Practice-Generated Questions - NCBI

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Penny A. Jennett, PhD Jocelyn M. Lockyer, MHA I. John P. Parboosingh, MD William R. Maes, MLS

Practice-Generated Questions: A Method of Formulating True Learning Needs of Family Physicians 11

SUMMARY

A

RESUME

The importance of identifying true learning Dans cette etude, a laquelle ont participe 87 medecins de famille du sud de l'Alberta en fournissant 579 needs prior to planning and conducting questions cliniques, on a tente, apres revision et educational programs is well documented. analyse, de les regrouper par categories afin de In this study a collection of 579 clinical mieux planifier les sessions de formation medicale questions forwarded by 87 family physicians continue et les bulletins d'informations. On a aussi in southern Alberta was reviewed and examine la nature des questions soumises afin de determiner si certains groupes specifiques de analysed to determine if the questions medecins definis par des caracteristiques sociowould cluster and, therefore, be useful as ne presentaient pas des differences demographiques sources for planning continuing medical significatives selon le type de questions. Les resultats education (cMiE) conferences and de cette etude indiquent en effet que les questions newsletters. The nature of submitted generees par les medecins de famille se regroupent questions was also examined to determine if en categories et qu'il existe des variations significatives selon les differents groupes de particular groups of physicians, as identified medecins identifies. Les categories les plus by socio-demographic characteristics, frequentes furent le systeme genito-urinaire, les significantly differed by type of questions medicaments et leurs effets secondaires, interactions submitted. The study findings indicate that et contre-indications et celles traitant du systeme nerveux et des organes sensitifs. On a constate aussi the questions generated by the clinical des differences significatives selon le sexe, les practices of family practitioners did cluster milieux de pratique, l'annee et l'endroit de l'obtention into meaningful categories, and did vary du II devient beaucoup plus facile de traiter significantly by identified physician groups. desdiplome. problemes cliniques quotidiens lorsque les beQuestions relating to the genito-urinary soins d'apprentissage sont etablis par des questions system; adverse drug effects, interactions cliniques tres specifiques et pertinentes plutot que par and contraindications; and nervous system des besoins vaguement exprimes et trop larges. Cette fagon d'identifier les besoins d'apprentissage fournit and sense organs were most frequently un cadre optimal permettant de mieux planifier les submitted. The nature of questions sessions de formation medicale continue et d'influengenerated differed significantly by gender, cer les comportements ou les modeles de pratique. size of practice setting, and year and place of medical graduation. When highly relevant and specific clinical questions, as contrasted with broadly expressed needs, serve as sources of identified learning needs for CME planners, the daily clinical problems faced by practitioners are better addressed. The learning needs identified by this approach provide an optimum framework for planned ctm to influence physician behaviour or practice patterns. (Can Fam Physician 1989; 35:497-500.) Key words: continuing medical education, family physicians, clinical questions _ _~ ~ -

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Dr. Jennett is Assistant Professor in the Office of Medical Education. Ms. Lockyer is Administrative Assistant, Graduate Clinical and Continuing Medical Education. Dr. Parboosingh is Assistant Dean, Graduate Clinical and Continuing Medical Education. Mr. Maes is Head of Public Services for the Medical Library. All authors are members of the Faculty of Medicine, University of Calgary. Requests for reprints to: Penny Jennett, Ph.D., Office of Medical Education, 3330 Hospital Drive N.W., Calgary, Alta. T2N 4N1 One learns by asking oneself questions, then finding the answers....

pROVIDERS of hospital rounds, short courses, and educational materials for family physicians require access to good data to plan high-quality continuing medical education. Programmed group learning has been criticized for its emphasis on common needs2 when the practitioner requires highly specific information.3 While the importance of identifying the learning needs of practitioners prior to developing educational opportunities is now established,45 the commonly used methods are often limited in their capacity to address "real needs", and faculty may receive inadequate information, leading them to make incorrect assumptions about attendee needs.6 Literature has begun to appear that advocates the use of information generated from the day-to-day practice of the physician in the development of educational programs. Davis and colleagues7 reported on the strengths and limitations of introducing standardized patients into the practices of 14 family physicians as a means of identifying learning needs. Lockyer and colleagues8 concluded that the consulting process, supplemented with actual referral letters, is a useful method of needs assessment for family medicine. Clinical case recall was found to be a useful needs-identification method for obstetricians and family physicians in a study conducted by Parboosingh and colleagues.9 It seems reasonable that courses which focus on physician performance in specific clinical situations will not only transfer facts but also alter performance.2 498

