A Community of Practice of primary health care occupational therapists: Advancing practice-based knowledge.

INTRODUCTION: New contexts of practice demand that professionals engage in critical reflection to handle new situations and to create new knowledge that is responsive to professional practices situated in unique historical and social contexts. Community of Practice offers a framework for professions to reflect together on practice dilemmas and to generate practical solutions. METHODS: This paper presents a participatory action research project that traces the trajectory of a Community of Practice made up of seven occupational therapists working in primary health care and a researcher team, in Brazil. This study mapped the Community of Practice's trajectory between 2013 and 2017 through a group timeline analysis, which occurred gradually, in a collaborative mode. RESULTS: Three distinct phases in the trajectory of the development of the Community of Practice were identified: narrative perspectives were utilised as a means to identify dilemmas and difficulties in practice; the investigation of clients' needs and identification of issues was an ongoing process; and the generation of practice-based knowledge through the development of instruments to sustain clinical reasoning was a creative solution to practical dilemmas. CONCLUSION: Three main aspects were highlighted: the partnership between researchers and practitioners as a potential avenue for the production of knowledge relevant to professional practice; the negotiation of the dilemma of "putting practice into words" in the context of constantly changing local and global perspectives; and the investigation of situated practice as an important element that can strengthen, strain, resist or even modify hegemonic perspectives of knowledge production in our field.

Reclaiming a theoretical orientation to reflection in medical education research: a critical narrative review.

CONTEXT: Reflection and reflective practice have become popular topics of scholarly dialogue in medical education. This popularity has given rise to checklists, portfolios and other tools to inspire and document reflection. We argue that some of the common ways in which reflection has been applied are influenced by broader discourses of assessment and evidence, and divorced from original theories of reflection and reflective practice. METHODS: This paper was developed using a critical narrative approach. First we present two theoretical lenses provided by theories of reflection. Next we present a summary of relevant literature, indexed in PubMed from 2004 to 2014, relating to the application of reflection or reflective practice to undergraduate and postgraduate medical education. We categorise these articles broadly by trends and problematise the trends relative to the two theoretical lenses of reflection. RESULTS: Two relevant theoretical orientations of reflection for medical education are: (i) reflection as epistemology of practice, and (ii) reflection as critical social inquiry. Three prevalent trends in the application of reflection to medical education are: (i) utilitarian applications of reflection; (ii) a focus on the self as the object of reflection, and (iii) reflection and assessment. These trends align with dominant epistemological positions in medicine, but not with those that underpin reflection. CONCLUSIONS: We argue for continued theorising of and theoretically informed applications of reflection, drawing upon epistemologies of practice and critical reflection as critical social inquiry. These directions offer medical education research broad and deep potential in theories of reflection, particularly in relation to knowledge creation within uncertain and complex situations, and challenging of dominant discourses and structures. Future work could explore how dominant epistemological positions and discourses in medicine influence theories from other disciplines when these theories are deployed in medical education.

Measuring overuse with electronic health records data.

OBJECTIVES: To measure overuse of low-value care using electronic health record (EHR) data and manual chart review and to evaluate whether certain low-value services are better captured using EHR data. STUDY DESIGN: We implemented algorithms to extract performance on 13 Choosing Wisely-identified healthcare services using EHR data at a large physician practice group between 2011 and 2013. METHODS: We calculated rates of overuse using automated EHR extracts. We manually reviewed the charts for 200 cases of overuse for each measure to determine if they had clinical risk factors that could explain use of the low-value service and then calculated adjusted rates of overuse. We explored trends in overuse for each low-value service in the 3-year duration using logistic regression. RESULTS: Unadjusted rates of overuse ranged from 0.2% to 92%. Automated EHR extracts and manual chart review identified explanatory risk factors for most measures, although the magnitude varied: for some measures (eg, bone densitometry exam for women younger than 65 years), manual chart review did not identify many additional risks (3.0%). In contrast, in patients who had sinus computed tomography or an antibiotic prescription for uncomplicated acute rhinosinusitis, manual chart review identified more explanatory risk factors (22.5%) than the automated EHR extract (9.5%). Adjusted rates of overuse ranged from 0.2% to 61.9%. Eight services demonstrated a statistically significant decrease in overuse over 3 years, while 1 increased significantly. CONCLUSIONS: The use of EHR data, both extracted and manually abstracted, provides an opportunity to more accurately and reliably identify overuse of low-value healthcare services.

Physician perceptions of Choosing Wisely and drivers of overuse.

OBJECTIVES: Little is known regarding physicians' views on health service overuse or their awareness of the American Board of Internal Medicine Foundation's Choosing Wisely campaign. Through the Survey on Overuse and Knowledge of Choosing Wisely, we assessed physician views on hypothesized drivers of overuse and Choosing Wisely. STUDY DESIGN: We designed the survey to investigate physicians' knowledge of, awareness of, and feelings toward Choosing Wisely, along with their concerns about malpractice, perception of patient demand, discomfort with uncertainty, and cost-consciousness. Where possible, we used pre-validated survey instruments. METHODS: We distributed the survey to clinicians practicing at Atrius Health, the largest ambulatory care provider in Massachusetts. We analyzed 584 responses (72% response rate) and calculated 3 previously validated scales. RESULTS: Primary care physicians reported significantly greater awareness of Choosing Wisely (47.2%) than medical specialists (37.4%) and surgical specialists (27%). A majority (62%) of all respondents reported they found uncertainty involved in providing care disconcerting. Approximately one-third felt it unfair to ask physicians to be both cost-conscious and concerned with welfare, thought too much emphasis was placed on costs, and thought doctors were too busy to worry about costs. Surgical specialists were more concerned about malpractice, whereas primary care physicians reported feeling significantly more pressure from patients for tests and procedures. CONCLUSIONS: Knowledge of Choosing Wisely is limited, but primary care physicians are more aware of the campaign than specialists. Although hypothesized drivers of overuse are prevalent, most physicians support cost-consciousness in medicine and embrace their responsibility in reducing costs.