The impact of CME on physician performance and patient health outcomes: an updated synthesis of systematic reviews

High-Dose Opioid Prescribing in Individuals with Acute Pain: Assessing the Effects of US State Opioid Policies

BACKGROUND

How state opioid policy environments with multiple concurrent policies affect opioid prescribing to individuals with acute pain is unknown.

OBJECTIVE

To examine how prescription drug monitoring programs (PDMPs), pain management clinic regulations, initial prescription duration limits, and mandatory continued medical education affected total and high-dose prescribing.

DESIGN

A county-level multiple-policy difference-in-difference event study framework.

SUBJECTS

A total of 2,425,643 individuals in a large national commercial insurance deidentified claims database (aged 12-64 years) with acute pain diagnoses and opioid prescriptions from 2007 to 2019.

MAIN MEASURES

The total number of acute pain opioid treatment episodes and number of episodes containing high-dose (> 90 morphine equivalent daily dosage (MEDD)) prescriptions.

KEY RESULTS

Approximately 7.5% of acute pain episodes were categorized as high-dose episodes. Prescription duration limits were associated with increases in the number of total episodes; no other policy was found to have a significant impact. Beginning five quarters after implementation, counties in states with pain management clinic regulations experienced a sustained 50% relative decline in the number of episodes containing > 90 MEDD prescriptions (95 CIs: (Q5: - 0.506, - 0.144; Q12: - 1.000, - 0.290)). Mandated continuing medical education regarding the treatment of pain was associated with a 50-75% relative increase in number of high-dose episodes following the first year-and-a-half of enactment (95 CIs: (Q7: 0.351, 0.869; Q12: 0.413, 1.107)). Initial prescription duration limits were associated with an initial relative reduction of 25% in high-dose prescribing, with the effect increasing over time (95 CI: (Q12: - 0.967, - 0.335). There was no evidence that PDMPs affected high-dose opioids dispensed to individuals with acute pain. Other high-risk prescribing indicators were explored as well; no consistent policy impacts were found.

CONCLUSIONS

State opioid policies may have differential effects on high-dose opioid dispensing in individuals with acute pain. Policymakers should consider effectiveness of individual policies in the presence of other opioid policies to address the ongoing opioid crisis.

E-learning Interventions for Quality Improvement Continuing Medical Education-A Scoping Review

INTRODUCTION

Improving health care quality and patient safety are top priorities for the medical field. Robust continuing medical education (CME) programs represent major interventions to effectively teach quality improvement (QI) principles to practicing physicians. In particular, eLearning, a term describing online and distance learning interventions using digital tools, provides a means for CME interventions to reach broader audiences. Although there has been a focus on CME addressing QI, no knowledge synthesis has focused specifically on eLearning interventions. The purpose of this review was to examine the current landscape of eLearning interventions in QI-focused CME.

METHODS

We conducted a scoping review using the framework developed by Arksey and O'Malley as revised by Levac. We searched five databases and identified 2467 prospective publications, which two authors independently screened for inclusion. From each included article, two authors independently extracted data on the instructional modalities and QI tools used and met regularly to achieve consensus.

RESULTS

Twenty-one studies were included. Most studies used blended instruction (n = 12) rather than solely eLearning interventions. Salient findings included the importance of coaching from QI experts and institutional support for planning and implementing eLearning interventions. Lack of protected time and resources for participants were identified as barriers to participation in CME activities, with small practices being disproportionately affected.

DISCUSSION

Partnerships between CME developers and sponsoring organizations are vital in creating sustainable eLearning interventions for QI-focused CME. Remote coaching can be an effective strategy to provide ongoing support to geographically separated learners.

Reducing patients' rate of frequent attendance through a training intervention for physicians

BACKGROUND

Frequent attendance is a common issue for primary care health centres. The phenomenon affects the quality of care, increases doctors' workloads and can lead to burnout.This study presents the results of an educational intervention for primary care physicians, aimed at helping them to decrease the prevalence rate of excessive attendance by patients at their centres.

METHODS

A training programme was carried out for 11 primary care doctors in Barcelona who had patient lists totalling 20,064 patients. The goal of the training was to provide the participating physicians with techniques to curb frequent attendance. Additionally, the programme sought to offer them strategies to prevent professional burnout and tools to better organize their everyday medical practice. The study used a quasi-experimental design for an evaluation of an educational intervention, featuring a pre-test assessment (before the training programme) and a post-test assessment (after the training programme), as well as comparison with a control group that did not undergo the training. The study assessed the effects of the programme on the rates of frequent attendance of patients served by the participating physicians. These rates were compared with those registered by the patients seen by the control group physicians over the same period.

RESULTS

Among the group of physicians who received the training, the mean prevalence of patients who qualified as frequent attenders decreased from 22% prior to the training programme to 8% after completion of the programme. In other words, 14% of patients (2,809) limited the frequency of their visits to primary care physicians after their physicians had completed the training programme. Meanwhile, the study recorded an average decrease of 3.1 visits per year by the patients of the physicians who had undergone the training. Statistically significant differences between this group and the control group were observed.

CONCLUSIONS

The educational intervention proved effective at helping primary care physicians to decrease their patients' rates of frequent attendance. It also contributes to the impact research of continuing education on doctors and their patients. We need to increase primary care spending from the current 14% to the 25%, to address this problem, among others.

More Than Maintaining Competence: A Qualitative Study of How Physicians Conceptualize and Engage in Lifelong Learning

Purpose

Physicians have a professional responsibility to engage in lifelong learning. Some of this lifelong learning is required to maintain licensure and certification. Yet, this conceptualization captures only a small portion of the content areas and learning processes that physicians need to engage with to ensure quality patient care. Additionally, purposes beyond regulatory requirements and professional obligations likely drive physicians lifelong learning, though these purposes have not been explored. Given the centrality of lifelong learning to quality patient care, our study explores how physicians conceptualize and engage in lifelong learning.

Method

We conducted a qualitative interview study using an interpretivist approach. In 2019, we recruited 34 academic physicians from one institution. We analyzed our data to identify themes related to conceptualization of purposes, content areas, and processes of lifelong learning and actual lifelong learning practices.

Results

We interpreted participants' descriptions and examples of lifelong learning as serving three purposes: maintaining competence, supporting personal growth and fulfillment, and engaging in professional stewardship. Much of participants' discussion of lifelong learning centered around keeping up to date with medical knowledge and clinical/procedural skills, though some also mentioned efforts to improve communication, leadership, and teamwork. Participants engaged in lifelong learning through contextual, social, and individual processes.

Discussion

Academic physicians engage in lifelong learning for reasons beyond maintaining competence. Medical knowledge and clinical/procedural skills receive most attention, though other areas are recognized as important. Our findings highlight opportunities for a broader, more comprehensive approach to lifelong learning that spans all areas of medical practice.

Impact of Educational Activity Formats, Online or In-Person, on the Intention of Medical Specialists to Adopt a Clinical Behaviour: A Comparative Study

COVID-19 accelerated continuing professional development (CPD) delivered online. We aimed to compare the impact of in-person versus online CPD courses on medical specialists' behavioural intentions and subsequent behaviour. In this comparative before-and-after study, medical specialists attended in-person courses on nine clinical topics. A second group attended an adapted online version of these courses. Behavioural intention and its psychosocial determinants were measured before and immediately after the courses. Behaviour change was measured six months later. Generalised estimating equation (GEE) models were used to compare the impact of course formats. A total of 82/206 in-person registrants (mean age: 52±10 years; 50% men) and 318/506 on-line registrants (mean age: 49±12 years; men: 63%) participated. Mean intention before in-person courses was 5.99±1.31 and 6.43±0.80 afterwards (average intention gain 0.44, CI: 0.16-0.74; p=0.003); mean intention before online courses was 5.53±1.62 and 5.98±1.40 afterwards (average intention gain of 0.45, CI: 0.30-0.58; p<0.0001). Difference in intention gain between groups was not statistically significant. Behaviour reported six months later was not significantly associated with post-course intention in either group. However, the intention difference increased significantly among those who said they had adopted the targeted behaviour (paired wilcoxon test: n = 40 and p-value=0.002) while it did not increase significantly in the group of those who had not adopted a targeted behaviour (paired wilcoxon test: n = 16 and p-value=0.223). In conclusion, the increase in intention of specialists after CPD courses was similar whether the course was in-person or online. Also, an increase in intention in both groups signalled more likelihood of adoption.

"The genie is out of the bottle": a qualitative study on the impact of COVID-19 on continuing professional development

BACKGROUND

The onset of the COVID-19 pandemic catalysed a monumental shift in the field of continuing professional development (CPD). Prior to this, the majority of CPD group-learning activities were offered in-person. However, the pandemic forced the field to quickly pivot towards more novel methods of learning and teaching in view of social distancing regulations. The purpose of this study was to obtain the perspectives of CPD leaders on the impact of the pandemic to elucidate trends, innovations, and potential future directions in the field.

METHODS

Semi-structured interviews were conducted between April-September 2022 with 23 CPD leaders from Canada and the USA. Interviews were audio-recorded, transcribed, and de-identified. A thematic analysis approach was used to analyse the data and generate themes.

