'Change talk' among physicians in small group learning communities: An ethnographic study.

INTRODUCTION: Physicians face uncertainties in complex clinical environments. Small group learning initiatives allow physicians to decipher new evidence and address challenges. This study aimed to understand how physicians in small learning groups discuss, interpret and assess new evidence-based information to make decisions for practice. METHODS: An ethnographic approach was used to collect data from observed discussions between practising family physicians (n = 15) that meet in small learning groups (n = 2). Physicians were members of a continuing professional development (CPD) programme that provides educational modules with clinical cases and evidence-based recommendations for best practice. Nine learning sessions were observed over 1 year. Field notes documenting the conversations were analysed using ethnographic observational dimensions and thematic content analysis. Observational data were supplemented with interviews (n = 9) and practice reflection documents (n = 7). A conceptual framework for 'change talk' was created. RESULTS: Observations elucidated the following: Facilitators played a significant role in leading the discussion by focusing on practice gaps. As group members shared approaches to clinical cases, baseline knowledge and practice experiences were revealed. Members made sense of new information by asking questions and sharing knowledge. They determined what information was useful and whether it applied to their practice. They reviewed evidence, tested algorithms, benchmarked themselves to best practice and consolidated knowledge before committing to practice change(s). Themes from interviews emphasised that sharing of practice experiences played an integral part in decisions to implement new knowledge, helped validate guideline recommendations and provided strategies for feasible practice changes. Documented practice reflections regarding decisions for practice change(s) overlapped with field notes. CONCLUSION: This study provides empirical data on how small groups of family physicians discuss evidence-based information and make decisions for clinical practice. A 'change talk' framework was created to illustrate the processes that occur when physicians interpret and assess new information to bridge gaps between current and best practices.

Toward Practice-Based Continuing Education Protocols: Using Testing to Help Physicians Update Their Knowledge.

INTRODUCTION: Using assessment to facilitate learning is a well-established priority in education but has been associated with variable effectiveness for continuing professional development. What factors modulate the impact of testing in practitioners are unclear. We aimed to improve capacity to support maintenance of competence by exploring variables that influence the value of web-based pretesting. METHODS: Family physicians belonging to a practice-based learning program studied two educational modules independently or in small groups. Before learning sessions they completed a needs assessment and were assigned to either sit a pretest intervention or read a relevant review article. After the learning session, they completed an outcome test, indicated plans to change practice, and subsequently documented changes made. RESULTS: One hundred twelve physicians completed the study, 92 in small groups. The average lag between tests was 6.3 weeks. Relative to those given a review article, physicians given a pretest intervention: (1) reported spending less time completing the assigned task (16.7 versus 25.7 minutes); (2) performed better on outcome test questions that were repeated from the pretest (65.9% versus 58.7%); and (3) when the learning module was completed independently, reported making a greater proportion of practice changes to which they committed (80.0% versus 45.0%). Knowledge gain was unrelated to physicians' stated needs. DISCUSSION: Low-stakes formative quizzes, delivered with feedback, can influence the amount of material practicing physicians remember from an educational intervention independent of perceptions regarding the need to engage in continuing professional development on the particular topic.

Assessing Unperceived Learning Needs in Continuing Medical Education for Primary Care Physicians: A Scoping Review.

INTRODUCTION: Assessing needs before developing continuing medical education/continuing professional development (CME/CPD) programs is a crucial step in the education process. A previous systematic literature review described a lack of objective evaluation for learning needs assessments in primary care physicians. This scoping review updates the literature on uses of objective evaluations to assess physicians' unperceived learning needs in CME/CPD. Identifying and understanding these approaches can inform the development of educational programs that are relevant to clinical practice and patient care. The study objectives were to (1) scope the literature since the last systematic review published in 1999; (2) conduct a comprehensive search for studies and reports that explore innovative tools and approaches to identify physicians' unperceived learning needs; (3) summarize, compare, and classify the identified approaches; and (4) map any gaps in the literature to identify future areas of research. METHODS: A scoping review was used to "map" the literature on current knowledge regarding approaches to unperceived needs assessment using conceptual frameworks for planning and assessing CME/CPD activities. RESULTS: Two prominent gaps were identified: (1) performance-based assessment strategies are highly recommended in nonresearch articles yet have low levels of implementation in published studies and (2) analysis of secondary data through patient input or environmental scanning is emphasized in grey literature implementation strategies more so than in peer-reviewed theoretical and research articles. DISCUSSION: Future evaluations should continue to incorporate multiple strategies and focus on making unperceived needs assessments actionable by describing strategies for resource management.

Academic Half-Days: Facilitated Small Groups to Promote Interactive Learning.

