Should we screen aging physicians for cognitive decline?

OBJECTIVES: To synthesize evidence relevant for informed decisions concerning cognitive testing of older physicians. METHODS: Relevant literature was systematically searched in Medline, EMBASE, PsycInfo, and ERIC, with key findings abstracted and synthesized. RESULTS: Cognitive abilities of physicians may decline in an age range where they are still practicing. Physician competence and clinical performance may also decline with age. Cognitive scores are lower in physicians referred for assessment because of competency or performance concerns. Many physicians do not accurately self-assess and continue to practice despite declining quality of care; however, perceived cognitive decline, although not an accurate indicator of ability, may accelerate physicians' decision to retire. Physicians are reluctant to report colleagues' cognitive problems. Several issues should be considered in implementing cognitive screening. Most cognitive assessment tools lack normative data for physicians. Scientific evidence linking cognitive test results with physician performance is limited. There is no known level of cognitive decline at which a doctor is no longer fit to practice. Finally, relevant domains of cognitive ability vary across medical specialties. CONCLUSION: Physician cognitive decline may impact clinical performance. If cognitive assessment of older physicians is to be implemented, it should consider challenges of cognitive test result interpretation.

Reducing prescribing of benzodiazepines in older adults: a comparison of four physician-focused interventions by a medical regulatory authority.

BACKGROUND: The inappropriate and/or high prescribing of benzodiazepine and 'Z' drugs (BDZ +) is a major health concern. The purpose of this study was to determine whether physician or pharmacist led interventions or a simple letter or a personalized prescribing report from a medical regulatory authority (MRA) was the most effective intervention for reducing BDZ + prescribing by physicians to patients 65 years of age or older. METHODS: This was a four-armed, one year, blinded, randomized, parallel-group, investigational trial in Alberta, Canada. Participants were fully licensed physicians (n = 272) who had prescribed 4 times the defined daily dose (4 + DDD) or more of any BDZ + to an older patient at least once in the 3rd quarter of 2016. All physician-participants were sent a personalized prescribing profile by the MRA. They were then randomized into four groups that received either nothing more, an additional personal warning letter from the MRA, a personal phone call from an MRA pharmacist or a personal phone call from an MRA physician. The main outcomes were prescribing behavior change of physicians at one year in terms of: change in mean number of older patients receiving 4 + DDD BDZ + and mean dose BDZ + prescribed per physician. To adjust for multiple statistical testing, we used MANCOVA to test both main outcome measures simultaneously by group whilst controlling for any baseline differences. RESULTS: All groups experienced a significant fall in the total number of older patients receiving 4 + DDD of BDZ + by about 50% (range 43-54%) per physician at one year, and a fall in the mean dose of BDZ + prescribed of about 13% (range 10-16%). However, there was no significant difference between each group. CONCLUSIONS: A personalized prescribing report alone sent from the MRA appears to be an effective intervention for reducing very high levels of BDZ + prescribing in older patients. Additional interventions by a pharmacist or physician did not result in additional benefit. The intervention needs to be tested further on a more general population of physicians, prescribing less extreme doses of BDZ + and that looks at more clinical and healthcare utilization outcomes.

"Keep it short and sweet": Improving risk communication to family physicians during public health crises.

OBJECTIVE: To identify recommendations from family physicians in Canada on how public health agencies and professional organizations might improve future crisis and emergency risk communications. DESIGN: Qualitative content analysis. SETTING: Canada. PARTICIPANTS: Sixteen family physicians who have experienced a public health crisis. METHODS: Semistructured interviews were conducted with 16 family physicians practising in various regions across Canada who had experienced what they defined as a public health crisis. These events included environmental crises, like forest fires and hurricanes, and infectious disease crises, like the SARS (severe acute respiratory syndrome) and H1N1 outbreaks. Interview transcripts were coded using an inductive qualitative content analysis method, specifically focusing on recommendations from participants on how to improve risk communication to family physicians in the event of a future public health crisis. MAIN FINDINGS: Based on their personal experiences, participants had many explicit recommendations on how to improve risk communication strategies in the event of a future public health crisis. These included having a single trusted source of information; having timely and succinct communication; having consideration for learners; ensuring access to information for all physicians; improving public health and family medicine collaboration; having crisis information for patients; and creating communication infrastructure before a crisis occurs. CONCLUSION: This research provides thoughtful and varied considerations and advice from practising family physicians on how to improve risk communication from public health agencies and professional organizations to this group in the event of a public health crisis. With improved communications between these bodies and family physicians, practitioners will be better informed and prepared to provide the best possible care to their patient populations during such events.