RESULTS

Participants characterised COVID-19 as compelling widespread change in the field of CPD. From the interviews, researchers generated six themes pertaining to the impact of the pandemic on CPD: (1) necessity is the mother of innovation, (2) the paradox of flexibility and accessibility, (3) we're not going to unring the bell, (4) reimagining design and delivery, (5) creating an evaluative culture, and (6) a lifeline in times of turmoil.

CONCLUSION

This qualitative study discusses the impact of the pandemic on the field of CPD and leaders' vision for the future. Despite innumerable challenges, the pandemic created opportunities to reform design and delivery. Our findings indicate a necessity to maintain an innovative culture to best support learners, to improve the healthcare system, and to prepare for future emergencies.

Drug-related physician continuing medical education requirements, 2010-2020

INTRODUCTION

The crisis of drug-related harm in the United States continues to worsen. While prescription-related overdoses have fallen dramatically, they are still far above pre-2010 levels. Physicians can reduce the risk of overdose and other drug-related harms by improving opioid prescribing practices and ensuring that patients are able to easily access medications for substance use disorder treatment. Most physicians received little or no training in those subjects in medical school. It is possible that continuing medical education can improve physician knowledge of appropriate prescribing and substance use disorder treatment and patient outcomes.

METHODS

Descriptive legal review. Laws in all 50 states and the District of Columbia were searched for provisions that require all or most physicians to receive either one-time or continuing medical education regarding controlled substance prescribing, pain management, or substance use disorder treatment.

RESULTS

There has been a rapid increase in the number of states with relevant requirements, from three states at the end of 2010 to 42 at the end of 2020. The frequency and duration of required education varied substantially across states. In all states, the number of hours required in relevant topics is a small fraction of overall required continuing education, an average of 1 h per year. Despite recent shifts in the substances driving overdose, most requirements remain focused on opioids.

CONCLUSION

While most states have now adopted continuing education requirements regarding controlled substance prescribing, pain management, or substance use disorder treatment, these requirements comprise a small component of the required post-training education requirements. Research is needed to determine whether this training translates into reductions in drug-related harm.

Knowledge of the health personnel involved in the fluoride varnish therapy programs of primary schools in Tehran, Iran

INTRODUCTION

The World Health Organization (WHO) places great importance on oral health promotion programs in schools, given that approximately one billion people worldwide are students. This demographic not only includes the students themselves, but also extends to school staff, their families, and the broader community, all of whom are interconnected. The objectives of this study were firstly to assess the knowledge of health personnel conducting fluoride varnish treatment (FVT) in schools, and secondly to solicit their views on the effectiveness of their training methods.

METHODS

Data was collected from health personnel involved in FVT in schools, supervised by medical universities in Tehran province, using a questionnaire. The questionnaire was divided into four sections: demographic information, methods of receiving FVT training, respondents' knowledge regarding FVT, and opinions about the effectiveness of FVT training methods. The questionnaire was distributed via social media, phone conversations, and email. The collected data was analyzed using Mann-Whitney in SPSS Version 26. A regression model was also fitted to the data.

RESULTS

The present study included 403 participants. Among various educational methods, it was found that participation in previous workshops (P = 0.001) and FVT workshops (P = 0.013) was significantly correlated with a higher FVT knowledge score. Additionally, participation in previous oral health promotion programs was significantly associated with a higher knowledge score (P < 0.05). Therefore, a history of participating in previous health promotion programs significantly contributed to the participants' knowledge.

CONCLUSION

Participation in previous oral health programs was found to be significantly correlated with a higher knowledge score. The effectiveness of training programs can be attributed to participation in previous workshops and FVT workshops. This study provided insights into potential strategies for enhancing personnel training in national oral health programs.

Training pathologists to assess stromal tumour-infiltrating lymphocytes in breast cancer synergises efforts in clinical care and scientific research

A growing body of research supports stromal tumour-infiltrating lymphocyte (TIL) density in breast cancer to be a robust prognostic and predicive biomarker. The gold standard for stromal TIL density quantitation in breast cancer is pathologist visual assessment using haematoxylin and eosin-stained slides. Artificial intelligence/machine-learning algorithms are in development to automate the stromal TIL scoring process, and must be validated against a reference standard such as pathologist visual assessment. Visual TIL assessment may suffer from significant interobserver variability. To improve interobserver agreement, regulatory science experts at the US Food and Drug Administration partnered with academic pathologists internationally to create a freely available online continuing medical education (CME) course to train pathologists in assessing breast cancer stromal TILs using an interactive format with expert commentary. Here we describe and provide a user guide to this CME course, whose content was designed to improve pathologist accuracy in scoring breast cancer TILs. We also suggest subsequent steps to translate knowledge into clinical practice with proficiency testing.

The Impact of an Educational Intervention on Enhancing Clinical Knowledge of Physicians and Pharmacists Regarding Statins and Monitoring Parameters: The Experience of a Tertiary Teaching Hospital

Introduction

Understanding the latest guideline recommendations is crucial for healthcare professionals to apply statin therapy effectively. Thus, the purpose of this study was to evaluate the efficacy of an educational intervention in enhancing the awareness and understanding of physicians and pharmacists concerning risk assessment of Atherosclerotic cardiovascular disease (ASCVD) and the role of statin therapy.

Methods

This pre- and post-intervention study was conducted in Sana'a, Yemen's capital city, at the University of Science and Technology Hospital. The study was done between 11/2021-12/2021, and two separate educational sessions were ‎held. The McNemar's test and Wilcoxon signed-rank test were employed as necessary.

Results

Participants' awareness of the Framingham CVD risk calculator improved significantly from 40.4% pre-intervention to 78.7% post-intervention. Similarly, understanding of the parameters used in the 10-year ASCVD Risk calculator rose from 46.8% pre-intervention to 76.6% post-intervention. The ability to identify high, moderate, and low-intensity statin therapy, for instance, increased from 34% to 63.8% post-intervention. Regarding statins' contraindications, safety, and efficacy monitoring parameters, pre-intervention knowledge was unsatisfactory, and the educational intervention improved it significantly (p <0.05). For physicians, the median ASCVD risk assessment knowledge score was significantly improved from ‎‎4 (IQR = 3-5) pre-intervention to 7 (6.25-8) immediately post-intervention, while the statin therapy clinical knowledge median score ‎significantly improved from 3 (1.25-6.5) to 9 (7.25-14.75) post-education intervention, p-values were 0.002 and 0.003; respectively. For pharmacists, a similar significant improvement (p <0.05) in the overall knowledge scores for both ASCVD risk ‎assessment and statin therapy was noted.

Conclusion

The educational intervention improved participants' knowledge of statin therapy and ASCVD risk assessment. Therefore, further education lectures and training programs through continuing ‎medical ‎education on the up-to-date guidelines' recommendations should be regularly implemented to raise ‎awareness and improve ‎the clinical knowledge and appropriateness of statins use in clinical settings.‎.

A Toolkit for Delirium Identification and Promoting Partnerships Between Carers and Nurses: A Pilot Pre-Post Feasibility Study

BACKGROUND

Delirium is frightening for people experiencing it and their carers, and it is the most common hospital-acquired complication worldwide. Delirium is associated with higher rates of morbidity, mortality, residential care home admission, dementia, and carer stress and burden, yet strategies to embed the prevention and management of delirium as part of standard hospital care remain challenging. Carers are well placed to recognize subtle changes indicative of delirium, and partner with nurses in the prevention and management of delirium.

OBJECTIVE

To evaluate a Prevention & Early Delirium Identification Carer Toolkit (PREDICT), to support partnerships between carers and nurses to prevent and manage delirium.

DESIGN

A pre-post-test intervention and observation study.

MAIN MEASURES

Changes in carer knowledge of delirium; beliefs about their role in partnering with nurses and intended and actual use of PREDICT; carer burden and psychological distress. Secondary measures were rates of delirium.

PARTICIPANTS

Participants were carers of Indigenous patients aged 45 years and older and non-Indigenous patients aged 65 years and older.

INTERVENTION

Nurses implemented PREDICT, with a view to provide carers with information about delirium and strategies to address caregiving stress and burden.

KEY RESULTS

Participants included 25 carers (43% response rate) (n = 17, 68% female) aged 29-88 (M = 65, SD = 17.7 years). Carer delirium knowledge increased significantly from pre-to-post intervention (p =  < .001; CI 2.07-4.73). Carers' intent and actual use of PREDICT was (n = 18, 72%; and n = 17, 68%). Carer burden and psychological distress did not significantly change. The incidence of delirium in the intervention ward although not significant, decreased, indicating opportunity for scaling up.

CONCLUSION

The prevention and management of delirium are imperative for safe and quality care for patients, carers, and staff. Further comprehensive and in-depth research is required to better understand underlying mechanisms of change and explore facets of nursing practice influenced by this innovative approach.

Significant improvement of physicians' knowledge and clinical practice: an opportune, effective, and convenient continuing medical education program on functional dyspepsia

Aims

This cohort study aimed to explore the effect of a one-day online continuing medical education (CME) on the improvement of physicians' knowledge and clinical practice on functional dyspepsia (FD).

Methods

Physicians were invited to participate in this CME via medical education applications. FD training videos made in advance were sent to participants via a weblink. Before and after training, participants were required to finish the FD knowledge test and provide case information of FD patients. McNemar test, Wilcoxon rank-sum test, Freidman test, Chi-square test, quantile regression, and generalized estimating equations (GEE) were used to perform statistical analysis.

