1Centre for Professional Development, University of Montreal; 2Epidemiology Department, McGill University, Montreal, Quebec Correspondence and reprints: Dr Paolo Renzi, 2065 Alexandre de Sève Z8905, Montreal, Quebec H2L 2W5. Telephone 514-890-8000 ext 28031, fax 514-412-7579, e-mail renzip@earthlink.net PM Renzi, H Ghezzo, S Goulet, E Dorval, RL Thivierge. Paper stamp checklist tool enhances asthma guidelines knowledge and implementation by primary care physicians. Can Respir J 2006;13(4):193-197.

International guidelines recommend adding long-acting β2-agonists (LABA) to inhaled corticosteroids (ICS) as a step 3 or 4 strategy in children in whom ICS, with or without adjunct therapy, is ineffective in adequately controlling asthma [1–4]. Contrary to adults, the beneficial effects of ICS/LABA in children are limited to improving lung function and short-acting β2-agonist use (SABA), with no significant reduction in symptoms compared with ICS alone [5]; moreover, a nonsignificant trend towards more exacerbations requiring oral corticosteroids and/or hospital admissions raised concerns [5]. Asthma-related intubations and deaths linked to LABA [6] have led the US Food and Drug Administration to issue label changes recommending that LABA is discontinued once asthma control has been achieved [7]. Most asthmatic children can be successfully weaned off long-acting β2-agonists to inhaled corticosteroid monotherapy We are indebted to Pierre Gaudreault (University of Montreal, Montreal, Canada) and Caroline Chartrand (CHU Sainte-Justine, Montreal, Canada) who assisted in the diligent data collection during their patients' medical visits and thank the parents of the children enrolled in this study.

Background Focused bedside ultrasound is rapidly becoming a standard of care to decrease the risks of complications related to invasive procedures. The purpose of this study was to assess whether adding to the curriculum of junior residents an educational intervention combining web-based e-learning and hands-on training would improve the residents’ proficiency in different clinical applications of bedside ultrasound as compared to using the traditional apprenticeship teaching method alone. Methods Junior residents ( n = 39) were provided with two educational interventions (vascular and pleural ultrasound). Each intervention consisted of a combination of web-based e-learning and bedside hands-on training. Senior residents ( n = 15) were the traditionally trained group and were not provided with the educational interventions. Results After the educational intervention, performance of the junior residents on the practical tests was superior to that of the senior residents. This was true for the vascular assessment (94% ± 5% vs. 68% ± 15%, unpaired student t test: p < 0.0001, mean difference: 26 (95% CI: 20 to 31)) and even more significant for the pleural assessment (92% ± 9% vs. 57% ± 25%, unpaired student t test: p < 0.0001, mean difference: 35 (95% CI: 23 to 44)). The junior residents also had a significantly higher success rate in performing ultrasound-guided needle insertion compared to the senior residents for both the transverse (95% vs. 60%, Fisher’s exact test p = 0.0048) and longitudinal views (100% vs. 73%, Fisher’s exact test p = 0.0055). Conclusions Our study demonstrated that a structured curriculum combining web-based education, hands-on training, and simulation integrated early in the training of the junior residents can lead to better proficiency in performing ultrasound-guided techniques compared to the traditional apprenticeship model.