A descriptive report of end-of-life care practices occurring in two neonatal intensive care units.

BACKGROUND: In Canada and other developed countries, the majority of neonatal deaths occur in tertiary neonatal intensive care units. Most deaths occur following the withdrawal of life-sustaining treatments. AIM: To explore neonatal death events and end-of-life care practices in two tertiary neonatal intensive care settings. DESIGN: A structured, retrospective, cohort study. SETTING/PARTICIPANTS: All infants who died under tertiary neonatal intensive care from January 2009 to December 2013 in a regional Canadian neonatal program. Deaths occurring outside the neonatal intensive care unit in delivery rooms, hospital wards, or family homes were not included. Overall, 227 infant deaths were identified. RESULTS: The most common reasons for admission included prematurity (53.7%), prematurity with congenital anomaly/syndrome (20.3%), term congenital anomaly (11.5%), and hypoxic ischemic encephalopathy (12.3%). The median age at death was 7 days. Death tended to follow a decision to withdraw life-sustaining treatment with anticipated poor developmental outcome or perceived quality of life, or in the context of a moribund dying infant. Time to death after withdrawal of life-sustaining treatment was uncommonly a protracted event but did vary widely. Most dying infants were held by family members in the neonatal intensive care unit or in a parent room off cardiorespiratory monitors. Analgesic and sedative medications were variably given and not associated with a hastening of death. CONCLUSION: Variability exists in end-of-life care practices such as provision of analgesic and sedative medications. Other practices such as discontinuation of cardiorespiratory monitors and use of parent rooms are more uniform. More research is needed to understand variation in neonatal end-of-life care.

Cross-sectional study of rapid tapering of opioid prescriptions following medical regulatory intervention in Alberta from 2013 to 2020.

OBJECTIVE: To determine if inappropriate tapering/discontinuation of opioids to Alberta patients occurred from mid-2013-2020, as unintended consequences of prescribing guidelines, regulations and policies in response to the North American opioid crisis. DESIGN: A population-based, repeated cross-sectional time-series study. SETTING: Alberta, Canada. PARTICIPANTS: Residents of Alberta, Canada aged 18 and older who received an opioid dispense from a community pharmacy from 2013 to 2020. MAIN OUTCOME MEASURES: The prevalence of potential rapid tapering was measured at a given date (reference day), enveloped by a data window. Dose changes were measured as oral morphine equivalents (OME) per patient, at multiple time points ('data window' around a reference day). Chronic recipients were identified, and their prescriptions were contrasted 90 days before and after the reference day to measure OME/day changes. RESULTS: Approximately 9000 dispenses (totalling ~6 million OME) per day were analysed from 2013 to 2020. The total number of opioid recipients was highly cyclic in nature (peaking in winter). The number of chronic opioid recipients remained somewhat stable from ~70K in 2013 to ~86K at the end of 2020. The number of chronic high and very high dose recipients presented a significant decrease after 2017. Approximately 11%-12% of chronic high-dose recipients experienced potential rapid dose tapering at a rate of 50% or more prereference to postreference day at any given point of time. For chronic very high dose recipients, approximately 11.5% experience potential rapid dose tapering at a rate of 50% or more prereference to postreference day at any given point of time. Potential discontinuation remained constant and the interventions did not have a significant impact on the trend. CONCLUSION: The evidence suggests that changes in prescribing guidelines were not associated with an increase of rapid opioid tapering/discontinuation in Alberta.

Exploring Content Relationships Among Components of a Multisource Feedback Program.