Results

There were 397 of 430 (92.33%) physicians finished this CME program. The total score of the FD knowledge test after training was significantly higher compared with before training [488.3 (468.3-510.0) vs. 391.7 (341.7-450.0), p < 0.001]. Particularly, physicians from primary hospitals show more increase in total scores than physicians from secondary and tertiary hospitals. According to the GEE model, receiving this online training was an independent predictor of physicians' choice of upper gastrointestinal endoscopy in patients with FD [OR 1.73, 95%CI (1.09-2.73), p = 0.020], especially in PDS. Also, it was an independent predictor of physicians' choice of acid-suppressive drugs in patients with FD [OR 1.30, 95%CI (1.03-1.63), p = 0.026], especially in EPS and PDS overlapping EPS.

Conclusion

This one-day online CME program effectively and conveniently improved physicians' knowledge and clinical practice, providing new ideas for future CME and facilitating precise clinical management of FD patients with different subtypes especially in primary hospitals.

Engagement in Distance Healthcare Simulation Debriefing: A Concept Development and Framework

SUMMARY STATEMENT

Understanding distance health care simulation debriefing is crucial in light of the increased use of and emerging technology in remote education for reasons of accessibility, global collaboration, and continuous professional development. This article is a confluence of a number of previously published studies designed to serve as a foundation to develop the concept of "engagement in health care distance simulation debriefing" using the Schwartz-Barcott & Kim hybrid mixed methods model. The model uses 3 phases: theoretical (a realist systematic review of the literature), fieldwork (3 exploratory studies and 2 pilot experimental studies), and analytical (analysis of the theoretical and fieldwork findings through expert discussion). This study defines the concept of "engagement in health care simulation distance debriefing" through exploration of its uses and analysis in literature, interviews, and expert review. The hybrid approach to the analysis provided rigor to generate a new, reflective conceptual model. This conceptual model defines the complexity in engagement during distance debriefing and helps shape the development of simulationists and debriefers, leading to more effective distance simulations and debriefings.

Examining the Outcomes of Project ECHO® as an Interprofessional Community of Practice for Pediatric Feeding Clinicians

Project ECHO® is a virtual, interprofessional, cased-based peer-learning model. To date, no studies have explored ECHO as a model for pediatric feeding education. This study examined the outcomes of establishing a pediatric feeding ECHO network. Using a prospective, mixed-methods design, two cohorts of allied health professionals were recruited. Each cohort participated in eight, 90-min videoconference sessions incorporating a didactic presentation and clinical case presentation. The case was presented by a participant, with questions and recommendations provided by the ECHO network. Participants completed: (1) a learning needs analysis before the ECHO series, (2) a self-reported confidence questionnaire pre, post, and 3-month post, (3) a satisfaction questionnaire after each session, and (4) an overall satisfaction questionnaire post-ECHO series. Time spent by hospital allied health clinicians providing impromptu phone/email feeding support to external clinicians was recorded for 8 weeks prior to and 8 weeks during the ECHO series. Forty-seven participants were included in the study, attending an average of 5.8 sessions. Significant improvements in self-reported confidence were observed across the three time points (p < 0.01) with less experienced participants demonstrating greater improvements. Participants reported high satisfaction with ECHO, with 93% (40/43) wanting continued access to ECHO in future. The multidisciplinary format, interactivity, structure, and case-based nature of ECHO were considered beneficial. A 75% reduction in requests for support from clinicians in the same catchment area was noted during the ECHO series. Results demonstrated that Project ECHO is a viable model for pediatric feeding education for clinicians working in the field. Further research is needed to investigate the long-term effects and impacts on clinical care.

Stakeholder views on continuing professional development for doctors working in public primary care facilities in central Uganda: a qualitative study

Introduction

the primary care workforce in the public sector of Uganda is under the district health system. The doctors in this workforce provide leadership and frontline promotive, preventive, curative, rehabilitative, and palliative care. Their numbers are still low and therefore need effective support through continuing professional development (CPD). Part of the support is influenced by stakeholders whose views on CPD in the district health system are important. This study therefore explored the stakeholders' views on the CPD of doctors working in the district health system in central Uganda.

Methods

a qualitative exploratory study was done, and data was collected using an interview guide through in-depth interviews among ten purposively selected CPD stakeholders influencing different aspects of CPD activities of doctors working in public general hospitals and health center IVs. The interviews were recorded and transcribed verbatim and manually analyzed using deductive thematic analysis.

Results

five themes were categorized into; CPD practices, facilitators, benefits, challenges, and suggestions. Each of the themes had subthemes; CPD practices; training, mentorship and apprenticeship, support supervision, and quality improvement projects. Facilitators; internet services, grants, health facility managers, facility-based CPD providers, and regional CPD guidelines. Benefits; motivation, knowledge, teamwork, and renewal of practicing licenses. Challenges; workload, allowances, access, documentation, mindset, quality, structure of public health system, and sustainability. Suggestions; training needs analysis, collaboration, monitoring, e-CPD platforms, CPD resource centers, and individual CPD responsibility.

Conclusion

the stakeholders' views are an indication that effective CPD is a collaborative effort from both the primary care doctors and those in the leadership of the health care system.

Learning outcomes from a systematic review workshop series for junior doctors

BACKGROUND

Systematic reviews provide the highest level of evidence about a topic. Ten-week workshops in conducting systematic reviews were held with hospital doctors in 2019 and 2020.

AIM

This study analysed participants' feedback about the systematic review workshops to improve how we teach clinicians about conducting systematic reviews.

METHODS

Attendees completed a post-workshop survey (with multiple-choice and free-text items) to assess knowledge and skills gained. We compared the responses of senior and junior doctors. We used descriptive statistics for the quantitative data and compared groups using Χ2 testing. Qualitative data were analysed using conceptual content analysis.

RESULTS

Of 81 attendees, 52% completed the survey. Of those, 69% had no prior experience with systematic reviews, 93% reported increased knowledge and ability to conduct research and 69% reported increased ability to conduct systematic reviews. More senior than junior clinicians reported gaining knowledge about writing and publishing (37% vs 11%, P = 0.047) and making greater use of skills gained to conduct research (56% vs 23%, P = 0.029). Five themes were identified: learning through course structure; learning through course organisation; teaching style; flexible learning; and suggestions for progression and improvement. Respondents suggested running the workshops during protected teaching time, more time for some sessions, conducting the workshop series more often and making clinicians aware of the workshop series at hospital orientation.

CONCLUSION

The skills learnt from the systematic review workshop series impacted not only participants' research knowledge and skills, and plans to conduct future research, but also facilitated looking up medical literature in daily clinical work, supporting evidence-based clinical practice.

Integration of Women's Cardiovascular Health Content Into Healthcare Provider Education: Results of a Rapid Review and National Survey

Despite its importance, formal education in healthcare training programs on sex- and gender-specific cardiovascular disease (CVD) risk factors, symptoms, treatment, and outcomes is lacking. We completed rapid reviews of the academic and grey literature to describe the current state of women-specific CVD education in medical, nursing, and other healthcare education programs. Second, we analyzed results from a Canada-wide survey of healthcare professional education programs to identify gaps in curricula related to sex- and gender-specific training in CVD. Our academic review yielded only 15 peer-reviewed publications, and our online search only 20 healthcare education programs, that note that they specifically address women, or sex and gender, and CVD in their curricula. Across both searches, the majority of training and education programs were from the USA, varied greatly in length, delivery mode, and content covered, and lacked consistency in evaluation. Of surveys sent to 213 Canadian universities and other entry-to-practice programs, 80 complete responses (37.6%) were received. A total of 47 respondents (59%) reported that their programs included women-specific CVD content. Among those programs without content specific to CVD in women, 69.0% stated that its inclusion would add "quite a bit" or "a great deal" of value to the program. This study highlights the emerging focus on and substantial gaps in women-specific CVD training and education across healthcare education programs. All medical, nursing, and healthcare training programs are implored to incorporate sex- and gender-based CVD content into their regular curricula as part of a consolidated effort to minimize gaps in cardiovascular care.

Barriers and Facilitators in Continuous Medical Education Related to Allogeneic Stem Cell Transplantation: A Qualitative Study of Physicians

INTRODUCTION

This study explored qualitatively, in a sample of German hematologists working in clinical allogeneic hematopoietic stem cell transplantation (alloHSCT), perceptions of barriers and facilitators to participate in continuous medical education (CME), to provide detailed information on how to improve participation in CME activities related to alloHSCT, which may also be applicable to other areas of medicine.

METHODS

Based on a recruitment campaign of the German Association for Hematopoietic Stem Cell Transplantation (DAG-HSZT), 21 semi-structured telephone interviews were conducted, transcribed, and analyzed using framework analysis.

RESULTS

Three clusters of barriers were identified that explain why alloHSCT physicians may or may not participate in CME: individual constraints (e.g., better networking, young physicians being overwhelmed by the complexity of alloHSCT), structural constraints (e.g., time and financial issues, tailoring CME courses according to the targeted audience), and content-related constraints (e.g., requirement of CME sessions, provision of an overview of CME courses, more flexible offers). We discuss the ten most frequently raised issues, including the use of incentives and the need for support at the start of residency, staff shortages, and requirements for learning sessions.