Simulation has been used in medicine for decades to teach various skills and competencies. First seen as a way to enable the acquisition and repetition of primarily technical skills, simulation has gradually evolved into a key tool to teach more universal competencies. Consequently, simulation is now considered by many as the best method to learn non-technical skills such as collaboration, communication, and leadership. Various elements are behind this transition. The increasing complexity of modern health care and the explosion of knowledge specific to the various medical specialties have left little room for the physician’s traditional role as an omnipotent and omniscient practitioner. After a number of decades during which medical faculties promoted curricula focused on scholarly knowledge and acquiring technical skills, the need to identify and incorporate a broader range of non-technical competencies has emerged. At the same time, several experts showed that events involving poor non-technical skills, particularly communication, were responsible for a significant portion of patient morbidity and mortality. Numerous organizations and coalitions dedicated to the promotion of safer health care networks joined forces in urging academic and hospital administrations to work together to build curricula in which teamwork skills play a key role. All these elements contributed to the establishment of a new paradigm based on the need for acquiring and assessing teamwork skills, and for obtaining the tools to do so. Medical schools and hospitals responded by investing heavily in the creation and development of simulation-based learning centres. The attention that pedagogical experts and health managers have directed towards the acquisition and support of teamwork skills helped foster anesthesiologists’ involvement in the development and operation of the simulation centres. Applying concepts such as CRM (‘‘Crisis’’ or ‘‘Crew Resource Management’’), which aims to optimize teamwork, to the various fields of specialized medicine has largely resulted from the work of anesthesiologists. Indeed, the different environments in which anesthesiologists work (operating rooms, intensive care units, etc.) are often a source of complex professional interactions that are likely to influence quality of care and patients’ outcome. It is no surprise, therefore, that some institutions devoted considerable efforts and resources in order to simulate the professional activities taking place in those environments. Costly investments were often necessary in order to acquire the infrastructure and hardware used in the simulation centres. Personnel also had to be hired to operate these facilities and to design and implement the pedagogical contents. Even if an impressive number of tools dedicated to simulation-based teaching of non-technical skills have been developed in the past few decades, it should be emphasized here that their impact on patients’ outcome remains uncertain. Despite major investments in this field, few studies have dealt with the direct effects of simulationbased teaching on actual clinical performance or patients’ mortality. In this issue of the Journal, we find one of the rare papers addressing these issues. In their review, Boet et al. identified studies that attempted to measure the impact of CRM or non-technical skills teaching on quality of care and patients’ outcome. Despite abundant literature P. Drolet, MD (&) Departement d’Anesthesiologie, Faculte de Medecine, Universite de Montreal, C.P. 6128, Succursale Centre-ville, Montreal, QC H3C 3J7, Canada e-mail: pierre.drolet6060@videotron.ca

INTRODUCTION:There are numerous examples of care gaps that could be reduced through enhanced knowledge exchange and practice collaboration between medical specialist physicians. In this paper, we report preliminary results on using speed-dating sessions (SDSs) to stimulate the development of continuing interdisciplinary education (CIDE) activities.METHODS:In 2007, a 35-minute SDS was carried out during a 2-hour faculty development workshop to provide continuing medical education (CME) directors of Quebec's 35 medical specialist associations with a formal opportunity to quickly share clinical issues and goals. A post-workshop survey was used to assess participants' satisfaction and whether they had met new colleagues, learned about interdisciplinary issues, and discovered opportunities for collaboration. CME accreditation files were audited to assess the occurrence of CIDE activities in the year prior and the 2 years that followed the workshop. CME directors were called to assess whether the development of these activities was directly attributable to their participation in the SDS.RESULTS:CME directors of 26 specialist physician associations attended the faculty development workshop. The vast majority of survey respondents (n = 18/20) were satisfied with the SDS and believed that this method was a stimulating and efficient way to meet new colleagues, quickly share clinical issues and goals, learn about unexpected but important interdisciplinary issues, and identify opportunities for CIDE collaboration. Sixty percent (12/20) reported having identified at least 1 opportunity for collaboration that was worth pursuing in the near future, and 19% of attending CME directors (5/26) developed a CIDE activity within 2 years, as compared with none in the previous year and for the 9 nonparticipating associations.DISCUSSION:Results suggest that SDSs enhanced networking, knowledge exchange, and collaboration in continuing education among CME providers who participated in a faculty development activity on CIDE.

OBJECTIVE:To develop and evaluate items for inclusion in PRIDe (Preferred Role in Decision Making), a new tool to assess changes of role preference among professionals exposed to training in shared decision making (SDM). METHODS:This study was part of a pilot trial to evaluate the effectiveness of SDM training on the doctors' prescription of antibiotics for acute respiratory infections. Thirty-nine family physicians were randomized to immediate exposure to training or to delayed exposure. Potential items for PRIDe and a questionnaire about physicians' intention to engage in SDM were administered at baseline and at follow-up. RESULTS:Following analysis, we retained five items that captured a change in physicians' preference. The items' scores were pooled and the resulting tool showed limited internal consistency (Cronbach's alpha = 0.41) but significant test-retest reliability (immediate group: P = 0.03; delayed group: P = 0.008) and acceptable discriminant validity, with patients involved in decision making more actively after training than before (Fisher's test, P = .02). CONCLUSION:This initial step to develop an evaluation tool to assess changes in doctors' preference of role in decision making following SDM training shows promising results. The next step is to develop more clinical vignettes followed by questions inspired from this analysis. PRACTICE IMPLICATIONS:The PRIDe instrument can be used in the assessment of health professionals' attitude towards shared decision making after training in shared decision making. Additional research is needed to evaluate its validity before it can be recommended for use.

