Showing papers in "Journal of Continuing Education in The Health Professions in 2006"

Lost in knowledge translation: time for a map?

Abstract: There is confusion and misunderstanding about the concepts of knowledge translation, knowledge transfer, knowledge exchange, research utilization, implementation, diffusion, and dissemination. We review the terms and definitions used to describe the concept of moving knowledge into action. We also offer a conceptual framework for thinking about the process and integrate the roles of knowledge creation and knowledge application. The implications of knowledge translation for continuing education in the health professions include the need to base continuing education on the best available knowledge, the use of educational and other transfer strategies that are known to be effective, and the value of learning about plannedaction theories to be better able to understand and influence change in practice settings.

A guide to knowledge translation theory.

Abstract: Despite calls over several decades for theory development, there remains no overarching knowledge-translation theory. However, a range of models and theoretical perspectives focused on narrower and related areas have been available for some time. We provide an overview of selected perspectives that we believe are particularly useful for developing testable and useful knowledge-translation interventions. In addition, we discuss adjuvant theories necessary to complement these perspectives. We draw from organizational innovation, health, and social sciences literature to illustrate the similarities and differences of various theoretical perspectives related to the knowledge-translation field. A variety of theoretical perspectives useful to knowledge translation exist. They are often spread across disciplinary boundaries, making them difficult to locate and use. Poor definitional clarity, discipline-specific terminology, and implicit assumptions often hinder the use of complementary perspectives. Health care environments are complex, and assessing the setting prior to selecting a theory should be the first step in knowledge-translation initiatives. Finding a fit between setting (context) and theory is important for knowledge-translation initiatives to succeed. Because one theory will not fit all contexts, it is helpful to understand and use several different theories. Although there are often barriers associated with combining theories from different disciplines, such obstacles can be overcome, and to do so will increase the likelihood that knowledge-translation initiatives will succeed.

Knowledge to action

Abstract: The Journal of Continuing Education in the Health Professions, Vol. 26 No. 2, Spring 2006 Published online in Wiley InterScience (www.interscience.wiley.com) • DOI: 10.1002/chp.65 Correspondence: Tony Lewis, MA MB FRCGP, Teaching Fellow in Applied Human Sciences, Peninsula Medical School, St. Luke’s Campus, Exeter EX1 2LU United Kingdom; e-mail: tony.lewis@pms.ac.uk. The Journal of Continuing Education in the Health Professions, Volume 26, pp. 168. Printed in the U.S.A. Copyright (c) 2006 The Alliance for Continuing Medical Education, the Society for Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education. All rights reserved.

Research, public policymaking, and knowledge-translation processes: Canadian efforts to build bridges.

Abstract: Public policymakers must contend with a particular set of institutional arrangements that govern what can be done to address any given issue, pressure from a variety of interest groups about what they would like to see done to address any given issue, and a range of ideas (including research evidence) about how best to address any given issue. Rarely do processes exist that can get optimally packaged high-quality and high-relevance research evidence into the hands of public policymakers when they most need it, which is often in hours and days, not months and years. In Canada, a variety of efforts have been undertaken to address the factors that have been found to increase the prospects for research use, including the production of systematic reviews that meet the shorter term (but not urgent) needs of public policymakers and encouraging partnerships between researchers and policymakers that allow for their interaction around the tasks of asking and answering relevant questions. Much less progress has been made in making available research evidence to inform the urgent needs of public policymakers and in addressing attitudinal barriers and capacity limitations. In the future, knowledge-translation processes, particularly push efforts and efforts to facilitate user pull, should be undertaken on a sufficiently large scale and with a sufficiently rigorous evaluation so that robust conclusions can be drawn about their effectiveness.