CONCLUSION

There is a need for a paradigm shift in CME related to alloHSCT toward a more individualized and needs-based approach. Close monitoring of residents' needs and learning progress, as well as feedback systems, could help identify appropriate CME courses that should be integrated into a tiered learning system. CME should be more targeted to specific audiences (i.e., residents, fellows, and attendees) to provide training that is tailored to individual CME needs. On-demand courses can help balance work and family obligations. Finally, peer-reviewed, up-to-date information platforms should be expanded.

Challenges and needs in cerebrovascular disease pathway: A qualitative descriptive study from the patients' and healthcare professionals' perspectives

AIM(S)

To understand patients' and healthcare professionals' experiences to improve care in and across different domains of the cerebrovascular disease pathway.

DESIGN

A qualitative descriptive study.

METHODS

Semi-structured in-person interviews were conducted among 22 patients diagnosed with acute cerebrovascular disease and 26 healthcare professionals taking care of them in a single tertiary-level hospital from August 2021 to March 2022. Data were analysed using deductive and inductive content analysis. The consolidated criteria for reporting qualitative research was used to ensure reliable reporting.

RESULTS

Overall, 19 generic and 79 sub-categories describing perceived challenges with 17 generic and 62 sub-categories describing perceived needs were identified related to primary prevention, organization of stroke services, management of acute stroke, secondary prevention, rehabilitation, evaluation of stroke outcome and quality assessment, and life after stroke.

CONCLUSION

Several challenges and needs were identified in and across the different domains of the cerebrovascular disease pathway. There is a requirement for adequate resources, early initiation of treatment, early diagnostics and recanalization, dedicated rehabilitation services, long-term counselling and support, and impact evaluation of services to improve cerebrovascular disease care. Future research on caregivers', and clinical leadership experiences in and across the cerebrovascular disease pathway is needed to explore the provision of services.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The results of this study can be applied by organizations, managers and research for developing and improving services in the cerebrovascular disease pathway.

IMPACT

This study identified several patient-related, organizational and logistical needs and challenges, with suggestions for required actions, that can benefit the provision of effective, high-quality cerebrovascular disease care.

REPORTING METHOD

We have adhered to relevant EQUATOR guidelines with the COREQ reporting method.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement.

Domestic Violence in the Context of the COVID-19 Pandemic: A Synthesis of Systematic Reviews

The current systematic meta-review aimed to map out, characterize, analyze, and synthesize the overarching findings of systematic reviews on domestic violence (DV) in the context of COVID-19. Specifically, a systematic meta-review was conducted with three main objectives: (1) to identify what types and aspects of DV during COVID-19 have been reviewed systematically to date (research trends), (2) to synthesize the findings from recent systematic reviews of the theoretical and empirical literature (main findings), and (3) to discuss what systematic reviewers have proposed about implications for policy and practice as well as for future primary research (implications). We identified, appraised, and synthesized the evidence contained in systematic reviews by means of a so-called systematic meta-review. In all, 15 systematic reviews were found to be eligible for inclusion in the current review. Thematic codes were applied to each finding or implication in accordance with a set of predetermined categories informed by the DV literature. The findings of this review provide clear insight into current knowledge of prevalence, incidence, and contributing factors, which could help to develop evidence-informed DV prevention and intervention strategies during COVID-19 and future extreme events. This systematic meta-review does offer a first comprehensive overview of the research landscape on this subject. It allows scholars, practitioners, and policymakers to recognize initial patterns in DV during COVID-19, identify overlooked areas that need to be investigated and understood further, and adjust research methods that will lead to more robust studies.

Online learning in Health Professions Education. Part 1: Teaching and learning in online environments: AMEE Guide No. 161

Online learning in Health Professions Education (HPE) has been evolving over decades, but COVID-19 changed its use abruptly. Technology allowed necessary HPE during COVID-19, but also demonstrated that many HP educators and learners had little knowledge and experience of these complex sociotechnical environments. Due to the educational benefits and flexibility that technology can afford, many higher education experts agree that online learning will continue and evolve long after COVID-19. As HP educators stand at the crossroads of technology integration, it is important that we examine the evidence, theories, advantages/disadvantages, and pedagogically informed design of online learning. This Guide will provide foundational concepts and practical strategies to support HPE educators and institutions toward advancing pedagogically informed use of online HPE. This Guide consists of two parts. The first part will provide an overview of evidence, theories, formats, and educational design in online learning, including contemporary issues and considerations such as learner engagement, faculty development, inclusivity, accessibility, copyright, and privacy. The second part (to be published as a separate Guide) focuses on specific technology tool types with practical examples for implementation and integration of the concepts discussed in Guide 1, and will include digital scholarship, learning analytics, and emerging technologies. In sum, both guides should be read together, as Guide 1 provides the foundation required for the practical application of technology showcased in Guide 2.Please refer to the video abstract for Part 1 of this Guide at https://bit.ly/AMEEGuideOnlineLearning.

The Design and Evolution of an Adaptable CME Programme to Suit the Changing Educational Needs of the Clinical Community

Continuing medical education (CME) plays a critical role in healthcare, helping to ensure patients receive the best possible care and optimal disease management. Considering the obstacles to engaging in CME activities faced by the clinical community, as well as employing learning theory, Liberum IME developed Classroom to Clinic™ - a bespoke, accredited learning format that can be tailored to individuals' educational needs and time constraints. Through monitoring use, and incorporating qualitative and quantitative feedback, we continuously evaluate the usability, value and accessibility of this programme and adapt subsequent iterations accordingly. An example of this is the way we adapted our engagement of facilitators. Originally this was accomplished by targeting individuals for train-the-trainer events, but it was clear this was more effective in some countries than in others. To address this variability, we piloted launching a new module at a relevant large international congress. This aimed to instigate a cascade in education sharing, from congress attendees to peers at their clinics and across departments and hospitals. So far, the programme has reported encouraging improvements in uptake, as well as knowledge, competence and clinical practice, while qualitative feedback has allowed for the identification of further educational needs and continued evolution of the programme.

Virtual Patient Simulation Offers an Objective Assessment of CME Activity by Improving Clinical Knowledge and the Levels of Competency of Healthcare Providers

The main goal of continuing medical education (CME) is to help healthcare providers (HCP) improve their knowledge and levels of competency with an ultimate enhancement of their performance in practice. Despite the long and well-intentional history of CME, the proof of success (based on improved clinical outcomes) is difficult to obtain objectively. In the past several years, the traditional CME world has been disrupted by replacing multiple-choice questions with virtual simulation. We utilised an innovative, next-generation virtual patient simulation (VPS) platform to develop objective measures to assess the success of educational activities that can be applied to the CME. This VPS platform was used at five distinct educational events designed to assess learners' knowledge and competency in the guideline-driven management of Type 2 diabetes, hyperlipidaemia, and hypertension. A total of 432 learners (medical doctors, nurse practitioners, and clinical pharmacists) participated in these educational events of whom 149 went through two consecutive cases with a similar clinical picture and educational goals. Their ability to achieve glycaemic, lipid, and blood pressure control improved significantly as they moved from the first to the second case. The participants improved their test performance in all categories - between 5 and 38%, achieving statistically significant increases in the many goals examined. In conclusion, this study employed the pioneering application of technology to produce, collect and analyse the VPS data to evaluate objectively educational activities. This VPS platform allows not only an objective assessment of the effectiveness of the CME activity but also provides timely and helpful feedback to both learners and providers of a given educational event.

Surrendering to the Process: Innovation in Developing CPD for General Practice

In CME/CPD, a significant part of research is about effectiveness. Attention to the development process can be vital to understand how it impacts progress and results. This study aims to explore an innovative process of applying a combined approach using design-based research, collaborative innovation, and program theory to develop CPD about type 2 diabetes for GPs and clinic nurses with a group of interprofessional stakeholders. In particular, the development process of the combined approach and how it impacts the progress and the activities. We applied two qualitative methods. First, we analysed 159 documents from the development process, and second, eight semi-structured key informant interviews. Data were deductively analysed using 15 predefined elements derived from the combined approach combined with open coding analyses. The analysis showed how the combined approach structured the process. And the interviews broadened our understanding of the relationship between the process and the activities. Four additional themes were constructed from the open coding, including surrender to the process. Surrendering was a central part of the interviewees' participation in the process. The combined approach facilitated this unfamiliar experience of surrender. By supporting participants to surrender, the combined approach enabled an expansion of interprofessional collaboration and the development of innovative activities and learning methods in CPD on type 2 diabetes.

A Changing Landscape for Lifelong Learning in Health Globally

On 25 July 2022, the Continuing Professional Development (CPD) Special Interest Group of the Association for Medical Education in Europe came together to open up discussions during a live webinar on 'Exploring the Evolution of CPD'. The objective was to bring together global medical educators to consider perspectives of CPD from the role of global lifelong learners, the role of educators and the role of education providers and health regulators. The landscape of CPD is evolving, and the roles of each key player must include specific actions for facilitated change. Delivering competency outcomes-based learning, fit for purpose, to lifelong learners in health will require (1) learner agency, (2) leadership from educators and (3) providers of lifelong learning to come together to improve delivery of CPD that leads to meaningful change in practice care delivery.

