Educational outreach visiting - specialist physicians as visitors
The paper by Scott (BMJ July 4 2009) highlights the potential for
peers and colleagues to positively influence good clinical practice.1
Likewise, educational outreach visits (EOV) are another intervention that
can contribute to the evolution of practice of established practitioners
as highlighted in a recent systematic review2 which included two examples
where clinical opinion leaders have been involved in detailing visits. Can
EOV be further refined to increase its impact further?
We are conducting a randomised controlled pilot study which employs a
local practicing pulmonary physician to undertake EOV with family
physicians about the symptomatic treatment of breathlessness. General
practitioners (GP) are invited to participate in the study if they have
referred a patient with clinically significant refractory breathlessness
to the regional specialist palliative care service.
In line with the principles of EOV, qualitative findings to date with
more than 30 family physicians recruited include that:
- a two-way learning process is occurring where both the visitor
(specialist physician) and the GPs are understanding the barriers and
enablers to implementing the key messages from each other’s perspectives..
The specialist physician has been able to acknowledge in this one-to-one
setting often unspoken differences in practice such as access to
medications through hospital pharmacies compared with GPs’ lack of access
to identical medications in the community. For the GP, support and
assistance to make decisions in the face of uncertainty in clinical
assessment and new therapeutic options is a welcomed discussion.
- the setting in which practice is conducted (family or specialist
practice) is associated with differing pre-test probability 3 of finding
reversible pathology that can improve breathlessness in people with
progressive illnesses such as chronic obstructive lung disease, heart
failure or advancing cancer;
The use of a specialist physician may seem an expensive way to
conduct EOV, but there are data to suggest that information from trusted
peers and colleagues is particularly effective in influencing the practice
of established clinicians.4 Such information can exert marketing pressure
on behalf of the pharmaceutical industry 5 or, alternatively, convey
evidence-based messages generated independently of industry 6.
To date, using a practicing pulmonologist has been very well
received. The use of specialist physicians delivering EOV needs to be
further explored especially when clinical assessment is part of the
detailing message as they can provide insight and understanding into the
ambiguities of clinical assessment (e.g. a diagnosis of exclusion for
modifiable factors in refractory dyspnoea) and the therapeutic uncertainty
as key interventions from efficacy studies are brought to everyday
(effectiveness) practice.7,8,9
References
1. Scott I. Errors in clinical reasoning: causes and remedial
strategies. BMJ 2009;339:22-25.
2.. Ostini R, Hegney D, Jackson C, Williamson M, Mackson JM, Gurman
K, Hall W, Tett SE. Systematic review of interventions to improve
prescribing. Ann Pharmacother 2009;43:502-513.
3. Attia JR, Nair BR, Sibbritt DW, Ewald BD, Paget NS, Wellard RF, et
al. Generating pre-test probabilities: a neglected area in clinical
decision making. Med J Aust 2004;180:449-454.
4. O'Brien MA, Rogers S, Jamtvedt G, et al. Educational outreach
visits: effects on professional practice and health care outcomes.
Cochrane Database Syst Rev 2007;(4):CD000409.
5. Meffert JJ. Key opinion leaders: where they come from and how that
affects the drugs you prescribe. Dermatol Ther. 2009 May-Jun;22(3):262-8.
6. Carey M, Buchan H, Sanson-Fisher R.The cycle of change:
implementing best-evidence clinical practice. Int J Qual Health Care. 2009
Feb;21(1):37-43.
7. Jennings AL, Davies AN, Higgins JP, Gibbs JS, Broadley KE. A
systematic review of the use of opioids in the management of dyspnea.
Thorax 2002;57(11):939-44.
8. Uronis HE, Currow DC, McCrory DC, Samsa GP, Abernethy AP. Oxygen
for relief of dyspnoea in mildly- or non-hypoxaemic patient with cancer: a
systematic review and meta-analysis. Br J Canc 2008;98(2):294-299.
9. Abernethy AP, Currow DC, Frith P, Fazekas BS, McHugh A, Bui C.
Randomized, double blind, placebo controlled crossover trial of sustained
release morphine for the management of refractory dyspnea. Br Med J
2003;327(7414):523-8.