Clinical questions which arise during daily practice or which are searched for in a library have also recently been considered as sources of information to be used for assessing educational needs. On the basis of their studies of literature-search requests and areas of cME interest, Wender and colleagues10 conclude that library requests may be useful in assessing learning needs. In a pilot study, Jennett and colleagues11 concluded that the categorization of the questions generated by family physicians from patient management could be useful in identifying needs for CME courses and newsletters. The purpose of this paper is twofold. First, the clinical questions which arose from 87 family physicians' contacts with patients during the one half-day of practice were examined to determine whether the patient-generated questions clustered in a manner which could serve as a suitable method for identifying learning needs for family-physician programming. Secondly, as different CME programs appeal to different sub-groups of the physician population, the clustering of questions was studied to assess whether practitioners, identified by socio-demographic characteristics, differed significantly in terms of the nature of the questions which they raised.

Methods Eighty-seven practising physicians in southern Alberta volunteered to forward to the study group clinical questions that arose during a typical half-day of practice in which they saw a minimum of 25 patients. Practitioners were categorized by practice location (community of 500 000 as compared to a community of fewer than 50 000); school of graduation (in North America or outside of North

America); gender (male, female); and years since graduation (graduated 1970 or later, or before 1970). All questions were categorized by a health-record technician in two ways. First, the questions were classified according to the International Classification of Diseases - 9th Revision Clinical Modification (ICD. 9. CM). Secondly, the questions were categorized as diagnostic/investigation, general management, or therapeutics (pharmacology) inquiries. The Statistical Package for the So-

cial Sciences computer-programming package (spss) was used to collate and analyse the data. Analysis consisted of descriptive statistics to report the question data by category. Ttest analysis was used to determine whether the type of questions differed by physician socio-demographic characteristics.

Results The 87 family physicians forwarded a total of 579 questions to the study group. The average number of questions forwarded by the physicians was 6.8. The range was from one to 16 questions. Table 1 outlines the questions as they were categorized by ICD.9.CM and by diagnostic, management, and therapeutic classification. An analysis of the questions as categorized by ICD.9.CM indicates that questions related to the genitourinary system were the most common and accounted for 19.7% of all questions asked. Drug adverse effects/interactions/contraindications accounted for 13.5% of the questions. Other frequently occurring problems related to the nervous system and sense organs (11.9 %), musculo-skeletal system and connective tissue (11.2 %), and conditions in the perinatal period, pregnancy, childbirth and puerperium (10.9 %). Nearly one-half of the questions (45.8 %) related to general management and general treatment. The T-test analysis demonstrated that physicians in an urban setting (i.e., a community of 500 000) as compared to those in rural communities (i.e., a community of fewer than 50 000) were significantly more likely to ask questions relating to prevention and prophylactic treatment, blood and blood-forming organs, and diagnostic/investigative issues. Physicians who graduated from medical schools in Canada or the United States were more likely to ask questions diagnostic/investigative than were their colleagues who graduated outside of North America. Men rather than women were significantly more likely to ask questions relating to the circulatory system and to infectious and parasitic disease. Women significantly more frequently forwarded questions addressing pregnancy, childbirth, puerperium, and the perinatal period. Physicians who graduated in 1970 or later asked CAN. FAM. PHYSICIAN Vol. 35: MARCH 1989

