligence in medical decision-making is gaining popularity to advance medical decision-making and holds promise to improve patient outcomes. However, heterogeneous methods and outcomes make it difficult to assess the utility of collective intelligence approaches across settings and studies. A better understanding of collective intelligence and its applications to medicine may improve medical decision-making.

The Development of Practice Guidelines for a Palliative Care Multidisciplinary Case Conference

CONTEXT

In Ontario, we identified that few hospitals have developed multi-disciplinary case conferences or forums for discussion of patients with palliative care issues.

OBJECTIVE

We describe the process of creating a province-wide standards document for palliative care multidisciplinary case conferences (pMCCs).

METHODS

A provincial survey and a multidisciplinary cancer conference symposium identified pMCCs as a priority. A literature search focusing on pMCCs and their implementation was completed as well as a current state assessment (survey and interviews) to understand challenges with existing pMCCs in Ontario. A working group was then assembled to draft a recommendation report that was finalized by an expert panel.

RESULTS

A total of 22 articles were identified and 10 were used by the working group to create a framework for the pMCC guideline. The current state assessment identified substantial variability in pMCC structure and function. The expert panel made recommendations about meeting format (multidisciplinary discussion encouraged), frequency (at least every two weeks), type of cases to present, attendees (palliative care, nursing, primary care, social work, and community nursing), provider roles and responsibilities, and institutional requirements (pMCC coordinator, meeting room and videoconference capability). All patients (not just those with cancer) with palliative care needs were to be discussed at the pMCC, and pMCCs should serve as a crucial link between the hospital and community.

CONCLUSION

We have described the process of creating the first pMCC guideline. A key component of this guideline is that pMCCs should serve as a link between the hospital and community.

Paediatric tumour boards in Spain: a national survey

PURPOSE

Multidisciplinary tumour boards (MDTs) are conducted worldwide for the management of patients with cancer, and they deliver a higher standard of care by simultaneously involving different specialists in diagnosis and treatment planning. However, information of paediatric MDTs functioning is scarce. A pilot study was conducted in Spain in the frame of the European Expert Paediatric Oncology Reference Network for Diagnostics and Treatment (ExPO-r-Net).

METHODS

A specific questionnaire was designed regarding various features of MDT practice. Data collected included information on the centres and the team, infrastructure for meetings, MDT organization/logistics and clinical decision-making. The survey was distributed to all Paediatric Oncology Units that register patients in the Spanish Registry of Childhood Tumours (RETI-SEHOP).

RESULTS

32 out of 43 contacted centres responded the questionnaire (74 % response rate; 88 % response rate for centres with >25 new patients/year). All units with >25 new patients/year have a dedicated Paediatric MDT compared to 76 % of units with ≤25 new patients/year. MDTs should be improved at institutional level by clear protected time in service planning for all specialists involved, incentives for attendance and attendance registration. Clinical decision-making process and follow-up of recommendation adherence should be assessed and potential legal responsibilities for physicians participating in Tumour Board defined. Network collaboration through virtual MDTs, using available videoconferencing tools, is an opportunity to share expertise among centres.

Using Surgeon-Specific Outcome Reports and Positive Deviance for Continuous Quality Improvement

BACKGROUND

Using the thoracic morbidity and mortality classification to document all postoperative adverse events between October 2012 and February 2014, we created surgeon-specific outcome reports (SSORs) to promote self-assessment and to implement a divisional continuous quality improvement (CQI) program, on the construct of positive deviance, to improve individual surgeon's clinical performance.

METHODS

Mixed-methods study within a division of six thoracic surgeons, involving (1) development of real-time, Web-based, risk-adjusted SSORs; (2) implementation of CQI seminars (n = 6; September 2013 to June 2014) for evaluation of results, collegial discussion on quality improvement based on identification of positive outliers, and selection of quality indicators for future discussion; and (3) in-person interviews to identify facilitators and barriers to using SSORs and CQI. Interview transcripts were analyzed using thematic analysis.