Rapid Response:
Educational outreach visiting - specialist physicians as visitors
The paper by Scott (BMJ July 4 2009) highlights the potential for
peers and colleagues to positively influence good clinical practice.1
Likewise, educational outreach visits (EOV) are another intervention that
can contribute to the evolution of practice of established practitioners
as highlighted in a recent systematic review2 which included two examples
where clinical opinion leaders have been involved in detailing visits. Can
EOV be further refined to increase its impact further?
We are conducting a randomised controlled pilot study which employs a
local practicing pulmonary physician to undertake EOV with family
physicians about the symptomatic treatment of breathlessness. General
practitioners (GP) are invited to participate in the study if they have
referred a patient with clinically significant refractory breathlessness
to the regional specialist palliative care service.
In line with the principles of EOV, qualitative findings to date with
more than 30 family physicians recruited include that:
- a two-way learning process is occurring where both the visitor
(specialist physician) and the GPs are understanding the barriers and
enablers to implementing the key messages from each other’s perspectives..
The specialist physician has been able to acknowledge in this one-to-one
setting often unspoken differences in practice such as access to
medications through hospital pharmacies compared with GPs’ lack of access
to identical medications in the community. For the GP, support and
assistance to make decisions in the face of uncertainty in clinical
assessment and new therapeutic options is a welcomed discussion.
- the setting in which practice is conducted (family or specialist
practice) is associated with differing pre-test probability 3 of finding
reversible pathology that can improve breathlessness in people with
progressive illnesses such as chronic obstructive lung disease, heart
failure or advancing cancer;
The use of a specialist physician may seem an expensive way to
conduct EOV, but there are data to suggest that information from trusted
peers and colleagues is particularly effective in influencing the practice
of established clinicians.4 Such information can exert marketing pressure
on behalf of the pharmaceutical industry 5 or, alternatively, convey
evidence-based messages generated independently of industry 6.
To date, using a practicing pulmonologist has been very well
received. The use of specialist physicians delivering EOV needs to be
further explored especially when clinical assessment is part of the
detailing message as they can provide insight and understanding into the
ambiguities of clinical assessment (e.g. a diagnosis of exclusion for
modifiable factors in refractory dyspnoea) and the therapeutic uncertainty
as key interventions from efficacy studies are brought to everyday
(effectiveness) practice.7,8,9
References
1. Scott I. Errors in clinical reasoning: causes and remedial
strategies. BMJ 2009;339:22-25.
2.. Ostini R, Hegney D, Jackson C, Williamson M, Mackson JM, Gurman
K, Hall W, Tett SE. Systematic review of interventions to improve
prescribing. Ann Pharmacother 2009;43:502-513.
3. Attia JR, Nair BR, Sibbritt DW, Ewald BD, Paget NS, Wellard RF, et
al. Generating pre-test probabilities: a neglected area in clinical
decision making. Med J Aust 2004;180:449-454.
4. O'Brien MA, Rogers S, Jamtvedt G, et al. Educational outreach
visits: effects on professional practice and health care outcomes.
Cochrane Database Syst Rev 2007;(4):CD000409.
5. Meffert JJ. Key opinion leaders: where they come from and how that
affects the drugs you prescribe. Dermatol Ther. 2009 May-Jun;22(3):262-8.
6. Carey M, Buchan H, Sanson-Fisher R.The cycle of change:
implementing best-evidence clinical practice. Int J Qual Health Care. 2009
Feb;21(1):37-43.
7. Jennings AL, Davies AN, Higgins JP, Gibbs JS, Broadley KE. A
systematic review of the use of opioids in the management of dyspnea.
Thorax 2002;57(11):939-44.
8. Uronis HE, Currow DC, McCrory DC, Samsa GP, Abernethy AP. Oxygen
for relief of dyspnoea in mildly- or non-hypoxaemic patient with cancer: a
systematic review and meta-analysis. Br J Canc 2008;98(2):294-299.
9. Abernethy AP, Currow DC, Frith P, Fazekas BS, McHugh A, Bui C.
Randomized, double blind, placebo controlled crossover trial of sustained
release morphine for the management of refractory dyspnea. Br Med J
2003;327(7414):523-8.
Competing interests:
None declared
Competing interests: No competing interests