BACKGROUND:The misuse and limited effectiveness of antibiotics for acute respiratory infections (ARIs) are well documented, and current approaches targeting physicians or patients to improve appropriate use have had limited effect. Shared decision-making could be a promising strategy to improve appropriate antibiotic use for ARIs, but very little is known about its implementation processes and outcomes in clinical settings. In this matter, pilot studies have played a key role in health science research over the past years in providing information for the planning, justification, and/or refinement of larger studies. The objective of our study was to assess the feasibility and acceptability of the study design, procedures, and intervention of the DECISION+ program, a continuing medical education program in shared decision-making among family physicians and their patients on the optimal use of antibiotics for treating ARIs in primary care.METHODS:A pilot clustered randomised trial was conducted. Family medicine groups (FMGs) were randomly assigned, to either the DECISION+ program, which included three 3-hour workshops over a four- to six-month period, or a control group that had a delayed exposure to the program.RESULTS:Among 21 FMGs contacted, 5 (24%) agreed to participate in the pilot study. A total of 39 family physicians (18 in the two experimental and 21 in the three control FMGs) and their 544 patients consulting for an ARI were recruited. The proportion of recruited family physicians who participated in all three workshops was 46% (50% for the experimental group and 43% for the control group), and the overall mean level of satisfaction regarding the workshops was 94%.CONCLUSIONS:This trial, while aiming to demonstrate the feasibility and acceptability of conducting a larger study, has identified important opportunities for improving the design of a definitive trial. This pilot trial is informative for researchers and clinicians interested in designing and/or conducting studies with FMGs regarding training of physicians in shared decision-making.TRIAL REGISTRATION:Clinicaltrials.Gov NCT00354315.

BackgroundExperts estimate that the prevalence of antibiotics use exceeds the prevalence of bacterial acute respiratory infections (ARIs).ObjectiveTo develop, adapt and validate DECISION+ and estimate its impact on the decision of family physicians (FPs) and their patients on whether to use antibiotics for ARIs.DesignTwo-arm parallel clustered pilot randomized controlled trial.Setting and participantsFour family medicine groups were randomized to immediate DECISION+ participation (the experimental group) or delayed DECISION+ participation (the control group). Thirty-three FPs and 459 patients participated.InterventionDECISION+ is a multiple-component, continuing professional development program in shared decision making that addresses the use of antibiotics for ARIs.Main outcome measuresThroughout the pilot trial, DECISION+ was adapted in response to participant feedback. After the consultation, patients and FPs independently self-reported the decision (immediate use, delayed use, or no use of antibiotics) and its quality. Agreement between their decisional conflict was assessed. Two weeks later, patients assessed their decisional regret and health status.ResultsCompared to the control group, the experimental group reduced its immediate use of antibiotics (49 vs. 33% absolute difference = 16%; P = 0.08). Decisional conflict agreement was stronger in the experimental group (absolute difference of Pearson's r = 0.26; P = 0.06). Decisional regret and perceptions of the quality of the decision and of health status in the two groups were similar.Discussion and conclusionsDECISION+ was developed successfully and appears to reduce the use of antibiotics for ARIs without affecting patients' outcomes. A larger trial is needed to confirm this observation.

We introduce a primary care practice model for caring for patients with multimorbidity. Primary care for these patients requires flexibility and ongoing coordination, and it often must be tailored to individual circumstances. Such complex and flexible care could be accomplished within communities of practice, whose participants are willing to learn from their shared practice, further each other's goals, share their stories of success and failure, and promote the continued evolution of collective learning. Primary care in these communities would be conceived as a complex adaptive process in which the participants use an iterative approach to care improvement that integrates what they learn and do collectively over time. Clinicians in these communities would define common goals, cocreate care plans, and engage in reflective case-based learning. As community members manage their knowledge, gain insights, and develop new care strategies, they can improve care for patients with multiple conditions. Using a mix of methods, future research should explore the conditions that are necessary for collective learning within communities of clinicians who care for patients with multimorbidity and who develop new knowledge in practice. By understanding these conditions, we can foster the development of collective learning and improve primary care for these patients.