INTRODUCTION: A new multisource feedback (MSF) program was specifically designed to support physician quality improvement (QI) around the CanMEDS roles of Collaborator , Communicator , and Professional . Quantitative ratings and qualitative comments are collected from a sample of physician colleagues, co-workers (C), and patients (PT). These data are supplemented with self-ratings and given back to physicians in individualized reports. Each physician reviews the report with a trained feedback facilitator and creates one-to-three action plans for QI. This study explores how the content of the four aforementioned multisource feedback program components supports the elicitation and translation of feedback into a QI plan for change. METHODS: Data included survey items, rater comments, a portion of facilitator reports, and action plans components for 159 physicians. Word frequency queries were used to identify common words and explore relationships among data sources. RESULTS: Overlap between high frequency words in surveys and rater comments was substantial. The language used to describe goals in physician action plans was highly related to respondent comments, but less so to survey items. High frequency words in facilitator reports related heavily to action plan content. DISCUSSION: All components of the program relate to one another indicating that each plays a part in the process. Patterns of overlap suggest unique functions conducted by program components. This demonstration of coherence across components of this program is one piece of evidence that supports the program's validity.

Survey of physician attitudes to using multisource feedback for competence assessment in Alberta.

BACKGROUND: The use of multisource feedback (MSF) for assessing physician performance is widespread and rapidly growing. Findings from early very small research studies using highly selected participants suggest high levels of satisfaction and support. However, after nearly two decades of experience using MSF to evaluate all physicians in Alberta, we are sceptical of this. OBJECTIVES: To determine physicians' actual opinions of MSF using the entire physician population of Alberta, Canada DESIGN: Online survey. SETTING: Alberta, Canada. PARTICIPANTS: All physicians with a full licence to practice in Alberta in 2015. INTERVENTIONS: All participants were asked to grade how well they thought MSF was at assessing various aspects of physician performance using a 10-point Likert-type scale. There was also a text response field for written comments. OUTCOMES: Mean responses to quantitative questions. Qualitative content and thematic analysis of open-ended text responses.We analysed the data using SPSS V.23 and NVivo V.11 and built a multivariate model highlighting the predictors of high and low opinions of MSF. RESULTS: Survey response rate was high for physicians with 2215 responses (25%). The mean rating for how successful MSF was at assessing a variety of dimensions, varied from a low of 5.03/10 for medical knowledge to a high of 6.38/10 for professionalism and communication. Canadian-trained MDs rated MSF significantly lower on every dimension by approximately 20% compared with non-Canadian-trained MDs. CONCLUSIONS: Alberta physicians have much lower opinions about the ability of MSF to measure any dimension of their performance than what has been suggested in the literature. Canadian-trained MDs have a particularly low opinion of MSF for reasons that remain unclear. The results of this survey offer a serious challenge to the effectiveness of a programme that is designed to promote self-reflection and performance improvement.

Experiential knowledge of risk and support factors for physician performance in Canada: a qualitative study.

OBJECTIVE: To identify, understand and explain potential risk and protective factors that may influence individual and physician group performance, by accessing the experiential knowledge of physician-assessors at three medical regulatory authorities (MRAs) in Canada. DESIGN: Qualitative analysis of physician-assessors' interview transcripts. Telephone or in-person interviews were audio-recorded on consent, and transcribed verbatim. Interview questions related to four topics: Definition/discussion of what makes a 'high-quality physician;' factors for individual physician performance; factors for group physician performance; and recommendations on how to support high-quality medical practice. A grounded-theory approach was used to analyse the data. SETTING: Three provinces (Alberta, Manitoba, Ontario) in Canada. PARTICIPANTS: Twenty-three (11 female, 12 male) physician-assessors from three MRAs in Canada (the College of Physicians & Surgeons of Alberta, the College of Physicians and Surgeons of Manitoba and the College of Physicians and Surgeons of Ontario). RESULTS: Participants outlined various protective factors for individual physician performance, including: being engaged in continuous quality improvement; having a support network of colleagues; working in a defined scope of practice; maintaining engagement in medicine; receiving regular feedback; and maintaining work-life balance. Individual risk factors included being money-oriented; having a high-volume practice; and practising in isolation. Group protective factors incorporated having regular communication among the group; effective collaboration; a shared philosophy of care; a diversity of physician perspectives; and appropriate practice management procedures. Group risk factors included: a lack of or ineffective communication/collaboration among the group; a group that doesn't empower change; or having one disruptive or 'risky' physician in the group. CONCLUSIONS: This is the first qualitative inquiry to explore the experiential knowledge of physician-assessors related to physician performance. By understanding the risk and support factors for both individual physicians and groups, MRAs will be better-equipped to tailor physician assessments and limited resources to support competence and enhance physician performance.