questions relating to infectious and ily physicians have recognized the parasitic diseases and those relating to value and relevance of identifying the pregnancy, childbirth, and the perina- true, as well as the perceived, learntal period significantly more often ing needs of practising physicians. than did their colleagues who graduat- However, the time and costs of integrating objective strategies such as ed prior to 1970 (Table 2). practice profiles, medical audit, diDiscussion rect observation of physicians, and The questions generated by the studies of medical literature searches family physicians in this study did to obtain information has made such cluster in a manner that is helpful for diagnostic techniques difficult to intedetermining the general nature and grate into the planning process. The frequency of clinical questions cur- study shows that the generation of rently being posed by practising fami- practice-related questions could serve ly physicians in southern Alberta. as an attractive, less costly, objective Eleven of the 17 ICD. 9. CM catego- approach to the identification of true ries had 50 or more questions. The learning needs, as a minimum frequency of questions per category amount of practitioner time and efindicate specific areas that could be fort was required to generate the 579 addressed through hospital rounds, questions submitted. Using currently short courses, newsletters, and other available technology, such as a teleeducational events. The T-test analy- phone-answering machine and/or a sis will be helpful in the development mailbox in a central hospital location, of specific types of offerings geared to physicians could present questions physicians in larger rather than small- that have been troubling them. On a regular basis the questions could be er communities, earlier as compared to later graduates, and male- as com- centrally summarized and grouped for use in the planning of rounds, pared to female-practitioner groups. Because of the potential to change short course, newsletters, and other physician behaviour and practice pat- educational programs. Alternatively, terns, organizations providing educa- individual physicians could perioditional programs and materials to fam- cally assess the nature of questions

Table 1 Classification of Questions Submitted ICD.9.CM classification 579a Total # of questions submitted: 114 Genito-urinary system 78 Drug adverse effects/interactions/contraindications 69 Nervous system & sense organs 65 Musculo-skeletal system and connective tissue Certain conditions in perinatal period; 63 pregnancy, childbirth, puerperium 56 Digestive system 54 Circulatory system 52 Infectious & parasitic disease 52 Mental disorders 51 Endocrine, nutritional, metabolic, immunity 51 Prevention, prophylactic Tx 44 Respiratory diseases 38 Skin, subcutaneous tissue 27 Injury, poisoning 24 Neoplasms 18 Blood & blood-forming organs 7 Congenital anomalies Diagnostic, management, therapeutic classification 265 General management, general treatment 203 Diagnostic/investigative Pharmacology (therapeutics)

generated by patients in his/her own office practice. Family practitioners, alone or with the help of cME planners, could use these observations to plan and pursue learning activities specific to their unique clinical needs. Further studies must be carried out to detennine whether cME activities planned around specific family-practice questions are effective and well received. A pilot study has already reported that family practitioners and CMvE planners believe that the review of clusters of practice-generated questions submitted by family physicians would provide a satisfactory and beneficial approach to needs assessment.11 Investigators should design, implement, and evaluate an educational program based on the questions posed by family physicians and compare the results obtained with other studies in which the validity of other needs-assessment methods has been examined.m

Acknowledgements The authors wish to acknowledge Lynne Acton for her health-record technician assistance, and Son Nguyen for the data analyses.

Table 2 Differences in Classifications by Practice Location, place of M.D. Graduation, Gender, and Number of Years in Practice Classification Demographic 1. Prevention and Practice locationa prophylactic treatment 2. Blood and bloodforming organs 3. Diagnostic/investigative 1. Diagnostic/investigative Place of M.D. graduation 1. Circulatory system Gendera 2. Infectious and parasitic diseases 3. Pregnancy, childbirth, Puerperium and the perinatal period Number of years in practicea 1. Infectious and parasitic diseases 2. Pregnancy, childbirth, puerperium and the perinatal period a. Significant differences (p . 0.027).

