The May 3 issue of JAMA (subscription req’d for full text) contains a review of a book that we all should read: How Doctors Think: Clinical Judgment and the Practice of Medicine, by Kathryn Montgomery

The review, by Donald Moore, Jr., calls it “a thoughtful and provocative book that challenges us to reconceptualize our assumptions about how physicians think in the clinical encounter, how physicians-in-training are taught, and how physicians and patients interact.” And, he concludes, “How Doctors Think is a useful book for everyone involved in medicine, from medical educators, who could use it to develop a more humane approach to medical education, to individual practitioners, who could use it to help reflect on and improve their clinical practice.”

Recommended reading from Anne Taylor-Vaisey: Knowledge retention and improved patient outcomes are pretty much the purpose of continuing education, aren’t they? This study just published in the May issue of the American Journal of Surgery reports a positive outcome from a surgical CE event:

Cheifetz RE, Phang PT. Evaluating learning and knowledge retention after a continuing medical education course on total mesorectal excision for surgeons. Am J Surg 2006;191:687-690.

Abstract: The purpose of this study was to determine whether knowledge gained (as determined by a formal course test) by surgeons in a continuing education course on total mesorectal excision and rectal cancer management is retained 1 year later. A formal course test had been previously developed and validated. The test evaluated course content including pelvic anatomy, surgical techniques, imaging, pathology, adjuvant therapies, and cancer and functional outcomes. Validation was determined by the absence of change in pre- and posttest scores of the “expert” course instructors (n = 8, P = .6) and by a linear correlation in test scores with increasing level of general-surgery resident training (n = 16, P = .001). Significant learning by the 58 surgeons taking the course had been shown by improvement in test scores from before the course (mean score 19) to after the course (mean score 25.3, P = .001, out of a possible 33 total mark). At 1 year after the course, those course participants (n = 44, 76%) who had provided postcourse contact information were asked to complete the course test again. Responses were received from 18 surgeons (41% of those surveyed, 31% of the original course participants). The mean score on the test after 1 year was 23.8. Compared with the immediate posttest scores, there was no significant knowledge loss over the year (P = .09). We conclude that knowledge acquired during a continuing education course for surgeons on total mesorectal excision and rectal-cancer management is retained 1 year later.

Excerpt from Comments: Evaluation of CME programs tends to be focused, for the providers, on attendance and, for the participants, on satisfaction. Postcourse evaluation forms consist of questions rating the quality of the presentations and venue and a subjective assessment of whether or not course objectives were met. Little attention is generally paid to whether material was actually learned and even less so on whether practice is changed. Increasingly, CME programs will need to show their effectiveness in broader ways. For example, accreditation of courses by the Royal College of Physician and Surgeons of Canada currently lists assessment of learning as an optional component for course accreditation, but it is expected that fully accredited courses will have this mandated. Recommendations have already been made to the Association of American Medical Colleges promoting systems to measure learning and validate educational effectiveness of CME programs.

Pubmed record        Related articles        Journal issue (full text by subscription)

For more of Anne’s recommended reads, click here.

This is one story that just isn’t quitting: Now BusinessWeek is talking about “disease mongering.” Here’s a snip:

The skeptics aren’t convinced that doctors will be so discriminating, in part because many get their information about disease treatment from the drug industry. Pharmaceutical companies routinely subsidize continuing medical education courses for doctors. They fund research for diseases that then gets published in medical journals, and they underwrite patient advocate groups, which in turn promote the underwriter’s drugs on their Web sites. Witness the Child & Adolescent Bipolar Foundation: It lists four pharmaceutical companies as major donors, including Eli Lilly & Co. and Janssen LP, makers of leading mood stabilizers.

Some Australian oncologists are asking physicians who give rosy presentations on some pricey cancer drugs to come clean about their connections to pharma, according to The Age. Here’s a snip:

Dr Haines said that when he started oncology in the 1980s, doctors had meetings to discuss research over a cup of tea. Now the get-togethers were “lavish” dinners paid for by drug companies.



At a meeting a few years ago, he queried a drug’s effectiveness. He was told that perhaps he should pay for his own dinner.




“It was said with a smile, but it is ’shut up and don’t rock the boat’. It’s hard to get a decent opinion any more at these meetings, because no one wants to be left off the gravy train.




“(Other doctors) share my views and they say, ‘I agree, but I can’t afford (to speak) at this stage of my career.”‘




The doctors said they had accepted trips to major conferences and entered patients in drug company trials, but they were not paid as consultants to any pharmaceutical company.

Recommended reading from Anne Taylor-Vaisey: This article was just published in Cyberpsychology & behavior : the impact of the Internet, multimedia and virtual reality on behavior and society. (How's that for a title?) The December 2005 issue is free and it contains some pretty interesting articles.