Identifying Barriers and Facilitators for Increasing Uptake of Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitors in British Columbia, Canada, using the Consolidated Framework for Implementation Research

Background

Care gaps remain in modern health care despite the availability of robust, evidence-based medications. Although sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated profound benefits in improving both cardiovascular and kidney outcomes in patients, the uptake of these medications remain suboptimal, and the causes have not been systematically explored.

Objective

The purpose of this study was to use the Consolidated Framework for Implementation Research (CFIR) to describe the barriers and facilitators faced by clinicians in British Columbia, Canada, when prescribing an SGLT2 inhibitor. To achieve this, we conducted semistructured interviews using the CFIR with practicing family physicians, nephrologists, endocrinologists, and cardiologists in British Columbia.

Design

Semistructured interviews.

Setting

British Columbia, Canada.

Participants

Actively practicing family physicians, nephrologists, endocrinologists, and cardiologists in British Columbia.

Methods

Twenty-one clinicians were interviewed using questions derived from the CFIR. The audio recordings were transcribed verbatim, and each transcription was individually analyzed in duplicate using thematic analysis. The analysis focused on identifying barriers and facilitators to using SGLT2 inhibitors in clinical practice and coded using the CFIR constructs. Once the transcriptions were coded, overarching themes were created.

Results

Five overarching themes were identified to the barriers and facilitators to using SGLT2 inhibitors: current perceptions and beliefs, clinician factors, patient factors, medication factors, and health care system factors. The current perceptions and beliefs were that SGLT2 inhibitors are efficacious and have distinct advantages over other agents but are underutilized in British Columbia. Clinician factors included varying levels of knowledge of and comfort in prescribing SGLT2 inhibitors, and patient factors included intolerable adverse events and additional pill burden, but many were enthusiastic about potential benefits. Multiple SGLT2 inhibitor related adverse events like mycotic infections and euglycemic diabetic ketoacidosis and the difficulty in obtaining reimbursement for these medications were also identified as a barrier to prescribing these medications. Facilitators for the use of SGLT2 inhibitors included consensus among colleagues, influential leaders, and peers in support of their use, and endorsement by national guidelines.

Limitations

The experience from the clinicians regarding costs and the reimbursement process is limited to British Columbia as each province has its own procedures. There may be responder bias as clinicians were approached through purposive sampling.

Conclusion

This study highlights different themes to the barriers and facilitators of using SGLT2 inhibitors in British Columbia. The identification of these barriers provides a specific target for improvement, and the facilitators can be leveraged for the increased use of SGLT2 inhibitors. Efforts to address and optimize these barriers and facilitators in a systematic approach may lead to an increase in the use of these efficacious medications.

Self-reported preferences and barriers to continued professional development in primary care physicians: a cross-sectional web-based survey in Qatar

INTRODUCTION

High quality and effective primary healthcare is a national priority in Qatar. Continuing professional development (CPD) for physicians is a cornerstone of this objective, yet little is known about physicians' preferences or barriers to CPD participation.

METHOD

A needs assessment was conducted using a cross-sectional web-based survey of primary care physicians registered with the Department of Healthcare Practitioners (DHP) between March and June 2017.

RESULTS

Two-hundred-and-eighty-one complete surveys were submitted representing physicians in both public (N = 129) and private sectors (N = 152). Physicians completed medical degrees and postgraduate training across multiple countries, and most had been practicing in Qatar for 5 years or less. 'Activities during working hours', 'cost' and 'work commitments' were the most common barriers. There was little consensus regarding the optimal timing of CPD activities, although public sector physicians were more likely to indicate weekend activities as a barrier to participation (30% vs. 9%). Over 90% of participants preferred traditional lectures, workshops, case-based sessions, small group and online self-paced learning as formats for CPD delivery, however alternative modes of delivery were also deemed acceptable (> 80% agreement).

CONCLUSION

Understanding primary care physicians' barriers and preferences is an essential component of a larger necessitated needs assessment of CPD in primary care practitioners in Qatar. Further research is warranted to understand the underlying beliefs driving physicians' choices and the apparent variation between those working in the public and private sectors. CPD developers should consider approaches to mitigate perceived barriers and understand preferences to maximize the quality of participation.

Participation in Project ECHO to advance rural primary care providers' ability to address patient mental health needs

The COVID-19 pandemic shed light on the burden of behavioral health conditions prevalent in the United States (U.S.). Consequently, there is a behavioral healthcare provider shortage, particularly in rural areas, to support this need. Recently, primary care providers (PCPs) have shifted to incorporate behavioral health to their practice. However, many PCPs lack knowledge and skills to successfully manage their patients' behavioral health conditions. In response to the need for effective behavioral healthcare across the U.S. Weitzman ECHO launched the Advanced Primary Care (APC ECHO) Adult Psychiatry Module to provide continuing education (CE) for rural PCPs. This study presents the results from the APC ECHO pilot to demonstrate how CE can support PCPs in addressing their patients' mental health needs. Evaluators used a one-group repeated measures study design to assess the APC ECHO Module and understand learner outcomes and individual practice changes. Participant characteristics and individual practice changes were summarized using descriptive statistics, with support from open-ended responses to illustrate findings. Repeated measures analyses of covariance were applied to compare the differences in pre- and post-module learner outcomes. A total of 18 providers participated in the study, with the majority encompassing medical providers (72.2%). There was a significant increase in knowledge (pre-module: 21.11 + 6.99; post-module: 25.08 + 5.66; p < .01), self-efficacy (pre-module: 6.89 + 3.05; post-module: 9.78 + 3.25; p < .01), and skills (pre-module: 7.67 + 4.03; post-module: 10.06 + 3.23; p < .05) gained over the duration of the ECHO module. Additionally, participants indicated they are applying best practices learned through the module to their patients experiencing psychiatric conditions (3.96 + 0.09). This study suggests that tailored CE for PCPs can promote an increase in knowledge, self-efficacy, and skills to apply best practices when treating patients with behavioral health conditions. This, in turn, allows patients to receive more comprehensive care and mitigates access barriers, especially for rural populations.

Partnering with carers in the management of delirium in general acute care settings: An integrative review

OBJECTIVES

Delirium is a common, preventable condition. However, delirium is poorly recognised and often missed because symptoms are misinterpreted, and risk factors overlooked by health-care professionals. Carers usually have intimate knowledge about the person they care for. Therefore, they are well placed within care teams to implement delirium prevention strategies, identify symptoms and support the early diagnosis of delirium. The aim of this integrative review was to synthesise findings from the published research reporting on partnering with carers in the management of delirium in general acute care settings.

METHODS

Five databases (Medline-EBSCO, PubMed, PsycINFO, ProQuest, CINAHL and SCOPUS) were searched to identify primary research regarding partnering with carers in the management of delirium in acute care settings, and results were synthesised. PRISMA guidelines were adhered to, and quality appraisal was conducted using the Mixed Methods Appraisal Tool.

RESULTS

All seven studies reported that partnering with carers was a viable strategy in the management of delirium to maximise outcomes for people at risk of or experiencing delirium and that increasing carers' knowledge of delirium was key. The synthesis of findings also identified two themes: Increasing knowledge and Effective partnerships.

CONCLUSIONS

A collaborative approach to increasing carers' and nurses' knowledge about the management of delirium, coupled with education on how to develop therapeutic nurse-carer relationships, is important for ongoing effective partnerships in the management of delirium. Good communication supported effective partnerships, which enabled both nurses and carers the opportunity to express their needs and concerns and negotiate collaborative involvement in the management of delirium.

Continuing Medical Education in the Post COVID-19 Pandemic Era

Continuing medical education (CME) is a requirement for medical professionals to stay current in their ever-changing fields. The recent significant changes that have occurred due to the COVID-19 pandemic have significantly impacted the process of providing and obtaining CME. In this paper, an updated approach to successfully creating and administering CME is offered. Recommendations regarding various aspects of CME development are covered, including competitive assessment, marketing, budgeting, property sourcing, program development, and speaker and topic selection. Strategies for traditional and hybrid CME formats are also explored. Readers and institutions interested in developing CME, especially in the setting of the ongoing pandemic, will be able to use these strategies as a solid framework for producing CME. The recommendations and strategies presented within this paper are based on the authors' opinions, expert opinions, and experiences over 13 years of creating CME events and challenges brought about due to the COVID-19 pandemic.

The Emerging Role of Reinforcement in the Clinician's Path from Continuing Education to Practice

INTRODUCTION

Continuing education (CE) activities may affect clinicians' knowledge, skills, self-efficacy, and/or performance. Studies have suggested that self-efficacy may moderate or mediate the relationship between knowledge/competence and performance. Some results have shown that increases in knowledge/competence contributed to increases in self-efficacy. However, clinicians do not always learn something "new" when they participate in CE activities; rather, their knowledge or skills may be reinforced. This study examined whether self-efficacy was greater when clinicians reinforced what they already knew compared with when they learned something new.

METHODS

Hierarchical linear modeling was conducted to examine the moderating role of status of knowledge/competence post-CE (reinforced/improved) in the relationship between post-CE knowledge/competence score and self-efficacy across 153 online continuing medical education- and/or CE-certified activities.

RESULTS

The hierarchical linear modeling showed that learners with higher post-CE scores have higher post-self-efficacy ratings. Reinforced learners had higher post-CE-self-efficacy ratings than improved learners, controlling for post-CE score.