RESULTS

Interviews revealed enthusiastic support for SSORs as a means to improve patient care through awareness of personal outcomes with blinded divisional comparison for similar operations and diseases, and apply the learning objectives to continuous professional development and maintenance of certification. Perceived limitations of SSORs included difficulty measuring surgeon expertise, limited understanding of risk adjustment, resistance to change, and belief that knowledge of sensitive data could lead to punitive actions. All surgeons believed CQI seminars led to collegial discussions, whereas perceived limitations included quorum participation and failing to circle back on actionable items.

CONCLUSIONS

Real-time performance feedback using SSORs can motivate surgeons to improve their practice, and CQI seminars offer the opportunity to review and interpret results and address issues in a supportive environment. Whether SSORs and CQI can lead to improvements in rates of postoperative adverse events is a matter of ongoing research.

Being a surgeon--the myth and the reality: a meta-synthesis of surgeons' perspectives about factors affecting their practice and well-being

OBJECTIVES

Synthesize the findings from individual qualitative studies about surgeons' account of their practice.

BACKGROUND

Social and contextual factors of practice influence doctors' well-being and therapeutic relationships. Little is known about surgery, but it is generally assumed that surgeons are not affected by them.

METHODS

We searched international publications (2000-2012) to identify relevant qualitative research exploring how surgeons talk about their practice. Meta-ethnography (a systematic analysis of qualitative literature that compensates for the potential lack of generalizability of the primary studies and provides new insight by their conjoint interpretation) was used to identify key themes and synthesize them.

RESULTS

We identified 51 articles (>1000 surgeons) from different specialties and countries. Two main themes emerged. (i) The patient-surgeon relationship, described surgeons' characterizations of their relationships with patients. We identified factors influencing surgical decision making, communication, and personal involvement in the process of care; these were surgeon-related, patient-related, and contextual. (ii) Group relations and culture described perceived issues related to surgical culture (image and education, teamwork, rules, and guidelines); it highlighted the influence of a social dimension on surgical practice. In both themes, we uncovered an emotional dimension of surgeons' practice.

CONCLUSIONS

Surgeons' emphasis on technical aspects, individuality, and performance seems to impede a modern patient-centered approach to care and to act as a barrier to well-being. Our findings suggest that taking into account the relational and emotional dimensions of surgical practice (both with patients and within the institution) might improve surgical innovation, surgeons' well-being, and the attractiveness of this specialty.

Multidisciplinary cancer care: does it improve outcomes?

Multidisciplinary care has been advocated as a solution for increasingly complex treatment decisions in cancer patients. The impact of multidisciplinary care on patient survival has been studied, but evidence is limited by poor methodological quality. Lack of conclusive evidence for increased survival is balanced against improvements in quality of care, guideline adherence, reduction in wait times, and greater satisfaction for patients and care providers.

Assessing the feasibility of a virtual tumor board program: a case study

Multidisciplinary tumor boards involve various providers (e.g., oncology physicians, nurses) in patient care. Although many community hospitals have local tumor boards that review all types of cases, numerous providers, particularly in rural areas and smaller institutions, still lack access to tumor boards specializing in a particular type of cancer (e.g., hematologic). Videoconferencing technology can connect providers across geographic locations and institutions; however, virtual tumor board (VTB) programs using this technology are uncommon. In this study, we evaluated the feasibility of a new VTB program at the University of North Carolina (UNC) Lineberger Comprehensive Cancer Center, which connects community-based clinicians to UNC tumor boards representing different cancer types. Methods included observations, interviews, and surveys. Our findings suggest that participants were generally satisfied with the VTB. Cases presented to the VTB were appropriate, sufficient information was available for discussion, and technology problems were uncommon. UNC clinicians viewed the VTB as a service to patients and colleagues and an opportunity for clinical trial recruitment. Community-based clinicians presenting at VTBs valued the discussion, even if it simply confirmed their original treatment plan or did not yield consensus recommendations. Barriers to participation for community-based clinicians included timing of the VTB and lack of reimbursement. To maximize benefits of the VTB, these barriers should be addressed, scheduling and preparation processes optimized, and appropriate measures for evaluating impact identified.