BACKGROUND AND OBJECTIVES: Medical educators have expressed interest in using less didactic and more interactive formats for academic half-days (AHDs) in postgraduate residency training. We assessed the feasibility and effectiveness of implementing a practice-based small-group learning (PBSGL) process as one part of AHDs. METHODS: A mixed-methods approach was used. Over a two-year period, family medicine residents at the University of Calgary took part in PBSGL sessions during their AHDs, discussing clinical cases presented in evidence-based educational modules and reflecting on clinical experiences with the guidance of a trained peer facilitator. Data sources to explore experiences with the PBSGL process included an evaluation questionnaire, a practice reflection tool (PRT; documenting patient management plans) and individual interviews (n=19) with residents and faculty preceptors. RESULTS: Of 148 residents, 139 (93%) agreed to participate. Participants were divided into groups of 14-16 members to discuss 12 different module topics. Participants indicated that ongoing small-group interactions were helpful in meeting learning needs and provided opportunities to share and learn from experiences of others in a safe environment. Group facilitation by residents was successful. Level of resident participation and time to preread modules were factors contributing to successful small-group interactions. Modules were rated as effective learning tools, and sample cases were perceived as representing typical cases encountered in practice. Although participants intended to apply their learning to practice, follow through was hindered by lack of relevant clinical cases. CONCLUSIONS: Ongoing small-group learning facilitated by residents, coupled with evidence-based educational materials, was a feasible approach to AHDs.

How do clinicians use implementation tools to apply breast cancer screening guidelines to practice?

BACKGROUND: Implementation tools (iTools) may enhance uptake of guidelines. However, little evidence exists on their use by primary care clinicians. This study explored which iTools clinicians used and how often; how satisfied clinicians were with the tools; whether tool use was associated with practice changes; and identified mediators for practice change(s) related to breast cancer screening (BCS). METHODS: Canadian primary care providers who are members of the Practice-Based Small Group Learning Program (n = 1464) were invited to participate in this mixed methods study. An educational module was discussed in a small group learning context, and data collection included an on-line survey, practice reflection tools (PRTs), and interviews. The module included both the Canadian Task Force on Preventive Health Care revised guideline on BCS and iTools for clinician and/or patient use. After discussing the module and at 3 months, participants completed PRTs identifying their planned practice change(s) and documenting implementation outcome(s). Use of the iTools was explored via online survey and individual interviews. RESULTS: Seventy participants agreed to participate. Of these, 48 participated in the online survey, 43 completed PRTs and 14 were interviewed. Most survey participants (77%) reported using at least one of seven tools available for implementing BCS guideline. Of these (78%) reported using more than one tool. Almost all participants used tools for clinicians (92%) and 62% also used tools for patients. As more tools were used, more practice changes were reported on the survey and PRTs. Interviews provided additional findings. Once information from an iTool was internalized, there was no further need for the tool. Participants did not use tools (23%) due to disagreements with the BCS guideline, patients' expectations, and/or experiences with diagnosis of breast cancer. CONCLUSION: This study found that clinicians use tools to implement practice changes related to BCS guideline. Tools developed for clinicians were used to understand and consolidate the recommendations before tools to be used with patients were employed to promote decision-making. Mediating factors that impacted tool use confirmed previous research. Finally, use of some iTools decreased over time because information was internalized.

Is the Cognitive Complexity of Commitment-to-Change Statements Associated With Change in Clinical Practice? An Application of Bloom's Taxonomy.

INTRODUCTION: This study categorizes 4 practice change options, including commitment-to-change (CTC) statements using Bloom's taxonomy to explore the relationship between a hierarchy of CTC statements and implementation of changes in practice. Our hypothesis was that deeper learning would be positively associated with implementation of planned practice changes. METHODS: Thirty-five family physicians were recruited from existing practice-based small learning groups. They were asked to use their usual small-group process while exploring an educational module on peripheral neuropathy. Part of this process included the completion of a practice reflection tool (PRT) that incorporates CTC statements containing a broader set of practice change options-considering change, confirmation of practice, and not convinced a change is needed ("enhanced" CTC). The statements were categorized using Bloom's taxonomy and then compared to reported practice implementation after 3 months. RESULTS: Nearly all participants made a CTC statement and successful practice implementation at 3 months. By using the "enhanced" CTC options, additional components that contribute to practice change were captured. Unanticipated changes accounted for one-third of all successful changes. Categorizing statements on the PRT using Bloom's taxonomy highlighted the progression from knowledge/comprehension to application/analysis to synthesis/evaluation. All PRT statements were classified in the upper 2 levels of the taxonomy, and these higher-level (deep learning) statements were related to higher levels of practice implementation. CONCLUSION: The "enhanced" CTC options captured changes that would not otherwise be identified and may be worthy of further exploration in other CME activities. Using Bloom's taxonomy to code the PRT statements proved useful in highlighting the progression through increasing levels of cognitive complexity-reflecting deep learning.