DISCUSSION

This study contributes to an expanded understanding of the path from CE to practice. There was benefit to self-efficacy for learners who reinforced but did not improve their knowledge/competence. This study also suggests that pre-post questions can be considered part of the learning process.

RE-AIM applied to a primary care workforce training for rural providers and nurses: the Department of Veterans Affairs' Rural Women's Health Mini-Residency

Introduction

Application of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate workforce education and training programs targeting clinical health care staff has received relatively little attention. This paper aims to contribute to this area with RE-AIM findings from a women's health-focused workforce training program implemented by the U.S. Department of Veterans Affairs (VA). Over the past two decades, the rapid expansion of the women Veteran population in VA has necessitated a quick response to meet clinical demand. To address this health care need, the VA Offices of Rural Health (ORH) and Women's Health (OWH) partnered to deploy a primary care workforce development initiative for Rural Providers and Nurses-the Rural Women's Health Mini-Residency (Rural WH-MR)-to train VA clinicians in rural locations in skills for the care of women Veterans. Here we assess the applicability of RE-AIM as an evaluation framework in this context.

Methods

We evaluated the Rural WH-MR, relying on a primarily quantitative approach, rooted in RE-AIM. It included longitudinal and cross-sectional measurements from multiple quantitative and qualitative data sources to develop selected metrics. Data collection instruments consisted of pre-, post-, and follow-up training surveys, course evaluations, existing VA databases, and implementation reports. We developed metrics for and assessed each RE-AIM component by combining data from multiple instruments and then triangulating findings.

Results

Results from the Rural WH-MR program for fiscal years 2018-2020 indicate that RE-AIM provides an instructive evaluation framework for a rural workforce training program, particularly in eliciting clarity between measures of Reach vs. Adoption and focusing attention on both provider- and patient-level outcomes.

Discussion

We describe evaluation metric development and barriers to and facilitators of utilizing RE-AIM as an evaluation framework for a provider- and nurse-facing intervention such as this workforce training program. We also reflect upon RE-AIM benefits for highlighting process and outcomes indicators of a training program's success and lessons learned for evaluating rural workforce development innovations. Several of our observations have implications for training and evaluation approaches in rural areas with more limited access to health care services.

Journey from an Enabler to a Strategic Leader: Integration of the Medical Affairs Function in ESG Initiatives and Values

Like most private enterprises, the pharmaceutical industry has deeply rooted environmental, social, and governance (ESG) matters that challenge its long-term sustainability. Overcoming these external challenges requires collaborative and proactive steps as well as procedures guiding the adoption of ESG principles by all internal stakeholders. Environmental challenges such as climate change, and in addition the changes in society, have resulted in the need for governance addressing and coordinating efforts. The core function of medical affairs (MA) is connecting with stakeholders within a company and also between the company and external stakeholders. In this article, we describe the involvement of MA in several aspects of ESG, as a contributor, partner, and implementer. MA has a significant opportunity to emerge as a leading function involved in ESG strategies and their tactical implementation. Although the involvement of MA in the environment pillar of ESG is less, the function can implement changes relating to the conduct of meetings, clinical studies, and the digitalization of medical education via virtual platforms. Due to its patient centricity, MA is tasked to address social determinants of health to improve patients' outcomes. As a linking function within a company and with its external stakeholders, MA can provide proactive input in policy generation and enable effective governance by adherence to standards of accountability, ethics, and compliance, as well as transparency. Championing ESG is a collective responsibility that transcends any single department. It mandates a company-wide commitment. MA represents an essential pivot point in catalyzing the integration of ESG principles within industry, contributing to a healthcare ecosystem that is not merely more sustainable and ethical but also more conducive to patient health and public well-being.

Effect of a Peer Comparison and Educational Intervention on Medical Test Conversation Quality: A Randomized Clinical Trial

Importance

Medical test overuse and resulting care cascades represent a costly, intractable problem associated with inadequate patient-clinician communication. One possible solution with potential for broader benefits is priming routine, high-quality medical test conversations.

Objective

To assess if a peer comparison and educational intervention for physicians and patients improved medical test conversations during annual visits.

Design, Setting, and Participants

Randomized clinical trial and qualitative evaluation at an academic medical center conducted May 2021 to October 2022. Twenty primary care physicians (PCPs) were matched-pair randomized. For each physician, at least 10 patients with scheduled visits were enrolled. Data were analyzed from December 2022 to September 2023.

Interventions

In the intervention group, physicians received previsit emails that compared their low-value testing rates with those of peer PCPs and included point-of-care-accessible guidance on medical testing; patients received previsit educational materials via email and text message. Control group physicians and patients received general previsit preparation tips.

Main outcomes and measures

The primary patient outcome was the Shared Decision-Making Process survey (SDMP) score. Secondary patient outcomes included medical test knowledge and presence of test conversation. Outcomes were compared using linear regression models adjusted for patient age, gender, race and ethnicity, and education. Poststudy interviews with intervention group physicians and patients were also conducted.

Results

There were 166 intervention group patients and 148 control group patients (mean [SD] patient age, 50.2 [15.3] years; 210 [66.9%] female; 246 [78.3%] non-Hispanic White). Most patients discussed at least 1 test with their physician (95.4% for intervention group; 98.3% for control group; difference, -2.9 percentage points; 95% CI, -7.0 to 1.2 percentage points). There were no statistically significant differences in SDMP scores (2.11 out of 4 for intervention group; 1.97 for control group; difference, 0.14; 95% CI, -0.25 to 0.54) and knowledge scores (2.74 vs 2.54 out of 4; difference, 0.19; 95% CI, -0.05 to 0.43). In poststudy interviews with 3 physicians and 16 patients, some physicians said the emails helped them reexamine their testing approach while others noted competing demands. Most patients said they trusted their physicians' advice even when inconsistent with educational materials.

Conclusions and Relevance

In this randomized clinical trial of a physician-facing and patient-facing peer comparison and educational intervention, there was no significant improvement in medical test conversation quality during annual visits. These results suggest that future interventions to improve conversations and reduce overuse and cascades should further address physician adoption barriers and leverage patient-clinician relationships.

Trial Registration

ClinicalTrials.gov Identifier: NCT04902664.

Technology-Enhanced Learning in Medical Education Collection: Latest Developments

Technology-enhanced learning (TEL) refers to learning activities and environments that are potentially improved or enhanced with information and communication technologies (Shen and Ho, 2020; Wasson and Kirschner, 2020). TEL may be implemented in face-to-face, distance/remote and blended or hybrid modes; in various environments such as online, classrooms, workplaces, communities, and other built and natural environments; include a range of learning designs and pedagogies/andragogies; involve synchronous and asynchronous interactions amongst students, teachers, workplace staff and clients, and/or community members; and delivered with the support of various technologies (Wasson and Kirschner, 2020). To date, the Technology-Enhanced Learning in Medical Education collection, part of MedEdPublish, has received submissions relating to several technologies to support learning, including web conferencing, web 2.0, e-textbooks, e-portfolios, software, generative artificial intelligence, simulation mannequins and wearables for point-of-view video, often in combination. Learning designs included flipped classroom with interactive case discussions (Imran et al., 2022), e-portfolios (Javed et al., 2023), didactic teaching followed by demonstrations of clinical skills on a simulation mannequin (Zwaiman et al., 2023), interdisciplinary case discussions to promote interprofessional learning (Major et al., 2023), patient panels to share narratives and perspectives (Papanagnou et al., 2023), and team-based learning (Lee & Wong, 2023). In the four papers that included evaluation, participant reaction (feedback on learning activities) and/or learning (self-reported through surveys, with pre- vs post-training comparisons or at different timepoints during learning) were reported, corresponding to levels 1 and 2 of the commonly used outcomes-focused Kirkpatrick model of evaluation (Allen et al., 2022). Two papers focused on the work of health professions educators, including conducting the nominal group technique, a qualitative research method, via web conferencing (Khurshid et al., 2023); and using ChatGPT to assist with various medical education tasks (Peacock et al., 2023).

VARK preference and perception of online versus offline professional development training of medical laboratory technologists

OBJECTIVE

This study aims to understand the learning preferences and perception of medical laboratory technologists on sudden shift from offline to online training sessions during COVID-19 pandemic.

METHODS

Microsoft form containing twenty-four questions was circulated to the twenty-five laboratory technologists after 1 year of online continuous professional development training. VARK questionnaire was circulated to understand the learning style.

RESULTS

Provision of recording lectures, significant reduction of performance anxiety, anxiety associated with criticism, and QA sessions emerged as the major positive aspects of a virtual training platform. Analysis of learning preferences revealed that most technologists had a unimodal aural (45%) or kinesthetics (33%) than visual (11%) and reading (11%) learning preference. In bimodal learning preference, AK (44.44%) emerged as the predominant form. Forty percent of the technologists showed trimodal learning pattern with 50% among them showing an ARK pattern while 25% each showing VAK and VRK patterns of learning preferences.

CONCLUSION

Medical laboratory technologists adapted well to the sudden shift from offline to online continuous development programs. However, efficient managerial mechanisms to address the major perceived hurdles and designing a multimodal training module to accommodate the learning preferences of our technologists can ensure enthusiastic participation and effective learning among medical laboratory technologists.

