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Practice inquiry: clinical uncertainty as a focus for small-group learning and practice improvement.

ABSTRACT: PROBLEM: Many primary care physicians in nonacademic settings lack a collegial forum for engaging the clinical uncertainties inherent in their work. PROGRAM DESCRIPTION: "Practice Inquiry" is proposed as a set of small-group, practice-based learning and improvement (PBLI) methods designed to help clinicians better manage case-based clinical uncertainty. Clinicians meet regularly at their offices/clinics to present dilemma cases, share clinical experience, review evidence for blending with experience, and draw implications for practice improvement. From 2001 through 2005, Practice Inquiry was introduced to sites in the San Francisco Bay Area as a demonstration effort. Meeting rosters, case logs, a feedback survey, and meeting field notes documented implementation and provided data for a formative, qualitative evaluation. PROGRAM EVALUATION: Of the 30 sites approached, 14 held introductory meetings. As of summer 2006, 98 clinicians in 11 sites continue to hold regularly scheduled group meetings. Of the 118 patient cases presented in the seven oldest groups, clinician-patient relationship and treatment dilemmas were most common. Clinician feedback and meeting transcript data provided insights into how busy practitioners shared cases, developed trust, and learned new knowledge/skills for moving forward with patients. DISCUSSION: Ongoing clinician involvement suggests that Practice Inquiry is a feasible, acceptable, and potentially useful set of PBLI methods. Two of the Practice Inquiry's group learning tasks received comparatively less focus: integrating research evidence with clinical experience and tracking dilemma case outcomes. Future work should focus on reducing the methodological limitations of a demonstration effort and examining factors affecting clinician participation. Set-aside work time for clinicians, or other equally potent incentives, will be necessary for the further elaboration of these PBLI methods aimed at managing uncertainty.

SUBMITTER: Sommers LS

PROVIDER: S-EPMC1824750 | biostudies-other | 2007 Feb

REPOSITORIES: biostudies-other

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Project description:ObjectiveTo identify threshold concepts (TCs) for physicians undergoing postgraduate medical education (PGME) in general practice.DesignAn explorative, qualitative study with 65 min focus group interviews and thematic analysis was used. Participants were asked to describe their most transformative learning experiences. Heuristical TCs were identified from the thematic analysis.SettingAotearoa/New Zealand (A/NZ).ParticipantsFifty participants, mostly comprising current trainees and educators from urban centres, and of NZ/European ethnicity.ResultsTwenty TCs covering many aspects of postgraduate general practice experience were derived from themes identified in the data. Presented in medical proverbial form for ease of recollection, these included: Money makes the practice go round; Be a legal eagle; Manage time or it will manage you; Guidelines, GPs' little helpers; Right tool, right word, right place; The whole of the practice is greater than the sum of the parts; The personal enhances the professional; Beat biases by reflection; Chew the Complexity, Unpredictability, Diversity; Embrace the uncertainty; Not knowing is knowing; Seek and you shall find; Waiting and seeing, waiting and being; Look, listen, think between the lines; Treat the patient beyond the disease; No patient is an island; Words work wonders; Hearing is healing; Being you and being there; and; The relationship is worth a thousand consults. These TCs mapped onto core competencies in A/NZ's PGME in general practice curriculum.ConclusionsParticipants readily identified transformative and troublesome moments in their PGME in general practice. These findings confirmed evidence for a wide range of TCs with many newly identified in this study. All TCs were fundamentally based on the doctor-patient relationship, although often involving the context and culture of general practice. Actively incorporating and teaching these identified TCs in PGME in general practice may enable trainees to grasp these important learning thresholds earlier and more easily and aid in identity and role formation.

Project description:BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to meet and demonstrate outcomes across 6 competencies. Measuring residents' competency in practice-based learning and improvement (PBLI) is particularly challenging. PURPOSE: We developed an educational tool to meet ACGME requirements for PBLI. The PBLI template helped programs document quality improvement (QI) projects and supported increased scholarly activity surrounding PBLI learning. METHODS: We reviewed program requirements for 43 residency and fellowship programs and identified specific PBLI requirements for QI activities. We also examined ACGME Program Information Form responses on PBLI core competency questions surrounding QI projects for program sites visited in 2008-2009. Data were integrated by a multidisciplinary committee to develop a peer-protected PBLI template guiding programs through process, documentation, and evaluation of QI projects. All steps were reviewed and approved through our GME Committee structure. RESULTS: An electronic template, companion checklist, and evaluation form were developed using identified project characteristics to guide programs through the PBLI process and facilitate documentation and evaluation of the process. During a 24 month period, 27 programs have completed PBLI projects, and 15 have reviewed the template with their education committees, but have not initiated projects using the template. DISCUSSION: The development of the tool generated program leaders' support because the tool enhanced the ability to meet program-specific objectives. The peer-protected status of this document for confidentiality and from discovery has been beneficial for program usage. The document aggregates data on PBLI and QI initiatives, offers opportunities to increase scholarship in QI, and meets the ACGME goal of linking measures to outcomes important to meeting accreditation requirements at the program and institutional level.

Project description:Background: Pragmatic trials inform clinical decision with better generalizability and can bridge different streams of medicine. This study collated the expectations regarding pragmatic trial design of integrative medicine (IM) for diabetes and kidney diseases among patients and physicians. Dissonance between users' perspective and existing pragmatic trial design was identified. The association between risk of bias and pragmatism of study design was assessed. Method: A 10-group semi-structured focus group interview series [21 patients, 14 conventional medicine (ConM) and 15 Chinese medicine (CM) physicians] were purposively sampled from private and public clinics in Hong Kong. Perspectives were qualitatively analyzed by constant comparative method. A systematic search of four databases was performed to identify existing IM pragmatic clinical trials in diabetes or kidney disease. Primary outcomes were the pragmatism, risk of bias, and rationale of the study design. Risk of bias and pragmatism were assessed based on Cochrane risk-of-bias tool and PRECIS-2, respectively. The correlation between risk of bias and pragmatism was assessed by regression models with sensitivity analyses. Results: The subtheme on the motivation to seek IM service was analyzed, covering the perceived limitation of ConM effect, perceived benefits of IM service, and assessment of IM effectiveness. Patients expected IM service to retard disease progression, stabilize concomitant drug dosage, and reduce potential side effects associated with ConM. In the systematic review, 25 studies from six countries were included covering CM, Korean medicine, Ayurvedic medicine, and western herbal medicine. Existing study designs did not include a detailed assessment of concomitant drug change and adverse events. Majority of studies either recruited a non-representative proportion of patients as traditional, complementary, and integrative medicine (TCIM) diagnosis was used as inclusion criteria, or not reflecting the real-world practice of TCIM by completely dropping TCIM diagnosis in the trial design. Consultation follow-up frequency is the least pragmatic domain. Increase in pragmatism did not associate with a higher risk of bias. Conclusion: Existing IM pragmatic trial design does not match the patients' expectation in the analysis of incident concomitant drug change and adverse events. A two-layer design incorporating TCIM diagnosis as a stratification factor maximizes the generalizability of evidence and real-world translation of both ConM and TCIM.

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Practice inquiry: clinical uncertainty as a focus for small-group learning and practice improvement.

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