Contexte : Nous avons développé, à partir du concept bien connu de « speed dating » (France : drague accélérée ; Office de la langue française du Québec : rencontres éclairs), une méthode d'enseignement amusante mais néanmoins très efficace pour stimuler le partage des connaissances lors d'une formation de groupe.La méthode, surnommée « rencontres éclairs pédagogiques (REP) » par les auteurs, a été qualifiée de stimulante par les participants qui en ont fait l'expérience.Ces rencontres offrent une occasion formelle de partager efficacement les problèmes pratiques et les objectifs d'apprentissage.Elles permettent de rencontrer de nouveaux collègues et d'apprendre d'eux, les aident à identifier des perspectives de collaborations futures et des solutions novatrices.Les REP sont modulables en fonction des objectifs pédagogiques et permettent l'organisation d'activités de formation qui génèrent les résultats décrits plus haut.Objectifs : Au terme de cet atelier, les participants pourront (1) expliquer l'utilité de la méthode et (2) préparer et insérer des REP dans leurs propres activités de formation.Déroulement : La première partie de l'atelier sera consacrée à la présentation de la méthode, des résultats d'un projet de recherche sur son utilité en formation continue et d'une revue de la littérature sur le sujet dans les sciences de l'éducation.Les participants seront ensuite amenés à expérimenter eux-mêmes une session de REP avec leurs collègues.Nous animerons enfin une discussion en plénière afin que les participants partagent leurs expériences et discutent des aspects pédagogiques de la méthode et des modalités d'utilisation.

Background. Home environmental exposures may aggravate asthma. Few population-based studies have investigated the relationship between asthma control in children and home environmental exposures. Objective: Identify home environmental exposures associated with poor control of asthma among asthmatic children less than 12 years of age in Montreal (Quebec, Canada). Methods. This cross-sectional population-based study used data from a respiratory health survey of Montreal children aged 6 months to 12 years conducted in 2006 (n = 7980). Asthma control was assessed (n = 980) using an adaptation of the Canadian asthma consensus report clinical parameters. Using log-binomial regression models, prevalence ratios (PRs) with 95% confidence intervals (95% CIs) were estimated to explore the relationship between inadequate control of asthma and environmental home exposures, including allergens, irritants, mold, and dampness indicators. Subjects with acceptable asthma control were compared with those with inadequate disease control. Results. Of 980 children with active asthma in the year prior to the survey, 36% met at least one of the five criteria as to poor control of their disease. The population's characteristics found to be related with a lack of asthma control were younger age, history of parental atopy, low maternal education level, foreign-born mothers, and tenant occupancy. After adjustments, children living along high-traffic density streets (PR, 1.35; 95% CI, 1.00-1.81) and those with their bedroom or residence at the basement level (PR, 1.30; 95% CI, 1.01-1.66) were found to be at increased risk of poor asthma control. Conclusions. Suboptimal asthma control appears to be mostly associated with traffic, along with mold and moisture conditions, the latter being a more frequent exposure and therefore having a greater public health impact.

Introduction: It was hypothesized that after a continuing medical education (CME) event, practice enablers and reinforcers addressing main clinical barriers to preventive care would be more effective in improving general practitioners' (GPs) adherence to cardiovascular guidelines than a CME event only. Methods: A cluster-randomized trial was conducted on a convenience sample of 122 GPs who were randomly assigned to either CME only (control group) or CME with practice enablers and reinforcers (PER group). In the PER group, nurses visited GPs' offices once a month to implement the clinical intervention on patients ≥ 55 years old with a scheduled visit in the month following the nurse visit: (1) screening medical records for potentially undermanaged high-risk patients; (2) prompting physicians to reassess preventive care in these patients; (3) enclosing a checklist reporting most recent information relevant to guidelines' implementation; and (4) enclosing a summary of experts' recommendations in the form of a follow-up and treatment algorithm. Results: A retrospective chart audit of 2344 consenting patients, potentially undermanaged at baseline, demonstrated that the PER intervention following CME significantly improved adherence to guidelines compared to CME alone (OR: 1.78, 95% CI: 1.32–2.41). Discussion: The intervention was designed for self-implementation in primary care practices that have their own nursing staff. PER GPs were highly satisfied with the intervention; the majority said that they would implement it in their practice if someone trained their nurse, thus suggesting support for development of a multiprofessional CME program to disseminate this clinical approach to primary care practice groups.