Knowledge translation and interprofessional collaboration: Where the rubber of evidence-based care hits the road of teamwork

Abstract: Knowledge-translation interventions and interprofessional education and collaboration interventions all aim at improving health care processes and outcomes. Knowledge-translation interventions attempt to increase evidence-based practice by a single professional group and thus may fail to take into account barriers from difficulties in interprofessional relations. Interprofessional education and collaboration interventions aim to improve interprofessional relations, which may in turn facilitate the work of knowledge translation and thus evidence-based practice. We summarize systematic review work on the effects of interventions for interprofessional education and collaboration. The current evidence base contains mainly descriptive studies of these interventions. Knowledge is limited regarding the impact on care and outcomes and the extent to which the interventions increase the practice of evidence-based care. Rigorous multimethod research studies are needed to develop and strengthen the current evidence base in this field. We describe a Health Canada-funded randomized trial in which quantitative and qualitative data will be gathered in 20 general internal medicine units located at 5 Toronto, Ontario, teaching hospitals. The project examines the impact of interprofessional education and collaboration interventions on interprofessional relationships, health care processes (including evidence-based practice), and patient outcomes. Routes are suggested by which interprofessional education and collaboration interventions might affect knowledge translation and evidence-based practice.

Knowledge translation versus knowledge integration: a "funder's" perspective.

Abstract: Each year, billions of US tax dollars are spent on basic discovery, intervention development, and efficacy research, while hundreds of billions of US tax dollars are also spent on health service delivery programs. However, little is spent on or known about how best to ensure that the lessons learned from science inform and improve the quality of health services and the availability of evidence-based approaches. To close this discovery-delivery gap, researchers and their funding agencies not only must recognize the gap between basic discovery and intervention development, addressed in part through translational research investments, but they must also work together with practitioners and their funding agencies to recognize the growing gap between innovative interventions developed through research and what is actually delivered to reduce the burden of chronic disease within the United States. From a funding-agency perspective, the complexity of the challenges of translating lessons learned from science to public health, primary care, or disease specialty service settings requires a multifaceted partnership approach to accelerate the translation of research into practice. This essay reviews the background and challenges of closing the development-to-delivery gap and some exemplar strategies that have been used by funding agencies to address these challenges to date.

Knowledge translation in global health.

Abstract: We discuss the “know-do gap,” present a definition of knowledge translation, and discuss its relative importance in bridging the know-do gap. Some of the underlying causes of the know-do gap are listed, along with ongoing efforts to address them. Knowledge translation is considered a cross-cutting, nonlinear process that involves not only recent research findings but also knowledge that is created from the dynamic interaction of people who come together to solve public health problems, to learn, and ultimately to drive productive change. We also mention some of the activities undertaken by the World Health Organization in regards to knowledge translation. The search strategy has been nonsystematic, and reference is made to selected sources only.

Information-Seeking Behaviors and Reflective Practice.

Abstract: Introduction: As they care for patients, physicians raise questions, but they pursue only a portion of them. Without the best information and evidence, care and patient safety may be compromised. Understanding when and why problems prompt physicians to look for information and integrate results into their knowledge base is critical and shapes one part of reflection about care. This study explores the role of the Internet in gathering medical information as one step in that reflective practice, the barriers to its use, and changes in utilization over time. Methods: A questionnaire with 18 items adapted from previous studies was sent by facsimile to a randomly selected sample of U.S. physicians in all specialties and active in practice. Results: Specific patient problems and latest research in a specific topic most often prompt physicians to search on the Internet. Younger physicians and female physicians were most likely to seek information on a specific patient problem. Only 9% of all respondents (n = 2,500) searched for information during a patient encounter. When unsure about diagnostic and management issues for a complex case, 41.3% chose to consult with a colleague or read from a text (22.8%). Searching most often occurred at home after work (38.2%) or during breaks in the day (35.7%). Most (68.7%) found the information they were looking for more than 51% of the time. Searching was facilitated by knowing preferred sites and access in the clinical setting. The greatest barriers to answering clinical questions included a lack of specific information and too much information to scan. Discussion: Although physicians are increasingly successful and confident in their Internet searching to answer questions raised in patient care, few choose to seek medical information during a patient encounter. Internet information access may facilitate overall reflection on practice; physicians do not yet use this access in a just-in-time manner for immediately solving difficult patient problems but instead continue to rely on consultation with colleagues. Professional association Web sites and point-of-care databases are helpful. From physicians’ use of the Internet, professionals in continuing medical education must learn which search engines and sites are trusted and preferred.