Roy MJ, Sticha DL, Kraus PL, Olsen DE. Simulation and virtual reality in medical education and therapy: a protocol. Cyberpsychol Behav 2006;9:245-247.

Abstract: Continuing medical education has historically been provided primarily by didactic lectures, though adult learners prefer experiential or self-directed learning. Young physicians have extensive experience with computer-based or "video" games, priming them for medical education- and treating their patients-via new technologies. We report our use of standardized patients (SPs) to educate physicians on the diagnosis and treatment of biological and chemical warfare agent exposure. We trained professional actors to serve as SPs representing exposure to biological agents such as anthrax and smallpox. We rotated workshop participants through teaching stations to interview, examine, diagnose and treat SPs. We also trained SPs to simulate a chemical mass casualty (MASCAL) incident. Workshop participants worked together to treat MASCAL victims, followed by discussion of key teaching points. More recently, we developed computer-based simulation (CBS) modules of patients exposed to biological agents. We compare the strengths and weaknesses of CBS vs. live SPs. Finally, we detail plans for a randomized controlled trial to assess the efficacy of virtual reality (VR) exposure therapy compared to pharmacotherapy for post-traumatic stress disorder (PTSD). PTSD is associated with significant disability and healthcare costs, which may be ameliorated by the identification of more effective therapy.

PubMed Record  

For more of Anne’s recommended reads, check out ATV’s Page.

Recommended reading from Anne Taylor-Vaisey: From the May 2006 issue of Headache: Patwardhan MB, Samsa GP, Lipton RB, Matchar DB. Changing physician knowledge, attitudes, and beliefs about migraine: evaluation of a new educational intervention. Headache 2006; 46(5):732-741.

Objective: Use a presurvey of primary care providers (PCPs) enrolled in a continuing medical education (CME) program on headache management to ascertain their existing knowledge, attitudes, and beliefs regarding migraine and use a postsurvey to determine the extent to which the CME program has brought participant knowledge, attitudes, and skills closer to conformance with best evidence.

Background: Migraine is a common and debilitating condition, which PCPs may not always manage satisfactorily. In an effort to improve management, the American Headache Society has developed a CME program called BRAINSTORM that encourages PCPs to adopt the US Headache Consortium Guidelines for headache care.

Methods: A 20-item questionnaire was developed that covered the essential elements of migraine care. The questionnaire was administered before and after a BRAINSTORM* presentation to 254 consenting primary care clinicians attending a medical meeting at 1 of 6 sites. A control group of 112 comparable physicians who did not attend the presentation completed the same questionnaire. Prepresentation scores of attendees were compared to scores of nonattendees to assess the generalizability of results. Prepresentation scores on selected questions were used to assess participant baseline knowledge, attitudes, and beliefs. Pre- and postpresentation scores for attendees at all sites were compared using the Mantel-Haenszel statistic to assess the effectiveness of the BRAINSTORM CME. Pre- and postpresentation scores were compared by site using the Breslow-Day test to evaluate any differential impact based on CME location.

Results: Prepresentation scores of attendees and nonattendees were found to be similar. No significant difference in performance was noted across sites. A chi-square analysis revealed a statistically significant difference between pre- and postpresentation scores for 16 of the test's 20 questions. In the pretest, all participants scored <66% on 2 questions related to prevalence, impact, and pathophysiology of migraine, 2 questions pertaining to history taking/physical examination, and 3 migraine management questions. Attendee scores improved to >66% posttest on all except 2 questions related to prevalence, impact, and pathophysiology of migraine.

Conclusion: Our results indicate that PCPs need to acquire greater understanding about the epidemiology and pathophysiology of migraine and may require guidance in history taking and physical examination of migraine patients. Improvement in scores posttest confirms that the BRAINSTORM program has a significant immediate impact on the knowledge, beliefs, and attitudes of participants. The program could be strengthened to improve emphasis in some areas where posttest scores showed no improvement.

BRAINSTORM is a 2½-hour interactive program that uses video case vignettes, animation, and illustrations to examine the impact of headache on patients' lives and teach the diagnosis and treatment of patients with migraine disorders. Four distinct modules, each 20 minutes in length, convey specific educational messages on

(1) understanding the prevalence and impact of migraine,

(2) understanding migraine mechanisms,

(3) history taking/physical examination and diagnosis of migraine, and

(4) migraine management.

Physician experts act as facilitators for the program. To ensure that a consistent message is conveyed in every presentation, facilitators are trained by AHS and provided with a guidebook and a CD-ROM. They guide participant discussion of the materials presented and ensure time for questions and answers. All participants are provided with a workbook, a CD-ROM with program material, and directions to other educational resources for physicians and patients.

PubMed Record       Related Articles        Journal Record 

For more of Anne’s recommended reads, check out ATV’s Page.