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a. A number of questions were assigned to more than one category. CAN. FAM. PHYSICIAN Vol. 35: MARCH 1989

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BRIEF PRESCRIBING INFORMATION

ARTHRINOL* 325 ARTHRINOL* 500 (acetylsalicylic acid delayed-release capsules U.S.P.) Enteric coated with Sustained Action THERAPEUTIC OR PHARMACOLOGICAL CLASSIFICATION Analgesic, anfi-inflammatory and antipyretic ACTIONS Acetylsalicylic acid (ASA) interferes with the prodaction ot prostaglandins in various organs and tissues through acetylation at the enzyme cyclo-oxygenase. Prostaglandins are themselves powertal irritants tand produce headaches and pain an injection in man. Prostaglandins attn appear to sensiitze pain receptors to other noxious subatances sach as histamine and bradykinin. By preventing the synthesis and release of prostaglandins in inflammation, ASA may avert the sensitization of pain receptors. Acetytalicylic acid's antipyretic activity in doe to its ability to intertere with the production at prostaglandin E in the brain. Prostaglandin E, is one of the powertul pyretic agents known. ARTHRINOL* preparations consist at smalt enteric-coated ASA pellets contained in hard gelatin capsules. An such, their pharmacological effects are delayed following the initial dose. ARTHRINOL* capsules therefore are more useful tar chronic administration, as ia arthritis, than tar providing prompt reliet of pain and tever. The bioequivalence at ARTHRINOL* capsules to conventional enteric-coated tablets (Entrophent) was demonstrated in a single-dose, randomized, open-label, cross-over bioavailability study involving 24 male volunteers in both ted and tasted stute. Administration al a single 650 mg dose of both preparations to tasted subjects resulted in the following comparable mean salicylate pharmacokinetic parameters tar ARTHRINOL* sa Entrophent: C.., (mcg/mL): 32.7 us 31.7; tm., (hr): 5.3 u.s 6.0; apparent plasma elimination halt-life t, (hr): 2.6 ua 2.6. Salicylate pharmacokinetic parameters in fed subjects were similarly comparable: C,,.~: 32.2 as 29.8 mcg/mL; t_,,: 6.1 yas 7.0 hr; t, : 2.0 usa 2.7. Similarly, there were no significant differences observed between the regimens in terms of areas-under-the-curve or urinary excretion of salicylate either. The main difference observed in this study between ARTHIRINdOL and Entrophent was the fact that detectable salicylate blood levels occurred significantly earlier following adminstration at ARTHRINOL' than following Entrophent (1.4 us 3.1 bra in fasted subjects: 2.6 ua 5.3 hrs in fed subjects). In other comparative bioavailability study, at steady state, ARTHRINOL*, when administered at a dose of 1300 mg b. i. d. for 7 days, was shown to be absorbed mare rapidly and to a greater extent than Entrophent 650 mg q. i. d. far 7 days (t,,,,: 5.7 us 10.2 hrs; c,,,,: 09 us 02 mcg/mL; AUCu.,2: 790 vs 633 mcg hr/mL). Moreover, the administration of ARTH-RINOL* resuited in less subject-to-subject variability of plasma salicylate levels (mean between-subject coefficient of variation at plasma salicylate concentrations aver 24 bra.: 32% us 47%). la the same steady state bioavailability study, ARTHRINOL* 1500 mg b. i. d. produced significantly higher AUC's, maximum and morning plasma salicylate concentrations than either ARTHRINdOL 1300 mg b. i. d. or Entrophent 650 mg q. i. d. Affer absorbfion, ASA is rapidly hydrolyzed to salicylic acid. Salicylate is widely distributed throughout the body with highest concentrations found in the kidney cortex, liver, heart and lung. Brain concentrations are relatively low. The chief metabolic products are the conjugates with glycine (salicyluric acid) the ether or phenolic glucuronide (salicylic phenolic glucuronide) and the ester or acyl glucuronide (salicylic acyl glucaronide). A small fraction is oxidized to gentisic and other hydroxybenzoic acids. Excretion of salicylates is almost entirely via the kidney. INDICATIONS ARTHRINOL* (acetylsalicylic acid delayed-release capsules U.S.P.