Knowledge Translation in Developing Countries.

Abstract: There is increasing evidence that the application of knowledge in developing countries is failing. One reason is the woeful shortage of health workers, but as this is redressed, it is also crucial that we have an evidence base of what works to minimize the "know-do gap." The World Health Organization and other international organizations are actively building momentum to promote research to determine effective strategies for knowledge translation (KT). At this time, the evidence base for the effectiveness of those strategies is not definitive in developed countries and is relatively sparse in developing countries. It appears, however, that the effectiveness of these strategies is highly variable and dependent on the setting, and success hinges on whether the strategies have been tailored. A useful framework to provide direction for tailoring interventions is the Ottawa Model of Research Use (OMRU). Underlying OMRU is the principle that success rests with tailoring KT strategies to the salient barriers and supports found within the setting. The model recommends that barriers and supports found in the practice environment or as characteristics of potential adopters and the evidence-based innovation or research evidence be assessed and then the KT strategy tailored and executed. The model also recommends that whether the research has been applied and has resulted in improved health outcomes should be measured. Studies in developing countries, although few, illustrate that the OMRU approach may be a valid method of tackling the challenges of KT strategies to improve health care in developing countries.

Facilitating interpersonal interaction and learning online: linking theory and practice.

Abstract: Introduction:An earlier study of physicians' perceptions of interactive online learning showed that these were shaped both by program design and quality and the quality and quantity of interpersonal interaction. We explore instructor roles in enhancing online learning through interpersonal i

Continuing education, guideline implementation, and the emerging transdisciplinary field of knowledge translation.

Abstract: This article discusses continuing education and the implementation of clinical practice guidelines or best evidence, quality improvement, and patient safety. Continuing education focuses on the perspective of the adult learner and is guided by well-established educational principles. In contrast, guideline implementation and related concepts borrow from the fields of quality improvement and patient safety and from health services research. Relative to the question of improved clinical outcomes, both to some extent afford only partial understanding of a complex issue. Knowledge translation (KT) is a transformative concept that links the best elements of both broad fields and, in particular, adds educational elements to the work of health services researchers and others. Interdisciplinary in the extreme, KT is explored in some detail: its major elements (information, facilitation, context, the clinician-learner, among others) considered as variables in an equation leading to knowledge uptake and improved health care outcomes and an improved functioning health care system.

Promoting physicians' self-assessment and quality improvement: the ABIM diabetes practice improvement module.

Abstract: Introduction:The American Board of Internal Medicine (ABIM) recognized that certification and recertification must be based on an assessment of performance in practice as well as an examination of medical knowledge. Physician self-assessment of practice performance is proposed as one method

Knowledge for knowledge translation: The role of the Cochrane Collaboration

Abstract: Knowledge-translation (KT) activities, including continuing education, should be informed by the totality of available research evidence. Systematic reviews are a generic methodology used to synthesize evidence from a broad range of research methods addressing different questions. Over the past decade, there has been a dramatic increase in the availability of systematic reviews that could support KT activities. However, the conduct of systematic reviews is technically challenging, and it is not surprising that the quality of available reviews is variable. In addition, unless attempts are made to update systematic reviews, they rapidly become out of date. The Cochrane Collaboration is a unique, worldwide, not-for-profit organization that aims to help people make well-informed decisions about all forms of health care by preparing, maintaining, and promoting the accessibility of systematic reviews of the effects of health care interventions. Globally, over 13, 000 consumers, clinicians, policymakers, and researchers are involved with The Cochrane Collaboration and have to date produced over 2, 500 systematic reviews that can be used to inform KT activities. The Cochrane Collaboration publishes its reviews quarterly in The Cochrane Library. Cochrane reviews have been used to develop a number of KT-derivative products for professionals, consumers, and policymakers. Whereas most Cochrane Review groups focus on specific clinical areas, the Cochrane Effective Practice and Organisation of Care Group undertakes reviews of interventions to improve health care delivery and health care systems, including reviews of different KT activities. We summarize the activities of The Cochrane Collaboration and how these can contribute to KT activities.