From Two Dimensions to Multidimensions: A Mechanistic Model to Support Deliberate CPD Development, Coordination, and Evaluation

INTRODUCTION

The effectiveness of continuing professional development as an intervention to improve health professional behavior and patient health is variable and contentious. To clarify the causal relationships underlying program outcomes and facilitate a necessary shift from outcomes-only-based approaches to outcome-based and theory-based approaches in program development and evaluation, we developed a model of mechanisms mapped to relevant outcomes.

METHODS

Mechanisms identified in a prior realist synthesis of opioid agonist therapy continuing professional development programs were iteratively tested and refined using purposive and opportunistic sampling and realist approaches against two systematic reviews of programs in analgesic prescribing and palliative care. Further testing involved practical application within programs in sustainable health care and pain management.

RESULTS

Ninety reports on 75 programs and practical application to multiple additional programs informed the final model consisting of five distinct mechanisms: motivation transformation, expert influence, confidence development, self-efficacy facilitation, and community of practice expansion. The mechanisms and related analysis emphasize that continuing professional development is heterogeneous, complex, and context dependent.

DISCUSSION

Shifting toward outcome-based and theory-based approaches facilitates further conceptual shifts at intraprogram and interprogram and interintervention levels toward more deliberate program development and evaluation, increased program complementarity and subsequent collaboration. It clarifies opportunities for intercalation of continuing professional development with other intervention sciences. The model presents a resource for practitioners, researchers, and policymakers to advance continuing professional development planning, coordination, and evaluation.

Big Assumptions in Online and Blended Continuing Professional Development: Finding Our Way Forward Together

ABSTRACT

Continuing professional development (CPD) providers and faculty face a practice gap between our knowledge of effective practices in CPD and our implementation of them, particularly in online environments. Developmental psychologists Bob Kegan and Lisa Lahey have attributed such knowledge-implementation gaps to an "Immunity to Change" rooted in tacit "Big Assumptions." These Big Assumptions produce fears or worries, reveal competing commitments, and result in actions or inactions that hinder intended change. We sought to understand the barriers to change in online and blended CPD, to support CPD leaders in pursuing their goals for optimal use of technology in CPD. This inquiry arose from the 13th National Continuing Professional Development Accreditation Conference of the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada, a virtual conference held in October 2022. After introducing the Immunity to Change framework and best practices in online and blended learning, we invited audience members to list Big Assumptions in CPD through chat and polling software. These responses were analyzed and grouped into five interrelated Big Assumptions that suggest a number of key barriers to optimal implementation of online CPD. We present data that counter each Big Assumption along with practical approaches to facilitate desired change for CPD.

Outpatient management of urinary tract infections by medical officers in Nairobi, Kenya: lack of benefit from audit and feedback on adherence to treatment guidelines

INTRODUCTION

Acute uncomplicated urinary tract infections are common in outpatient settings but are not treated optimally. Few studies of the outpatient use of antibiotics for specific diagnoses have been done in sub-Saharan Africa, so little is known about the prescribing patterns of medical officers in the region.

METHODS

Aga Khan University has 16 outpatient clinics throughout the Nairobi metro area with a medical officer specifically assigned to that clinic. A baseline assessment of evaluation and treatment of suspected UTI was performed from medical records in these clinics. Then the medical officer from each of the 16 clinics was recruited from each clinic was recruited with eight each randomized to control vs. feedback groups. Both groups were given a multimodal educational session including locally adapted UTI guidelines and emphasis on problems identified in the baseline assessment Each record was scored using a scoring system that was developed for the study according to adequacy of history, physical examination, clinical diagnosis matching recorded data, diagnostic workup and treatment. Three audits were done for both groups; baseline (audit 1), post-CME (audit 2), and a final audit, which was after feedback for the feedback group (audit 3). The primary analysis assessed overall guideline adherence in the feedback group versus the CME only group.

RESULTS

The overall scores in both groups showed significant improvement after the CME in comparison to baseline and for each group, the scores in most domains also improved. However, audit 3 showed persistence of the gains attained after the CME but no additional benefit from the feedback. Some deficiencies that persisted throughout the study included lack of workup of possible STI and excess use of non-UTI laboratory tests such as CBC, stool culture and H. pylori Ag. After the CME, the use of nitrofurantoin rose from only 4% to 8% and cephalosporin use increased from 49 to 67%, accompanied by a drop in quinolone use.

CONCLUSION

The CME led to modest improvements in patient care in the categories of history taking, treatment and investigations, but feedback had no additional effect. Future studies should consider an enforcement element or a more intensive feedback approach.

Evaluating the impact of continuing professional development courses on physician behavioral intention: a pre-post study with follow-up at six months

BACKGROUND

Continuing professional development (CPD) for health professionals includes educational activities to maintain or improve skills. We evaluated the impact of a series of CPD courses by identifying factors influencing physicians' intention to adopt targeted behaviors and assessing self-reported behavior adoption six months later.

METHODS

In this pre-post study, eligible participants attended at least one in-person course at the Fédération des Médecins Spécialistes du Québec annual meeting in November 2019. Before and afterwards, participants completed CPD-REACTION, a validated questionnaire based on Godin's integrated model for health professional behavior change that measures intention and psychosocial factors influencing intention. We used Wilcoxon signed-rank test to compare pre- and post-course intention scores and linear regression analyses to identify factors influencing intention. We also compared the post-course intention scores of participants reporting a behavior change six months later with the scores of those reporting no behavior change six months later. Qualitative data was collected only six months after courses and responses to open-ended questions were analyzed using the Theoretical Domains Framework.

RESULTS

A total of 205/329 course attendees completed CPD-REACTION (response rate 62.3%). Among these participants, 158/329 (48%) completed the questionnaire before CPD courses, 129/329 (39.2%) only after courses and 47/329 (14.3%) at 6 months. Study population included 192 physicians of whom 78/192(40.6%) were female; 59/192(30.7%) were between 50 and 59 years old; and 72/192 (37.5%) were surgical specialist physicians. Mean intention scores before (n = 158) and after (n = 129) courses were 5.74(SD = 1.52) and 6.35(SD = 0.93) respectively. Differences in mean (DM) intention before and afterwards ranged from - 0.31(p = 0.17) to 2.25(p = 0.50). Multivariate analysis showed that beliefs about capabilities (β = 0.15, p = 0.001), moral norm (β = 0.75, p < 0.0001), and beliefs about consequences (β = 0.11, p = 0.04) influenced post-course intention. Post-course intention was correlated with behavior six months later (DM = 0.63; p = 0.02). Qualitative analysis showed that facilitators to behavior adoption after six months were most often related to the TDF domains of beliefs about capabilities. Most frequent barriers to adoption related to lack of resources.

CONCLUSIONS

Overall, scores for intention to adopt targeted behaviors increased after the courses. CPD providers could increase participants' intention by including interventions that emphasize beliefs about capabilities, moral norm and beliefs about consequences.

Radiology for anatomy educators: Success of an online, 2-day course for radiology training

Incorporation of radiology training into anatomy education from community college to health professional schools is becoming increasingly popular. However, anatomy educators generally lack training in common radiology modalities, including X-ray, CT, MRI, and ultrasound. Professional development or continuing education courses provide current and new educators the chance to gain new skills within a short timeframe. Here, a 2-day, online course for anatomy educators was created. The goals of which were for the participants: to gain basic knowledge of different radiology modalities, recognize normal radiographic images, and apply that information to common diseases or injuries in interactive case studies. Each day focused on different modalities, where Day 1 studied X-ray, CT, and MRI; and Day 2 studied Ultrasound. A 10-question pre- and post-test was taken by attendees for each day of instruction on a voluntary basis. Following the completion of the course, attendees were provided a survey to determine their perceptions on course content and knowledge acquired. Most attendees instructed undergraduates at 4-year universities, though several attendees came from community colleges and high schools. All attendees showed a significant improvement in knowledge from their pre- to post-test scores in X-ray, CT, MRI, and ultrasound following training. This was also reflected in their survey responses, where attendees felt the course was effective in increasing their knowledge and confidence in radiology. Overall, this study demonstrates the effectiveness of online continuing education courses and the need for more introductory radiology courses for anatomy educators.

Experience of practicing obstetrician-gynecologists in a surgical training program in total laparoscopic hysterectomy

BACKGROUND

Advanced surgical techniques, such as total laparoscopic hysterectomy, are often challenging to acquire beyond fellowship training programs for practicing obstetrician-gynecologists. A lack of formative data currently exist for continuing medical education programs, limiting our understanding of how improvement in surgical skills and training programs occur.

OBJECTIVE

This study aimed to investigate how practicing obstetrician-gynecologists acting as trainees experience a program that aims to teach them total laparoscopic hysterectomy, and to assess whether their surgical skills improve according to data from formative assessment tools and qualitative data from open-ended survey questions and in-depth interviews.

STUDY DESIGN

We report a process analysis of formative data collected during a pilot implementation trial of a surgical training program targeting practicing obstetrician-gynecologists. Eleven consultant obstetrician-gynecologists and 4 experienced surgical mentors participated in 4 hospitals in Queensland, Australia. Total laparoscopic hysterectomy was performed in 700 patients over the course of the study. A total laparoscopic hysterectomy surgical mentorship training program of 10 training days with up to 3 total laparoscopic hysterectomy procedures per day was performed. Both the obstetrician-gynecologists and the surgical mentor completed a formative assessment questionnaire analyzing the trainee's performance after each surgical procedure. Mentors were formatively assessed by the Structured Training Trainer Assessment Report (STTAR) and at the completion of the study by the mini-STTAR, a summative assessment of quality of mentorship. Obstetrician-gynecologists, mentors, hospital leaders, and surgical administrative staff participated in qualitative interviews about the training program.