Encouraging Reflection and Change in Clinical Practice: Evolution of a Tool.

This article describes the systematic development and gradual transformation of a tool to guide participants in a continuing medical education program to reflect on their current practices and to make commitments to change. The continuous improvement of this tool was influenced by evolving needs of the program, reviews of relevant educational literature, feedback from periodic program surveys, interviews with group facilitators, and results from educational research studies. As an integral component of the educational process used in the Practice Based Small Group Learning Program, the current tool is designed to help family physicians think about what has been learned during each educational session and examine issues related to the implementation of evidence-based changes into their clinical practice. Lessons learned will be highlighted. Both the developmental processes employed and the practice reflection tool itself have applicability to other educational environments that focus on continuing professional development.

17ß-Estradiol alters the response of subfornical organ neurons that project to supraoptic nucleus to plasma angiotensin II and hypernatremia.

This study was done in urethane anesthetized, ovariectomized (OVX) female rats that were either implanted or not implanted with silastic capsules containing17ß-estradiol (E2) to investigate the effect of systemic changes in E2 on the discharge rate of subfornical organ (SFO) neurons that projected to supraoptic nucleus (SON) and responded to changes in plasma levels of angiotensin II (ANG II) or hypernatremia. Extracellular single unit recordings were made from 146 histologically verified single units in SFO. Intra-carotid infusions of ANG II excited ~57% of these neurons, whereas ~23% were excited by hypertonic NaCl. Basal discharge rate of neurons excited by ANG II or hypertonic NaCl was significantly lower in OVX+E2 rats compared to OVX only animals. The response of SFO neurons antidromically activated by SON stimulation to intra-carotid injections of ANG II or hypertonic NaCl was greater in the OVX only compared to the OVX+E2 rats. Intra-carotid injections of E2 in either group attenuated not only the basal discharge of these neurons, but also their response to ANG II or hypertonic NaCl. In all cases this inhibitory effect of E2 was blocked by an intra-carotid injection of the E2 receptor antagonist ICI-182780, although ICI-182780 did not alter the neuron's response to ANG II or hypertonic NaCl. Additionally, ICI-182780 in the OVX+E2 animals significantly raised the basal discharge of SFO neurons and their response to ANG II or hypertonic NaCl. These data indicate that E2 alters the response of SFO neurons to ANG II or NaCl that project to SON, and suggest that E2 functions in the female to regulate neurohypophyseal function in response to circulating ANG II and plasma hypernatremia.

Women's views on reminder letters for screening mammography: Mixed methods study of women from 23 family health networks.

OBJECTIVE: To explore women's perspectives on the acceptability and content of reminder letters for screening mammography from their family physicians, as well as such letters' effect on screening intentions. DESIGN: Cross-sectional mailed survey followed by focus groups with a subgroup of respondents. SETTING: Ontario. PARTICIPANTS: One family physician was randomly selected from each of 23 family health networks and primary care networks participating in a demonstration project to increase the delivery of preventive services. From the practice roster of each physician, up to 35 randomly selected women aged 50 to 69 years who were due or overdue for screening mammograms and who had received reminder letters from their family physicians within the past 6 months were surveyed. MAIN OUTCOME MEASURES: Recall of having received reminder letters and of their content, influence of the letters on decisions to have mammograms, and interest in receiving future reminder letters. Focus group interviews with survey respondents explored the survey findings in greater depth using a standardized interview guide. RESULTS: The response rate to the survey was 55.7% (384 of 689), and 45.1% (173 of 384) of responding women reported having mammograms in the past 6 months. Among women who recalled receiving letters and either making appointments for or having mammograms, 74.8% (122 of 163) indicated that the letters substantially influenced their decisions. Most respondents (77.1% [296 of 384]) indicated that they would like to continue to receive reminders, and 28.9% (111 of 384) indicated that they would like to receive additional information about mammograms. Participants in 2 focus groups (n = 3 and n = 5) indicated that they thought letters reflected a positive attitude of physicians toward mammography screening. They also commented that newly eligible women had different information needs than women who had had mammograms done in the past. CONCLUSION: Reminder letters were considered by participants to be useful and appeared to influence women's decisions to undergo mammography screening.

Using a novel small-group approach to enhance feedback skills for community-based teachers.