The difficulty with experience: does practice increase susceptibility to premature closure?

Abstract: Introduction:A recent review of the physician performance literature concluded that the risk of prematurely closing one's diagnostic search increases with years of experience. To minimize confounding variables and gain insight into cognitive issues relevant to continuing education, the curre

The prevalence and special educational requirements of dyscompetent physicians.

Abstract: Underperformance among physicians is not well studied or defined; yet, the identification and remediation of physicians who are not performing up to acceptable standards is central to quality care and patient safety. Methods for estimating the prevalence of dyscompetence include evaluating available data on medical errors, malpractice claims, disciplinary actions, quality control studies, medical record review studies, and in-stream assessments of physician performance. These data provide a range of estimates from 0.6% to 50%, depending on the method. A reasonable estimate of dyscompetence appears to be 6% to 12%. Age-related cognitive decline, impairment due to substance use disorders, and other psychiatric illness can contribute to underperformance, diminishing physicians' insight into their level of performance as well as their ability to benefit from an educational experience.Currently, dyscompetent physicians in the United States are identified through either the legal system or peer review. The primary method of resolving issues of underperformance in physicians is through continuing medical education (CME). Although a number of specialized assessment and education programs exist in the United States, these programs are largely underutilized. Similar programs exist in Canada and have provided evidence of the efficacy of a more specialized and individualized educational approach for underperforming physicians. Current specialty programs focused on this population employ individual assessments of knowledge and performance, individually designed educational programs, long-term plans for maintenance of educational activity, and repeated assessment of performance level. Noting that few CME programs offer these requirements, a number of changes to current medical quality assurance programs that might foster such educational requirements for underperforming physicians are provided.

Knowledge translation: Resolving the confusion

Abstract: The Journal of Continuing Education in the Health Professions, Vol. 26 No. 1, Winter 2006 Published online in Wiley InterScience (www.interscience.wiley.com) • DOI: 10.1002/chp.45 The Journal of Continuing Education in the Health Professions, Volume 26, pp. 3–4. Printed in the U.S.A. Copyright (c) 2006 The Alliance for Continuing Medical Education, the Society for Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education. All rights reserved.

Improving Performance through Knowledge Translation in the Veterans Health Administration.

Abstract: The Veterans Health Administration (VA) provides a case study for linking performance measurement, information technology, and aligned research efforts to facilitate quality improvement in a large, complex health system. Dialogue between clinical researchers and VA leaders occurs through structured activities (e.g., the Quality Enhancement Research Initiative); engagement with formal policymaking bodies (e.g., development of clinical guidelines and performance measures); and informally through local, regional, and national work groups responsible for implementing evidence-based clinical initiatives. Important lessons for knowledge translation from the VA experience include the following: research needs to generate clinical evidence relevant to the needs of patients served by the health system; researchers need to systematically study the process of evidence implementation itself to increase the capability of the health system to improve performance; although print and Web-based dissemination structures are important, direct accessibility of researchers to policymakers and clinical leaders through formal and informal mechanisms is key; and both top-down and bottom-up activities are needed to integrate evidence-based practice across a large health system. As VA care moves from hospital and clinic into community-based settings and faces a new veteran population with different needs and expectations, knowledge-translation activities must develop new forms of evidence and more direct interaction with veterans and their caregivers.

Improving adherence to hand hygiene among health care workers

Abstract: Increased adherence to hand hygiene is widely acknowledged to be the most important way of reducing infections in health care facilities. Despite evidence of benefit, adherence to hand hygiene among health care professionals remains low. Several behavioral and organizational theories have been proposed to explain this. As a whole, the success of interventions to improve adherence to hand hygiene among health care professionals has been limited. Recent data suggest that a multifaceted intervention, including the use of feedback, education, the introduction of alcohol-based hand wash, and visual reminders, may increase adherence to hand-hygiene recommendations. Although the "active ingredient" of such an intervention is unknown, there is evidence that the use of feedback may be the key to increasing adherence. In this article, we review the theoretical basis for interventions and provide an overview of the evidence for interventions. Coherent and methodologically sound research is required to better understand the factors contributing to hand-hygiene behavior among health care professionals.

