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PATIENT ISSUE CLINICAL ISSUES EDUCATIONAL ISSUES The patient may not be aware of the trade-offs between the harms and benefits of screening13 What information does the physician need to inform this discussion? What is the best way to present this information to the patient? Some issues to consider: Approximately 50% of Canadians have inadequate health literacy and numeracy skills13
Well-designed knowledge translation tools can provide information on harms and benefits that support decision making
What is the natural history of cancer progression and the natural history of breast cancer?
What is the concept of overdiagnosis, and how does it apply to screening for breast cancer?
What outcome measures should be used to determine the benefits of screening? What outcome measures are potentially misleading?
How should knowledge translation tools be used to support decision making on screening?
The patient feels she should be screened more frequently than recommended for breast cancer There are conflicting guideline recommendations on screening intervals for mammography: The Canadian Task Force on Preventive Health Care recommends screening every 2-3 y14
The Canadian Association of Radiologists and the Canadian Society of Breast Imaging recommend screening every 1-2 y15
How do we assess the quality of guidelines providing recommendations on screening for breast cancer?
How are screening interval recommendations determined?
The patient is anxious and has concerns regarding her risk for breast cancer16 In clinical circumstances where there is a trade-off between harms and benefits, shared decision making is the desired approach
Patient values and preferences do influence screening decisions
The physician might feel pressured to pursue further screening as a way to manage the patient’s health anxiety
Adequate skills in shared decision making (communicating risk and eliciting the patient’s preferences and values) are necessary
Adequate skills in the management of health anxiety are required
The patient has increased awareness of breast cancer because of her friend’s illness Strong statements and beliefs on the benefits of screening are often provided by cancer survivors and advocacy groups Understand the paradox of screening, which is an increased incidence and a perceived sense of benefit as a result of increased screening17
FACTOR CONCEPTS FOR TEACHING Evolving understanding of the harms and benefits of screening There is a trade-off between benefits and harms
A better understanding of concepts, such as overdiagnosis and the natural history of disease, related to screening decision making is needed
Multiplicity of guideline recommendations on screening Guidelines can have conflicting recommendations on screening for the same condition
Rise of social media and online sources of health care information on screening Patients have many sources of information that can be biased or misleading
Consider the media reliance of the survivor21,27
More rigorous methods for evaluating the quality of evidence Use GRADE: Grading of Recommendations Assessment, Development and Evaluation28
New tools to evaluate guideline trustworthiness and quality Use G-TRUST: Guideline Trustworthiness, Relevance, and Utility Scoring Tool29
Need for effective communication with patients on the potential harms and benefits of screening Use natural frequencies to foster insight
Use knowledge translation tools in decision making with patients
Recognize and employ shared decision making in clinical situations where there are trade-offs between harms and benefits
Evolution of strong patient advocacy groups on screening Understand how belief systems influence clinical decision making
Need to understand the complex, adaptive nature of primary care Screening decisions can be influenced by factors including patient values and preferences
Different patients with similar issues will make different screening choices
CHALLENGE STRATEGIES FOR IMPROVING TEACHING COMMENTS Need for learning objectives and implementation of new resources Use a case-based guidebook illustrating how to apply theory to practice
Use real clinical cases that cite applied evidence
There is a need to move away from sporadic evidence-based teaching to a more integrated approach linked to day-to-day practice and direct interactions with patients Limited or outdated understanding of core concepts in screening Translate learning objectives into strategies for teaching
Ensure there are structured learning opportunities on core concepts
Provide updated information on the key concepts of screening
Many physicians and educators are unaware of the key concepts that have become well known over the past 10 y Limited training time and available resources Leverage academic faculty members to adapt the curriculum
Ensure these topics are seen at many points and reinforced throughout the curriculum
A longitudinal learning approach starting in medical school is needed
Engage stakeholders, including medical schools, provincial regulatory bodies, and the College of Family Physicians of Canada
Reinforce the key concepts through existing learning and continuing professional development formats More effective integration of screening at the time of the patient encounter10 Facilitate the integration of shared decision making as an effective approach to addressing conflicting recommendations and enabling better screening decisions
Teach shared decision making
Teach and use knowledge translation tools
Assemble a package of knowledge translation tools
Consider a visit dedicated to prevention and screening
Shared decision making improves decision quality and patient outcomes, and it supports better health care resource use. A key challenge to address is the need to provide tools that can be used at the point of care.
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