The impact of clarity about the effects of change on clinical competencies in practice-linked continuing medical education

Abstract

How and why doctors do change their petformance and practice? What is the role of learning in this change? Fox's theory of Change and Learning postulated that clarity about the reason for change, the kinds of changes that were needed and effects of change were more likely to lead to learning which is directed at solving concrete problems. The role of clarity was investigated using a quasi experimental design. The competencies of forty-two general practitioners (GPs) in diagnosing and managing a specific problem of generalised anxiety disorder (GAD) were assessed by standardised patients (SPs) who were trained to simulate a severe form of the disorder. The use of SPs enabled observation of clinical competencies in real practice. A treatment group of 21 doctors was assisted to achieve clarity (independent variable) through a one-to-one problem-based learning process that was modified to include the process of reflection-on-action. That process was aimed at assisting the doctors to reflect on ~ ir clinical reasoning process, to recognise the effects of change on their professional competence an~ ti~~ outcomes, to identify the desired changes in clinical enci to be aware of the knowl~ a~ slilll deficit and to recognise new useful info at is to be mtegra m ~ new cli~ calwei:formance. Rel~~t information on the. diagnosis o GAD was ·\/ . rail :ll in f1 ~rmation p~ckage cons1stmg of a booklet and videotape on What you need to know about anxie/y<llisorders. Information on the treatment was only given in the packa e. The information on alprazolam.as a new medication was the indicator of the information-seeking beha • our. The control group o~ l Wcrtors was given the information package only. Both groups were encou ged to consult oth;r~.!ll'&s'°f.information. Pre-intervention assessment showed no significant differ nces in the competetJ.Gies between the control and treatment groups. None of the doctors had know led of GAD d its'trei°"tment. /0 ., The post-intervention assessment reveal nf si • cant improvement in the control group. The treatment group showed significant improveiμent n t component skills of inquiry for psycho-social history, treatment and interpersonal skil:l:s, and overall mean. t maintained or did not decline in specific examination. patient satis clion ::ruia i estigation habits. It did not show changes in the inquiry for symptoms. personal • ~ ryJllld general examination. In the composite competency of diagnosis and management. 8 doctors unproved to a 1 el where they could diagnose anxiety disorder and treat the patients correctly (level A). Ten doctors improved their ability to diagnose the anxiety state but did not recognise anxie disorder as the cause (level B). Three doctors did not even recognise the anxiety state (level C). There were incremental differences in the compelencies of level A doctors compared to non A doctors. Level A doctors were significantly better in the treatment skills. However the thirteen doctors who did not make the correct diagnosis achieved a significantly higher overall petformance compared to the control group. The intervention worked equally well with doctors at all levels of the pre-intervention diagnostic ability. With regards to information-seeking behaviour, level A doctors significantly sought more information from the learning package to prescribe alprazolam and to advise patients on the management. It is concluded that (a) provision of information alone is insufficient to change practice behaviour (b) problem-solving and reflection are fundamental processes in effecting learning and change ( c) different levels of clarity were achieved by the problem-solving and reflection process ( d) the level of clarity reached determined the information-seeking behaviour (e) provision of information at the point-ofnecd facilitated information-seeking and learning (f) the incremental change implies that there are other factors within the individual, the behaviour and the environment and their interactions which determine learning and change in practice. Practice-linked methods of CME and information management systems are recommended.