Promoting the skills of knowledge translation in an online master of science course in primary health care.

Abstract: We present 4 key arguments: (1) knowledge translation requires tacit and explicit knowledge that must be introduced into the organization as well as simply acquired by individuals; (2) educating for knowledge translation must go beyond conveying facts and developing capability; (3) a constructivist and collaborative approach to education can address the needs of learners for knowledge translation; and (4) the online environment, if appropriately used, has many useful features for supporting constructivist and collaborative learning. We illustrate these arguments with reference to a part-time online master of science course whose learners are mostly senior health care professionals engaged in knowledge translation.

Effects of a distance learning program on physicians' opioid- and benzodiazepine-prescribing skills.

Abstract: Introduction:Opioid misuse is common among patients with chronic nonmalignant pain. There is a pressing need for physicians to increase their confidence and competence in managing these patients.Methods:A randomized controlled trial of family physicians (N = 88) attending 1 of 4 continuing m

What constitutes commercial bias compared with the personal opinion of experts

Abstract: Introduction: The presence of commercial messages in continuing medical education (CME) is an ongoing cause of concern. This study identifies actions perceived by CME participants to convey commercial bias from CME faculty. Methods: A questionnaire listing actions associated with CME activities was distributed to 230 randomly selected participants from 7 CME activities designated for AMA PRA Category 1 Credit™. The activities were held over an 8-month period. Participants were asked to complete the questionnaire before participating in the live activity. Results: Nine actions identified by over 50% of all respondents were perceived to convey commercial bias. The most critical ones reflecting commercial bias were speaking about only one agent, not providing a balanced presentation of all agents, and faculty relationships with commercial supporters. Ten actions identified by over 50% of the respondents were perceived to convey personal opinion of the faculty. The most prevalent actions were the influence of mentors or teachers, relating general practice habits from the faculty member's own experience, and cultural differences among patient populations. More than half the respondents who indicated they perceived commercial bias in certified activities attributed this perception to an overall impression, instead of 1 or 2 specific actions. Discussion: Actions were identified that conveyed differences between commercial messages and personal opinion. CME providers should define commercial bias for participants, faculty, and planners and provide education about that definition.

Effectiveness of an enhanced peer assessment program: introducing education into regulatory assessment

Abstract: Introduction: The College of Physicians and Surgeons of Ontario developed an enhanced peer assessment (EPA), the goal of which was to provide participating physicians educational value by helping them identify specific learning needs and aligning the assessment process with the principles of continuing education and professional development. In this article, we examine the educational value of the EPA and whether physicians will change their practice as a result of the recommendations received during the assessment. Methods: A group of 41 randomly selected physicians (23 general or family practitioners, 7 obstetrician-gynecologists, and 11 general surgeons) agreed to participate in the EPA pilot. Nine experienced peer assessors were trained in the principles of knowledge translation and the use of practice resources (tool kits) and clinical practice guidelines. The EPA was evaluated through the use of a postassessment questionnaire and focus groups. Results: The physicians felt that the EPA was fair and educationally valuable. Most focus group participants indicated that they implemented recommendations made by the assessor and made changes to some aspect of their practice. The physicians' suggestions for improvement included expanding the assessment beyond the current medical record review and interview format (eg, to include multisource feedback), having assessments occur at regular intervals (eg, every 5 to 10 years), and improving the administrative process by which physicians apply for educational credit for EPA activities. Conclusions: The EPA pilot study has demonstrated that providing detailed individualized feedback and optimizing the one-to-one interaction between assessors and physicians is a promising method for changing physician behavior. The college has started the process of aligning all its peer assessments with the principles of continuing professional development outlined in the EPA model.

Evaluation of an online bioterrorism continuing medical education course.