Eastern Canadian Colorectal Cancer Consensus Conference: standards of care for the treatment of patients with rectal, pancreatic, and gastrointestinal stromal tumours and pancreatic neuroendocrine tumours

The annual Eastern Canadian Colorectal Cancer Consensus Conference was held in Halifax, Nova Scotia, October 20-22, 2011. Health care professionals involved in the care of patients with colorectal cancer participated in presentation and discussion sessions for the purposes of developing the recommendations presented here. This consensus statement addresses current issues in the management of rectal cancer, including pathology reporting, neoadjuvant systemic and radiation therapy, surgical techniques, and palliative care of rectal cancer patients. Other topics discussed include multidisciplinary cancer conferences, treatment of gastrointestinal stromal tumours and pancreatic neuroendocrine tumours, the use of folfirinox in pancreatic cancer, and treatment of stage ii colon cancer.

[Conditions of decision making of admission or non-admission in surgical intensive care unit]

OBJECTIVES

To describe the condition of the decision-making of admission and non-admission in intensive care unit.

STUDY DESIGN

Non-interventional observational cohort.

PATIENTS AND METHODS

Retrospective analysis of declarative terms of decision-making of patients admitted or denied in a surgical intensive care unit. The decision-making in the two admitted or not admitted troops was compared.

RESULTS

That it is during a non-admission (149 decisions) or of an admission (149 decisions), the decision-making process was not very different. The instruction of the files was regarded as collegial in nearly 80% of the cases by the intensivist in load. The dialogue precedent the decision utilized generally several speakers but who could be residents. The participation of the patient and/or his close relations, as that of the ancillary medical personnel was rare. No person of confidence or anticipated directive was quoted. More than 50% of the decisions were taken within a time lower than 30 minutes. The decisions of non-admission were considered to be more difficult than the decisions of admission. Traceability was not automatically given.

CONCLUSION

Thus, this study shows that in its current form the intensivists of the service estimate that in the majority of the cases the instruction of the files was collegial. However, the conditions of seniorisation of the decision, the collection of opinion of the patient and/or his close relations and the traceability are tracks of improvement to be implemented in certain circumstances of admission or non-admission.

Critically reflective work behavior of health care professionals

INTRODUCTION

Better understanding of critically reflective work behavior (CRWB), an approach for work-related informal learning, is important in order to gain more profound insight in the continuing development of health care professionals.

METHODS

A survey, developed to measure CRWB and its predictors, was distributed to veterinary professionals. The authors specified a model relating CRWB to a Perceived Need for Lifelong Learning, Perceived Workload, and Opportunities for Feedback. Furthermore, research utilization was added to the concept of CRWB. The model was tested against the data, using structural equation modeling (SEM).

RESULTS

The model was well represented by the data. Four factors that reflect aspects of CRWB were distinguished: (1) individual CRWB; (2) being critical in interactions with others; (3) cross-checking of information; and (4) openness to new findings. The latter 2 originated from the factor research utilization in CRWB. The Perceived Need for Lifelong Learning predicts CRWB. Neither Perceived Workload nor Opportunities for Feedback of other practitioners was related to CRWB.

DISCUSSION

The results suggest that research utilization, such as cross-checking information and openness to new findings, is essential for CRWB. Furthermore, perceptions of the need for lifelong learning are more relevant for CRWB of health care professionals than qualities of the workplace.

Evidence-based medicine training and implementation in surgery: the role of surgical cultures

PURPOSE

This qualitative study identifies cultural factors that influence the effective implementation of evidence-based medicine (EBM) in surgical practice among Australian surgeons.

METHODS

In-depth interviews (n = 22) were conducted with surgeons from a variety of specialties within a large hospital system in Victoria, Australia. The interviews explored the surgeons' understanding of EBM; and challenges to the adoption of EBM. The canons and procedures of the Miles and Huberman's Matrix Analyses approach to qualitative research guided the coding and organization of the data derived from the semi-structured interviews.