The greatest resource for improving interprofessional learning and practice is the knowledge, wisdom, and energy of professionals who adapt to challenging situations in their everyday work. We call collective capability the ability of a group of professionals to balance two interdependent levels of organization of practice: what professionals know and what they do collectively over time. Organizing what professionals know links the relational value--caring for patients--to the knowledge value of practice. Organizing what professionals do includes human and organizational factors that facilitate collective work and learning: technical skills for care delivery, institutional support, and a complex mix of emotional, ethical and moral factors involved in social decision-making. Performance gaps can result from a lack of an integrated knowledge framework or from a disembodied knowledge that is not anchored in practice. Opportunities for continuous learning can be seized by documenting the source of the performance gap, and providing the relevant resources to establish the balance between the organization of knowledge and the organization of work.

1Institut de cardiologie et de pneumologie de l’Université Laval, Quebec City; 2Patient Health Management Department, Merck Frosst Canada, Kirkland; 3Hôpital du Sacré-Coeur, Montreal; 4Clinique Médicale Sainte-Foy, Quebec City; 5Groupe de recherche en gestion thérapeutique, Université de Montréal; 6Continuing Medical Education Office, Faculty of Medicine, Université de Montréal, Hôpital Sainte-Justine, Montreal, Quebec Correspondence: Dr Louis-Philippe Boulet, Hôpital Laval, 2725, Chemin Sainte-Foy, Quebec City, Quebec G1V 4G5. Telephone 418-656-4747, fax 418-656-4762, e-mail lpboulet@med.ulaval.ca L-P Boulet, E Dorval, M Labrecque, M Turgeon, T Montague, RL Thivierge. Towards Excellence in Asthma Management: Final report of an eight-year program aimed at reducing care gaps in asthma management in Quebec. Can Respir J 2008;15(6):302-310.

BACKGROUND AND OBJECTIVESAsthma care in Canada and around the world persistently falls short of optimal treatment. To optimize care, a systematic approach to identifying such shortfalls or 'care gaps', in which all stakeholders of the health care system (including patients) are involved, was proposed.METHODSSeveral projects of a multipartner, multidisciplinary disease management program, developed to optimize asthma care in Quebec, was conducted in a period of eight years. First, two population maps were produced to identify regional variations in asthma-related morbidity and to prioritize interventions for improving treatment. Second, current care was evaluated in a physician-patient cohort, confirming the many care gaps in asthma management. Third, two series of peer-reviewed outcome studies, targeting high-risk populations and specific asthma care gaps, were conducted. Finally, a process to integrate the best interventions into the health care system and an agenda for further research on optimal asthma management were proposed.RESULTSKey observations from these studies included the identification of specific patterns of noncompliance in using inhaled corticosteroids, the failure of increased access to spirometry in asthma education centres to increase the number of education referrals, the transient improvement in educational abilities of nurses involved with an asthma hotline telephone service, and the beneficial effects of practice tools aimed at facilitating the assessment of asthma control and treatment needs by general practitioners.CONCLUSIONSDisease management programs such as Towards Excellence in Asthma Management can provide valuable information on optimal strategies for improving treatment of asthma and other chronic diseases by identifying care gaps, improving guidelines implementation and optimizing care.

Background: In North America, although it varies according to the specific type of acute respiratory infections (ARI), use of antibiotics is estimated to be well above the expected prevalence of bacterial infections. The objective of this pilot clustered randomized controlled trial (RCT) is to assess the feasibility of a larger clustered RCT aiming at evaluating the impact of DECISION+, a continuing professional development (CPD) program in shared decision making, on the optimal use of antibiotics in the context of ARI.Methods/design: This pilot study is a cluster RCT conducted with family physicians from Family Medicine Groups (FMG) in the Quebec City area, Canada. Participating FMG are randomised to an immediate DECISION+ group, a CPD program in shared decision making, (experimental group), or a delayed DECISION+ group (control group). Data collection involves recruiting five patients consulting for ARI per physician from both study groups before (Phase 1) and after (Phase 2) exposure of the experimental group to the DECISION+ program, and after exposure of the control group to the DECISION+ program (Phase 3). The primary outcome measures to assess the feasibility of a larger RCT include: 1) proportion of contacted FMG that agree to participate; 2) proportion of recruited physicians who participate in the DECISION+ program; 3) level of satisfaction of physicians regarding DECISION+; and 4) proportion of missing data in each data collection phase. Levels of agreement of the patient-physician dyad on the Decisional Conflict Scale and physicians' prescription profile for ARI are performed as secondary outcome measures.Discussion: This study protocol is informative for researchers and clinicians interested in designing and/or conducting clustered RCT with FMG regarding training of physicians in shared decision making.Trial Registration: ClinicalTrials. gov Identifier: NCT00354315.