Abstract: Introduction: Much of the international community has an increased awareness of potential biologic, chemical, and nuclear threats and the need for physicians to rapidly acquire new knowledge and skills in order to protect the public's health. The present study evaluated the educational effectiveness of an online bioterrorism continuing medical education (CME) activity designed to address clinical issues involving suspected bioterrorism and reporting procedures in the United States. Methods: This was a retrospective survey of physicians who had completed an online CME activity on bioterrorism compared with a nonparticipant group who had completed at least 1 unrelated online CME course from the same medical school Web site and were matched on similar characteristics. An online survey instrument was developed to assess clinical and systems knowledge and confidence in recognition of illnesses associated with a potential bioterrorism attack. A power calculation indicated that a sample size of 100 (50 in each group) would achieve 90% power to detect a 10% to 15% difference in test scores between the two groups. Results: Compared with nonparticipant physicians, participants correctly diagnosed anthrax (p = .01) and viral exanthem (p = .01), but not smallpox, more frequently than nonparticipants. Participants knew more frequently than nonparticipants who to contact regarding a potential bioterrorism event (p = .03) Participants were more confident than nonparticipants about finding information to guide diagnoses of patients with biologic exposure (p = .01), chemical exposure (p = .02), and radiation exposure (p = .04). Discussion: An online bioterrorism course shows promise as an educational intervention in preparing physicians to better diagnose emerging rare infections, including those that may be associated with a bioterrorist event, in increasing confidence in diagnosing these infections, and in reporting of such infections for practicing physicians.

Clinical Teachers' Attitudes toward the Efficacy of Evidence-Based Medicine Workshop and Self-Reported Ability in Evidence-Based Practice in Iran.

Abstract: INTRODUCTION Evidence-based medicine (EBM) has been introduced in medical schools worldwide, but there is little known about effective methods for teaching EBM skills, particularly in developing countries. This study assesses the impact of an EBM workshop on clinical teachers' attitudes and use of EBM skills. METHODS Seventy-two clinical teachers attended two half-day workshops on EBM. Participants completed precourse and postcourse questionnaires using a 5-point Likert scale. Nonparametric 2-sample Wilcoxon rank-sum tests were performed to compare responses. RESULTS Attitudes about EBM improved (3.2 precourse vs 3.4 postcourse), as did self-reported EBM skills (3.1 vs 4.4, p < .0001). DISCUSSION An EBM workshop may improve clinical teachers' abilities and skills in using EBM. However, carefully designed studies are required to evaluate the long-term effects of EBM curricula in changing behaviors, practice patterns, and patient care outcomes.

Research to practice in The Journal of Continuing Education in the Health Professions: a thematic analysis of volumes 1 through 24.

Abstract: Introduction: Authors have stressed the importance of the broader contextual influences on practice improvement and learning and have expressed concern about gaps between research and practice This implies a potential expansion of the knowledge base for continuing education in the health professions (CEHP) and an increased emphasis on research evidence for that knowledge How has the content of The Journal of Continuing Education in the Health Professions (JCEHP) reflected those changes? What are the implications for CEHP practitioners? Methods: Based on all abstracts, tables of contents, and editorials, a thematic analysis was completed for volumes 1 through 24 of JCEHP All texts were downloaded into qualitative analysis software and coded Main code categories included demographics of articles, concepts relating to CEHP as a discipline, knowledge translation and outcomes-oriented continuing education, and theories and frameworks Key themes were identified Results: Key themes include categories of topics included in JCEHP over the years, the increased prominence of research in JCEHP, a dual research evidence-to-practice gap, the professionalization of continuing education providers, and interdisciplinarity and the links with broader frameworks that have been proposed for CEHP Discussion: Two sets of research-to-practice gaps are portrayed in the journal: the gap between clinical research and practice and the gap between research and practice in CEHP To close the first gap, authors have asserted that the second gap must be addressed, ensuring that CEHP practices themselves are evidence based, driven by theory-based research This is a variation on prior debates regarding the need to define CEHP as a discipline, which uses the language of professionalization The increased focus of continuing education on the contexts of health care providers' practices has multiplied the topics that are potentially relevant to CEHP practice

Physician-Patient Encounters: The Structure of Performance in Family and General Office Practice.