RESULTS

Surgeons had a good understanding of EBM, but viewed it as little more than a system of evidence, which was often divorced from actual clinical practice. The data also suggested that surgical culture(s) and typologies of surgical style were important variables in the implementation of EBM. The results suggest that the ideal method of EBM implementation is workplace instruction led by surgeons, who exhibit scientist and/or clinician styles of surgical practice; EBM training should occur early in the surgeons' careers; and EBM practice should be role modelled in the presence of trainees by surgeons who exhibit either a scientist and/or clinician style of surgical practice.

CONCLUSIONS

The study findings suggest that using pre-existing surgical culture(s) and styles is an important component in the implementation of EBM in surgery. The effective use of the scientist and/or clinician surgeon within the apprenticeship model and the context-specific collegial networks of the surgical profession appear to be key elements in ensuring the successful implementation of EBM in surgery.

Role of telehealth/videoconferencing in managing cancer pain in rural American Indian communities

OBJECTIVES

This project is aimed at determining the feasibility and effect of using videoconferencing to deliver cancer-related pain management education and case consultation to health care providers in rural AI/AN communities.

METHODS

The project provided four educational sessions and nine case conferences to health care providers at tribal clinics in Washington State and Alaska using videoconferencing with pain experts at the University of Washington. A cross-sectional, descriptive study design was used to survey the participating providers. Measures included satisfaction with the telehealth system and self-perceived competence in pain management.

RESULTS

Fifty-two providers from 11 sites attended the educational sessions. Ninety-three providers from 16 sites participated in the case conferences. Case conference participants scored significantly higher on perceived competence in treating pain compared with clinic providers who did not attend. Educational session participants and case conference participants both reported a high level of satisfaction with videoconferencing.

CONCLUSIONS

Telehealth is a feasible and effective way to deliver cancer-related pain management education and increase competence among rural health care providers.

Exploratory evaluation of surgical skills mentorship program design and outcomes

INTRODUCTION

There are few opportunities for mentorship of practicing surgeons and no evidence to guide the design of such programs. This study explored outcomes and barriers associated with the design of surgical mentorship programs.

METHODS

Interviews were held with organizers, mentors, and protégés of 2 programs. Data from 23 participant interviews and 23 nonparticipant surveys were analyzed thematically.

RESULTS

Participation was greater in the program where planning was participatory and mentors visited protégés. Scheduling was a key barrier, and existing relationships enabled mentorship. Most nonparticipants said they were already trained or had no interest in the skill. Mentorship was valued for exchange of tacit knowledge, hands-on learning, and real-time feedback. Mentorship prompted participants to realize gaps in skill; several said they already adopted the new skill, and many were interested in ongoing mentorship.

DISCUSSION

Several beneficial outcomes appear to be associated with mentorship, but longitudinal evaluation is required. Telementoring and train-the-trainer models may promote participation in surgical mentorship. Participants suggested that technical training be integrated within pre- and postmentorship education and follow-up. Such programs can only be implemented if issues of sponsorship and funding are addressed.

Self-directed learning needs, patterns, and outcomes among general surgeons

INTRODUCTION

To explore the relationship between self-directed learning (SDL) needs, patterns, barriers, and outcomes among nonacademic general surgeons.

METHODS

Participants dictated details of SDL episodes associated with cancer patient management from October 2007 to March 2008. Transcripts were coded thematically. Frequencies were calculated for elements of each SDL stage. Statistical significance among subgroups was established with the use of the Pearson chi-square test, adjusted for clustering by surgeon. Participants were interviewed by telephone, and transcripts were analyzed by qualitative methods.

RESULTS

Of 21 consenting surgeons, 15 submitted 115 cases, and 108 were analyzed. Most involved breast (40.7%), colon (18.5%), or rectal cancer (13.0%); 2 or more clinical tasks (41.7%); and 2 or more questions (89.8%). Information was sought from the Internet (48.1%), colleagues (24.2%), or both (6.8%). Information was partially, or not relevant for 21.3% of cases. Evidence was new for 66.7%, and confirmed knowledge for 10.7% of cases. Learning helped surgeons formulate new (34.2%), or confirm original (16.5%) management plans, or determine that referral was appropriate (39.2%). Use of codified sources was associated with information retrieval (P < .05), and identifying new evidence leading to a change in management from that initially proposed (P < or = .001).