RESULTS

Over time, there was a demonstrated improvement in trainee performance reported by both mentors and trainees in all competency assessment tool domains as the case number increased, with mentors consistently rating trainees' performance higher than the trainees themselves. Most trainees were satisfied with their mentor in all 31 areas during formative assessment, and at the end of the training, structure, attributes, and role modeling were all rated high (average score >4.5; range, 3.79-5.00), whereas training behavior was rated slightly lower at 4.1 (range, 3.79-4.45). Qualitative interviews demonstrated that the trainees found the training to be a beneficial, hands-on experience.

CONCLUSION

Formative assessment clearly documented improvement in surgical skills during a total laparoscopic hysterectomy training program for consultant obstetrician-gynecologists.

Learning Outcomes and Educational Effectiveness of E-Learning as a Continuing Professional Development Intervention for Practicing Surgeons and Proceduralists: A Systematic Review

BACKGROUND

Electronic learning (e-Learning) has become a prevalent mode of delivering medical education. We aimed to determine the learning outcomes and educational effectiveness of e-Learning as a continuing professional development (CPD) intervention for practicing surgeons and proceduralists.

METHODS

We searched MEDLINE databases and included studies reporting learning outcomes of e-learning CPD interventions for practicing surgeons and physicians performing technical procedures. We excluded articles only studying surgical trainees and those not reporting learning outcomes. Two reviewers independently screened, extracted data, and assessed study quality using the Critical Appraisal Skills Programme (CASP) tools. Learning outcomes and educational effectiveness were categorized using Moore's Outcomes Framework (PROSPERO: CRD42022333523).

RESULTS

Of 1307 identified articles, 12 were included- 9 cohort studies, one randomized controlled trial and 2 qualitative studies, with a total of 2158 participants. Eight studies were rated as moderate, five as strong, and 2 as weak in study quality. E-Learning CPD interventions included web-based modules, image recognition, videos, a repository of videos and schematics, and an online journal club. Seven studies reported participants' satisfaction with the e-Learning interventions (Moore's Level 2), 4 reported improvements in participants' declarative knowledge (Level 3a), 1 reported improvements in procedural knowledge (Level 3b) and five reported improvements in participants' procedural competence in an educational setting (Level 4). No studies demonstrated improvements in participants' workplace-based performance, the health of patients, or community health (Levels 5-7).

CONCLUSIONS

E-Learning as a CPD educational intervention is associated with high satisfaction and improvements in knowledge and procedural competencies of practicing surgeons and proceduralists in an educational setting. Future research is required to investigate whether e-Learning is associated with higher-level learning outcomes.

Web-Based Learning for General Practitioners and Practice Nurses Regarding Behavior Change: Qualitative Descriptive Study

BACKGROUND

Supporting patients to live well by optimizing behavior is a core tenet of primary health care. General practitioners and practice nurses experience barriers in providing behavior change interventions to patients for lifestyle behaviors, including low self-efficacy in their ability to enact change. Web-based learning technologies are readily available for general practitioners and practice nurses; however, opportunities to upskill in behavior change are still limited. Understanding what influences general practitioners' and practice nurses' adoption of web-based learning is crucial to enhancing the quality and impact of behavior change interventions in primary health care.

OBJECTIVE

This study aimed to explore general practitioners' and practice nurses' perceptions regarding web-based learning to support patients with behavior change.

METHODS

A qualitative, cross-sectional design was used involving web-based, semistructured interviews with general practitioners and practice nurses in Queensland, Australia. The interviews were recorded and transcribed using the built-in Microsoft Teams transcription software. Inductive coding was used to generate codes from the interview data for thematic analysis.

RESULTS

In total, there were 11 participants in this study, including general practitioners (n=4) and practice nurses (n=7). Three themes emerged from the data analysis: (1) reflecting on the provider of the Healthy Lifestyles suite; (2) valuing the web-based learning content and presentation; and (3) experiencing barriers and facilitators to using the Healthy Lifestyles suite.

CONCLUSIONS

Provider reputation, awareness of availability, resources, content quality, usability, cost, and time influence adoption of web-based learning. Perceived quality is associated with culturally tailored information, resources, a balance of information and interactivity, plain language, user-friendly navigation, appealing visual presentation, communication examples, and simple models. Free web-based learning that features progress saving and module lengths of less than 2 hours alleviate perceived time and cost barriers. Learning providers may benefit by including these features in their future behavior change web-based learning for general practitioners and practice nurses.

Cognitive perspectives on maintaining physicians' medical expertise: I. Reimagining Maintenance of Certification to promote lifelong learning

Until recently, physicians in the USA who were board-certified in a specialty needed to take a summative test every 6-10 years. However, the 24 Member Boards of the American Board of Medical Specialties are in the process of switching toward much more frequent assessments, which we refer to as longitudinal assessment. The goal of longitudinal assessments is to provide formative feedback to physicians to help them learn content they do not know as well as serve an evaluation for board certification. We present five articles collectively covering the science behind this change, the likely outcomes, and some open questions. This initial article introduces the context behind this change. This article also discusses various forms of lifelong learning opportunities that can help physicians stay current, including longitudinal assessment, and the pros and cons of each.

Experience with the Implementation of Continuous Medical Education among Mother-and-Child Healthcare Providers in Ukraine: A Case Study Based on Two International Collaboration Initiatives

BACKGROUND

Healthcare labor market shortages due to migration, inadequate investments, and lack of continuous training are essential concerns in the Eastern European region. This article aims to describe and reflect on the experience with the implementation of continuous medical education among mother-and-child healthcare providers in Ukraine, including achievements, challenges, and barriers. We analyze this case based on two international collaboration initiatives: the Swiss-Ukrainian program in mother-and-child health that ran from 2000 to 2015, supplemented by the recent Ukrainian-Swiss project "Medical education development" in 2018-2023.

METHODS

We use a case study approach as the methodology for our study. We collected data from documents (project reports reviews) and in-depth interviews with stakeholders. We apply the method of directed qualitative content analysis.

RESULTS

As a result of the Swiss-Ukrainian collaborations, the knowledge and awareness of medical personnel were greatly improved. Modern clinical concepts not well understood at the outset became commonplace and were incorporated into clinical activities. Nevertheless, obstacles to the implementation and rapid uptake of changes were found in the lack of knowledge of the English language among medical doctors, the fear of changes, and the lack of openness and readiness for novel evidence-based clinical practices. However, primary healthcare practitioners in this new project seem to be more inclined to change.

CONCLUSIONS

A modernized continuous medical education which is based on the values of openness, respect, dialogue, and professionalism can be implemented with the input of an international assistance program despite the resistance of the system towards change.

Addressing educational gaps through multidisciplinary team education in eosinophilic oesophagitis management

Once considered a rare disease, eosinophilic oesophagitis (EoE) is becoming increasingly prevalent, yet many healthcare professionals (HCPs) remain unfamiliar with the underlying pathophysiology and optimal management approaches. For this study, we developed a faculty-led, online, continuing medical education activity on EoE. The effectiveness of this activity was evaluated according to Moore's framework, with changes in knowledge and competence (Moore's Levels 3 and 4) assessed for a cohort of gastroenterologists, dietitians, allergists and immunologists (N = 300), using questionnaires completed before and after participation. Changes in HCP confidence in treating EoE were also reported and remaining educational gaps were identified. The activity was viewed by a global audience of 5,330 participants within 6 months, and significant improvements in knowledge and competence were reported following participation in the activity across all specialities, regions and experience (mean [standard deviation] score pre- versus post-activity: 4.32 [1.38] versus 5.46 [0.82]; p < 0.001). Confidence in treating EoE also increased from pre- to post-activity, with the proportion of participants reporting that they felt moderately or extremely confident increasing from 53% to 82%. Several educational unmet needs were identified, which can be used to inform the design of future educational activities in EoE.

Perspectives of Swiss Paediatric Health Care Professionals on Factors Influencing Physical Activity Participation in Children with Disabilities

AIM

Investigation of the perspectives of paediatric health care professionals (PHCPs) in Switzerland regarding factors that influence participation in physical activity programs for children and adolescents with disabilities or chronic conditions (CADCCs). Evaluation of self-reported exercise counselling behavior of those professionals.

METHOD

A cross-sectional survey was used to collect the opinions of 171 PHCPs working with CADCCs using a structured questionnaire. The information obtained was evaluated by performing a combined quantitative and qualitative statistical analysis.

RESULTS

PHCPs in Switzerland think that CADCC do not get enough physical activity and see the underlying reasons in lacking information/knowledge and organizational factors. We found that the level of knowledge about disability sports opportunities among PHCPs has a positive influence on their exercise counselling behaviour.

CONCLUSIONS

We propose three approaches to increase the level of physical activity in CADCC: Establishing personalized exercise counseling, intensifying information about disability sports programmes towards PHCPs, and improving inclusion and integration in PE lessons or regular sports clubs.