Abstract: Introduction: The College of Physicians and Surgeons of Ontario, the regulatory authority for physicians in Ontario, Canada, conducts peer assessments of physicians’ practices as part of a broad quality assurance program. Outcomes are summarized as a single score, and there is no differentiation between performance in various aspects of care. In this study, we test the hypothesis that physician performance is multidimensional and that dimensions can be defined in terms of physician-patient encounters. Methods: Peer assessment data from 532 randomly selected family practitioners were analyzed using factor analysis to assess the dimensional structure of performance. Content validity was confirmed through consultation sessions with 130 physicians. Multiple-item measures were constructed for each dimension and reliability calculated. Analysis of variance determined the extent to which multiple-item measure scores would vary across peer assessment outcomes. Results: Six performance dimensions were confirmed: acute care, chronic conditions, continuity of care and referrals, well care and health maintenance, psychosocial care, and patient records. Discussion: Physician performance is multidimensional, including types of physicianpatient encounters and variation across dimensions, as demonstrated by individual practice. A conceptual framework for multidimensional performance may inform the design of meaningful evaluation and educational recommendations to meet the individual performance of practicing physicians.

A model of teaching-learning transactions in generalist-specialist consultations.

Abstract: Introduction: A new paradigm in continuing medical education is characterized by emphasis on physicians' learning in practice. Consistent with this paradigm, our study examined a subset of clinical practice—generalist-specialist consultations—from an educational perspective. Methods: We applied the grounded-theory method with semistructured interviews. Ten primary care physicians and 9 internal medicine subspecialists were interviewed regarding their approaches to learning and teaching during generalist-specialist consultations. Results: Based on 48 formal and informal consultations reported by physicians, we developed a theory of teaching-learning transactions in generalist-specialist consultations. Discussion: As a teaching-learning transaction, the mutual learning process in generalist-specialist consultations involves 3 components: needs assessment, dialogue, and sufficiency. Providers of continuing medical education may use the proposed theoretical framework to help clinicians and health care organizations analyze and enhance educationally valuable interactions at the interface of primary and secondary care.

Impact of commercial support on continuing pharmacy education.

Abstract: Introduction: There is a serious debate over the involvement of the pharmaceutical industry in continuing education. Policies that govern the planning of continuing education for pharmacists center on the potential conflict of interest when there is commercial support for programs. The purpose of this study was to investigate the impact of commercial support on the provision and perceived outcomes of continuing pharmacy education. Methods: A survey was administered online to a national sample of accredited providers of continuing pharmacy education, resulting in 134 responses. The 64-item survey was developed to measure the planning practices of these providers and their perceptions of the educational and noneducational consequences of commercial support for continuing education. Results: One hundred thirty-four usable questionnaires (34%) were received from 386 leaders in pharmacy education. Approximately 86% of providers and 43% of programs received commercial support. Although the Accreditation Council for Pharmacy Education requires that providers review instructional content and materials for commercially supported programs before delivery, only 43% always did so. Commercial support was perceived to have consequences for provider organizations, pharmacists, and patients, such as increased cost and use of drugs and financial dependency of providers and participants on industry support. Discussion: The results of our study lead to the conclusions that commercial support of continuing education is widespread, affects continuing education programs, and is perceived to have significant educational and noneducational consequences. The profession should ensure that continuing education guidelines are unambiguous related to specific practices that are allowable and unallowable when receiving commercial support. Future research should study the consequences of commercial support behaviorally by examining the effects on pharmacy professionals' practice and pharmaceutical care.

Professional isolation and performance assessment in New Zealand

Abstract: Introduction:Solo and nonurban practice, nonmembership of a professional group, and aging are all associated with underperformance and may be indicators of professional isolation. Although it may lead to underperformance in physicians, there are no clear measures to assess professional isola