Recommendations on breast cancer screening and prevention in the context of implementing risk stratification: impending changes to current policies.

In recent years, risk stratification has sparked interest as an innovative approach to disease screening and prevention. The approach effectively personalizes individual risk, opening the way to screening and prevention interventions that are adapted to subpopulations. The international perspective project, which is developing risk stratification for breast cancer, aims to support the integration of its screening approach into clinical practice through comprehensive tool-building. Policies and guidelines for risk stratification-unlike those for population screening programs, which are currently well regulated-are still under development. Indeed, the development of guidelines for risk stratification reflects the translational aspects of perspective. Here, we describe the risk stratification process that was devised in the context of perspective, and we then explain the consensus-based method used to develop recommendations for breast cancer screening and prevention in a risk-stratification approach. Lastly, we discuss how the recommendations might affect current screening policies.

The longitudinal case study: from Schön's model to self-directed learning.

BACKGROUND: Rapid changes observed in information technologies, medical practice, and learning methods encourage physicians to develop new updating strategies. To test its feasibility and to help physicians devise new learning and updating strategies, the knowing-in-action model developed by Schön was applied in planning and evaluating an interactive workshop. Acquisition of knowledge was tested. METHODS: The office and hospital charts of a family physician were reviewed. They were used to prepare a longitudinal case study, based on the real-life story of a hypertensive patient followed by her doctor over a period of 15 years. The clinician's approach to solving clinical problems was triangulated for credibility with general practitioners, specialists, and the information available in the literature. This longitudinal case study was used to develop an interactive educational workshop. The workshop was presented to physicians who had registered in an accredited continuing medical education event. Changes in pre- and postevent knowledge among the participants were assessed using touch pad technology to evaluate the effectiveness of this approach on the acquisition of knowledge related to management of arterial hypertension and associated clinical problems. RESULTS: A comparison of pre- and post-test data showed a significant improvement in knowledge for participants who answered all questions on both questionnaires (n = 8/37). The average score of these participants increased from 5.5 of 10 before the workshop to 8.3 of 10 after the workshop (p < .05). Participants reported a high satisfaction rate for the event. FINDINGS: A workshop using the longitudinal case study enables physicians to perceive their daily practice through a continuing education activity in which they experience the processes of reflection in action and reflection on action described by Schön. It also increases awareness of the gap between current practice and experts' recommendations and provides an opportunity to evaluate the means for bridging or closing this gap. It sensitizes the physician to patients' changing needs and prompts the clinician to reflect on the who, what, when, where, and how of learning.

Educational skills and knowledge needed and problems encountered by continuing medical education providers.

BACKGROUND: The objective of this study was to identify the training needs and difficulties encountered by continuing medical education (CME) providers in Quebec. METHODS: A questionnaire comprised of open-ended and closed questions was sent to 224 general practitioners across Quebec who organize CME meetings. To complement and validate the data, interviews were conducted with 18 physicians selected from this group, based on their years of experience with CME, and with the managers of two organizations involved in CME. RESULTS: The questionnaire response rate was 54%. Quantitative analysis was used to identify the main training needs expressed by CME providers affiliated with the Quebec Federation of General Practitioners, namely, methods for identifying needs (74%), group leadership techniques (69%), basic principles in adult education (69%), and organization of CME activities (66%). The main problems encountered by respondents in their duties are stimulating and maintaining the interest and participation of physicians in formal CME activities (52%), identifying and meeting physicians' educational needs (32%), and motivating physicians to get involved in any kind of CME initiative (18%). The interviews highlighted the wide disparity in the approaches used by CME providers when planning activities and the failure of providers to pass on relevant information to their successors. IMPLICATIONS: Based on the difficulties and the training needs identified, we were able to develop tools (structured training program, biannual newsletter, reference books, and resources) suited to the needs of general practitioners who organize CME activities.

An interactive workshop: An effective means of integrating the Canadian Cardiovascular Society clinical practice guidelines on congestive heart failure into Canadian family physicians' practice.

OBJECTIVE: To use an interactive workship as a means of integrating clinical practice guidelines on congestive heart failure into Canadian family physicians' practice. SETTING: Interested practitioners from the Association des Médecins Omnipraticiens de Québec, the Centre de Santé Publique de Québec and the continuing medical education (CME) department, Merck Frosst Canada, Montreal, formed the initial task force. Train-the-trainer sessions took place in many provinces in a variety of CME settings. DESIGN: The interactive, problem-based workshop was facilitated by local interested general practitioners, while local experts served as consultants to reinforce key messages from clinical practice guidelines and to guide participants through the learning process. MAIN RESULTS: By December 31, 1996, 187 family practitioners and 81 specialists had been trained in train-the-trainer sessions across the country. A total of 1698 general practitioners had participated in over 52 workshops during the same time. Pre- and postworkshop testing indicate that the workshops improved knowledge, and that the knowledge gained during the workshop was retained at three- and six-months' follow-up. Separate chart evaluations conducted before and after the workshop showed that participants provided more complete chart information related to congestive heart failure and that they significantly increased their use of angiotensin-converting enzyme inhibitor therapy after the workshop. Participant evaluation of the workshop also indicates a high index of satisfaction with the presentation and the content of the workshop as being relevant to clinical practice. CONCLUSION: An interactive, problem-based, small group workshop developed by a core group of interested practitioners and guided by local trained facilitators and experts is an effective teaching tool through which clinical practice guidelines can be successfully transferred into clinical practice in a timely and meaningful way.