BACKGROUND: As medical education expands into distant settings, challenges in providing faculty development to busy clinical teachers increase-especially for those who have difficulty accessing sessions offered at academic centers. DESCRIPTION: Sixty-five clinical teachers participated in six small-group workshops, using a printed module on the topic of delivering feedback. The modules included teaching-learning "cases," tools, and a summary of medical literature. The group facilitator did not require expertise in delivering feedback. Surveys inquired about impact immediately after the session and at 3 months. EVALUATION: Analysis confirmed that participants found the workshop format valuable, and the majority committed to making changes in their approaches to providing feedback. At follow-up, most participants reported that planned changes had been implemented. CONCLUSIONS: A low-tech approach to faculty development, using facilitated small-group discussion of a specially prepared educational module, is feasible for any site and can enhance teaching approaches in both urban and rural practice settings.

Acceptability of reminder letters for Papanicolaou tests: a survey of women from 23 Family Health Networks in Ontario.

OBJECTIVE: To explore women's perspectives on the acceptability and content of reminder letters from the family physician for Papanicolaou (Pap) test screening and the effect of reminder letters on compliance with screening recommendations. METHODS: A population-based survey was conducted in 23 Family Health Networks and Primary Care Networks participating in a demonstration project to increase the delivery of preventive services in Ontario. Questionnaires were mailed to randomly selected women aged 35 to 69 years who had received a reminder letter for a Pap test from their family physician within the previous six months. Two focus groups were conducted with a volunteer sample of respondents. RESULTS: The usable response rate was 54.3% (406/748). Two-thirds (65.8%, 267/406) of women who completed the survey recalled receiving the reminder letter. Overall, 52.3% (212/405) reported having a Pap test in the past six months. Among women who recalled the reminder letter and scheduled or had a Pap test, 71.4% (125/175) reported that the letter influenced their decision to be screened. The majority of respondents (80.8%, 328/406) wanted to continue to receive reminder letters for Pap tests from their physician, and 34.5% (140/406) wanted to receive additional information about cervical screening. Focus group interviews indicated that women who have had a Pap test may still be unsure about screening recommendations, what the test detects, and the rationale for follow-up procedures. CONCLUSIONS: Reminder letters in family practice were viewed as useful and influenced women's decisions to undergo Pap test screening. Women who have had a Pap test may still need additional information about the test.

Translating learning into practice: lessons from the practice-based small group learning program.

UNLABELLED: PROBLEM ADDRESSED The need for effective and accessible educational approaches by which family physicians can maintain practice competence in the face of an overwhelming amount of medical information. OBJECTIVE OF PROGRAM: The practice-based small group (PBSG) learning program encourages practice changes through a process of small-group peer discussion-identifying practice gaps and reviewing clinical approaches in light of evidence. PROGRAM DESCRIPTION: The PBSG uses an interactive educational approach to continuing professional development. In small, self-formed groups within their local communities, family physicians discuss clinical topics using prepared modules that provide sample patient cases and accompanying information that distils the best evidence. Participants are guided by peer facilitators to reflect on the discussion and commit to appropriate practice changes. CONCLUSION: The PBSG has evolved over the past 15 years in response to feedback from members and reflections of the developers. The success of the program is evidenced in effect on clinical practice, a large and increasing number of members, and the growth of interest internationally.

Direct projections from caudal ventrolateral medullary depressor sites to the subfornical organ.

Experiments were performed in the male Wistar rat to investigate the projections from cardiovascular responsive sites in the ventrolateral medulla (VLM) to the subfornical organ (SFO). Unilateral iontophoretic injections of Phaseolus vulgaris leucoagglutinin (PHA-L) were made into either caudal VLM (CVLM) sites at which microinjection of l-glutamate (10 nl; 0.25 M) elicited decreases in mean arterial pressure or into rostral VLM (RVLM) sites at which l-glutamate microinjection elicited increases in arterial pressure. After a survival period of 7-10 days, transverse sections of the forebrain and brainstem were processed for PHA-L immunoreactivity. After injections of PHA-L into the CVLM, axonal and presumptive terminal labeling was found bilaterally throughout the rostrocaudal extent of the SFO, although most of the projections were observed within the rostral half of the nucleus. Within the SFO, labeling was found primarily in the lateral aspects of the nucleus, often in close proximity to blood vessels. In addition, CVLM injections resulted in labeling within the organum vasculosum of the laminae terminalis (OVLT) and within the ventral and dorsal components of the median preoptic nucleus (MnPO) bilaterally, but with an ipsilateral predominance. In contrast, PHA-L injections into the RVLM did not result in axonal labeling in the SFO or OVLT, although a few labeled axons were found to course through the region of the ventral component of MnPO. These data have demonstrated that neurons within the cardiovascular responsive region of the CVLM send direct axonal projections to the SFO and other structures of the laminae terminalis, and suggest that the CVLM may function in the modulation of the activity of neurons of circumventricular organs to intra- and extracellular signals of body fluid balance.