( is indicated for the relief of mild to moderate pain, fever and inflammation of a variety at conditions such ax arthritis, bursitis, burns, dysmenorrhea, fractures, injuries, low buck and neck pain, myositis, neuralgia, sprains and strains, synovihas, and following surgical procedures. Because at its delayed and sustained-release properties, ARTHRINOL* is more useful for chronic administrations than for providing prompt relief of acute pain and fever. ARTHRINOL* is indicated whenever reduced gastric intolerance to ASA is desired. CONTRAINDICATIONS Salicylate sensifivity, active peptic ulcer. PRECAUTIONS Administer salicylates cautiously to patients with a history of gastrointestinal ulcerations, bleeding tendencies, signit icant anemia or hypoprothrombinemia, severe hepatic damage or Vitamin K deficiency, as well un to those with asthma and other allergic conditions, including those patients known to be allergic to other non-steroidal antiinflammatory drugs. Patients with angioedema are particularly likely to have hypersensitivity reactions. Special precautions are necessary when administering salicylates to patients with chronic renal insufficiency. Patients taking ASA daily are at an increased risk of developing gastrointestinal bleeding following the ingestion of alcohol. Caution is necessary when salicylates and anticoagulants are prescribed concurrently, as salicylates can potentiate the action of anticoagulants and depress the concentration at prothrombin in the plasma. Diabetics receiving concurrent salicylate-hypoglycemic therapy should be monitored closely, and reduction of the sulfonylurea hypoglycemic drug dosage or insulin requirements may be necessary. Caution is advised when prescribing salicylate containing medications tar children and teenagers with influenza or chicken pox, because of possible association with Reye Syndrome, a rare but serious illness. Pregnancy: Because of possible effects an the neonate and the potential increase of maternal blood loss, ASA should be avoided during the last three months of pregnancy, unless the potential benefit outweighs the potential risks. ASA interferes with maternal and infant blood clotting and may lengthen the gestation and parturition time. Salicylate may appear in human breast milk and thus should be administered to nursing mothers with caution. Salicylates can produce changes in thyroid function tests. Sodium excretion produced by spironolactone may be decreased by salicylate administration. Salicylates in large doses are uricosuric agents, smaller amounts may depress uric acid clearance and thus decrease the uricosuric effects at other drugs. Salicylates alan retard the renal elimination of methotresate. Salicylates, in doses greater than 2 g per day, have a hypoglycemic effect Salicylates compete with a large number at drugs (e. g. phenytoin, thyroxin, warfarin, naprosin and others) for salicylate binding sites. Uremia and/or reduced albumin levels are likely to produce higher concentrations of free drug which maj increase the pharmacological effect. Hepatotoxicity which is dose dependent and not associated with hypersensitivity may occur. Acute hepatitis been reported rarely in patients with systemic lupus erythematosus and juvenile rheumatoid arthritis with total plasma salicylate concentrations above 25 mg/100 mL (1.8 mMol/L). Prolonged excessive use of salicylates in analgesic mixtures may produce papillary necrosis and interstitial nephritis. ADVERSE EFFECTS The following adverse effects, pertaining to conventional ASA dosage forms, should be kept in mind when administering ARTHRINOL*: Gastrointestinal: nausea, vomiting, diarrhea, gastrointestinal bleeding and/or ulceration, dyspepsia, heartburn. Ear: tinnitus, vertigo, hearing loss. Hematologic: Leukopenia, thrombocytopenia, purpura, anemia. Dermatologic and hypersensihvity: urticaria, angioedema, pruritus, akin eruptions, asthma, anaphylaxis: patients with a history of angioedema are at higher risk to develop anaphylactic reaction. Miscellaneous: mental confusion, drowsiness, sweating, thirst, acute reversible hepatotoxicity. SYMPITOMS AND TREATMENT OF OVERDOSAGE Signs of mild salicylate toxicity may occur at concentrations sf 1.5 mMol/L (200 mcg/mL(, severe toxic effects may occur above 3.0 mMol/L (400 mcg/mL(. In mild overdosage these may include sapid and deep breathing, nausea, vomiting, vertigo, tinnitus, flushing, sweating, thirst and tachycardia. In