DISCUSSION

Numerous individual and systemic barriers may prevent practicing physicians from undertaking SDL, but provision of structured guidance prompted SDL and resulted in several beneficial outcomes. Further research is needed to validate these findings, and investigate who should support SDL, and how.

Challenges in multidisciplinary cancer care among general surgeons in Canada

Background

While many factors can influence the way that cancer care is delivered, including the way that evidence is packaged and disseminated, little research has evaluated how health care professionals who manage cancer patients seek and use this information to identify whether and how this could be supported. Through interviews we identified that general surgeons experience challenges in coordinating care for complex cancer patients whose management is not easily addressed by guidelines, and conducted a population-based survey of general surgeon information needs and information seeking practices to extend these findings.

Methods

General surgeons with privileges at acute care hospitals in Ontario, Canada were mailed a questionnaire to solicit information needs (task, importance), information seeking (source, frequency of and reasons for use), key challenges and suggested solutions. Non-responders received up to three reminder packages. Significant differences among sub-groups (age, setting) were examined statistically (Kruskal Wallis, Mann Whitney, Chi Square). Standard qualitative methods were used to thematically analyze open-ended responses.

Results

The response rate was 44.2% (170/385) representing all 14 health regions. System resource constraints (60.4%), comorbidities (56.4%) and physiologic factors (51.8%) were top-ranked issues creating information needs. Local surgical colleagues (84.6%), other local colleagues (82.2%) and the Internet (81.1%) were top-ranked sources of information, primarily due to familiarity and speed of access. No resources were considered to be highly applicable to patient care. Challenges were related to limitations in diagnostics and staging, operative resources, and systems to support multidisciplinary care, together accounting for 76.0% of all reported issues. Findings did not differ significantly by surgeon age or setting of care.

Conclusion

General surgeons appear to use a wide range of information resources but they may not address the complex needs of many cancer patients. Decision-making is challenged by informational and logistical issues related to the coordination of multidisciplinary care. This suggests that limitations in system capacity may, in part, contribute to variable guideline compliance. Further research is required to evaluate the appropriateness of information seeking, and both concurrent and consecutive mechanisms by which to achieve multidisciplinary care.

Predictors of multivisceral resection in patients with locally advanced colorectal cancer

BACKGROUND

Practice guidelines recommend en bloc multivisceral resection (MVR) for all involved organs in patients with locally advanced adherent colorectal cancer (LAACRC) to reduce local recurrence and improve survival. We found that MVR was performed in one-third of eligible American patients in the Surveillance, Epidemiology and End Results cancer registry but that study could not identify factors amenable to quality improvement. This study was conducted to examine rates, and predictors of MVR among Canadian patients with LAACRC.

METHODS

Rates of MVR were examined by observational study. Eligible patients were aged 20-74 years who had surgery for nonmetastatic LAACRC from July 1997 to December 2000. Patient, tumor, surgeon, and hospital characteristics were extracted from medical records. Summary statistics were compared by type of surgery (MVR, partial MVR, standard resection). To identify factors associated with MVR we analyzed operative notes and transcripts from interviews with general surgeons using standard qualitative methods.

RESULTS

Factors associated with MVR included fewer years in practice, preoperative treatment planning, involvement of surgical consultants, and access to diagnostic imaging and systems to enable preoperative multidisciplinary planning. Judgments regarding the nature of peritumoral adhesions, resectability, and personal technical skill may mediate decision-making. Many surgeons would prefer to refer patients than undertake complicated, lengthy cases.

CONCLUSION

Further research is required to validate these findings in larger studies and among patients undergoing surgery for conditions other than LAACRC, and evaluate strategies to improve rates of MVR through enhanced individual awareness and system capacity.