more severe cases, acid-base disturbances including respiratory alkalosis and metabolic acidosis can occur. Severe cases may show fever, dehydration, oliguria, hemorrhage, excitement, confusion, convulsions or coma and respiratory failure. Hypoglycemia or hyperglycemia may occur. Treatment is largely symptomatic and supportive. Induce vomiting and perform gastric lavage, then administer activated charcoal. Treatment consists of prevention and management at acid-base and fluid and electrolyte disturbances. Renal clearance is increased by increasing urine flow and by alkaline diuresis but care must be taken in this approach to not farther aggravate metabolic acidosis and hypokalemia. Acidemia should be prevented by administration of adequate sodium containing fluids and sodium bicarbonate. Hypoglycemnia is an occasional accompaniment of salicylate overdosage and can be managed by glucose solutions. If a hemorrhagic diathesis is evident, give vitamin K. Peritoneal or hemodialysis may be required if serum salicylate concentrations are greater than 7.25 mMol/L (1.0 mg/mL( 6 hours affer ingestion, in complex acid base disturbances not responsive to conventional therapy, it the patient is in renal failure or it the patient is deteriorating despite appropriate clinical care. Use general supportive measures for depressed respiration. Treat convulsiosn with a suitable drug of choice according to the patient's clinical condition and the physician's judgment. Hyperthermia and dehydration are an immediate threat to life. Initial therapy must be directed to their correction. DOSAGE Analgesic and antipyretic: Usual adult dose is two capsules two to four times a day, consecutive doses not to be taken at less than four-hour intervals. Patients should be advised not to exceed 4.00g ASA daily. If underlying condition requires the use of ARTHRINOL* for more than 5 days, a physician should be consulted. Anti-inflammatory: Adults: Because the suppression of inflammation increases even when the dosage of salicylates is raised beyond toxic levels, the therapeutic objective is to employ as large a dose as possible short of toxicity. 3 or 4 capsules of ARTHRINOL' 325 or ARTHRINOL* 500. B. I. 0., T. I. D. orG0. I. D., as required. Dosage needs to ha adjusted individually to achieve maximum therapeutic salicylate blond levels (generally between 150 and 300 mcg/mL(. Titrate the dosage by starting with 2.61to 4 g daily according lathe size, age and sex of the patient. If necessary, the dosage is then gradually adjusted by daily increments at 0. g to 0.65 g ASA until symptoms of salicylism e.g. tinnitus occurs. Then the dosageis decreased by the same amount daily until tinnitas disappears and maintained at that level as long as necessary. Plasma salicylate concentration determination is recommended because at wide variations in pharmacokinetics, particularly if high dosage regimen are used, or in the elderly or in those with hearing impairment. AVAILABILITY ARTHRINOL* 325 is available as red and colorless capsules, each containing 325 mg ASA, in battles at 100, and blister packages of 24 capsules. ARTHRIN4OL' 500 is available as orange and colorless capsules, each containing 500 mg ASA, in baffles of 100 and 500. Alan available in blister packages at 24 capsules and physicians' samples oft6 capsules.

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Refenences: 1. Leonardo, J.R. and Levy, G.: Absorption and Metabolism of Aspirin Administered in Enteric-Coated Tablets. JAMA 1005: 193(2): 93-98. 2. Data an file, Sterling Drag Ltd. 3. Anslow, J. A., Greene, D.S., Hooper, J.W., Wagner, G.S.: Faster and More Reliable Delivery at Salicylic Acid From Enteric-Coated Aspirin Granules Versus Enteric-Coated Aspirin Tablets. Current Therapeutic Research 1984: 36(5): 811-818: 4. Lanza, F. L., Rack, M.F., Wagner, GOS., Balm, T.K.: Reduction in Gastric Mucxsal Hemorrhage and Ulceration with Chronic High-Level Dosing at EntenicCoated Aspirin Granules Two and Four Times a Day. Digestive Disease and Sciences 1985: 30(6): 509-512. 5. Portek, I., Graham, G., Fleming, A,: EtrC-Cote Peltize Aspirin.PGasroitesina BloodLossA an BiaaiaiAt. Me JAu-Int191 2:392-40. 6. Be tof C.,C1--n I,

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