What should educators teach to improve preventive health care?

Roland Grad; Viola Antao; Neil R. Bell; James A. Dickinson; Raphael Rezkallah; Harminder Singh; Olga Szafran; Earle Waugh; Guylène Thériault

doi:10.46747/cfp.6808583

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Figure 1.
Developing learning objectives: An example using the doctor-patient communication theme.
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Figure 2.
When to engage in SDM based on the strength and direction of a GRADE³³ guideline recommendation

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Table 1.

Teaching preventive health care: Themes and concepts in sequence.

THEMES	CONCEPTS (NOT A COMPLETE LIST)	ARTICLES
1. Epidemiology and complexity in primary care Subthemes: Ecology of medical care Lower prevalence of serious disease Lower test accuracy in early stages of disease Variability of disease progression	Complex adaptive environment of primary care Natural history of disease and the heterogeneity of its progression Implications of overdiagnosis (eg, as an outcome of the hunt for cancer) Risk variation in different populations	Better decision making in preventive health screening. Balancing benefits and harms¹⁰ Overdiagnosis: causes and consequences in primary health care¹¹
2. Measures of outcome and effect size Subthemes: Quantitative information on benefits and harms of preventive interventions Quality of evidence Resolving conflicts in evidence or guidelines	Magnitude of benefits and harms— measures of outcome and effect size (eg, change in absolute risk of an outcome, not only relative risk) Lead time and length time bias (eg, 5-year survival as an outcome is a misuse of a measure in screening for disease) GRADE framework for guideline recommendations Tools for critical thinking on guidelines (eg, G-TRUST)	Understanding and communicating risk. Measures of outcome and the magnitude of benefits and harms¹² Update on task force terminology and outreach activities. Advancing guideline usability for the Canadian primary care context¹³ Choosing guidelines to use in your practice¹⁴ Screening: when things go wrong¹⁵ Preventive health care and the media¹⁶
3. Doctor-patient communication Subthemes: SDM: What is it? When and when not to engage Evaluation and implementation of knowledge translation tools	Implications of conditional guideline recommendations for decision making Effective methods of communicating harms to patients Components of SDM: risk communication and values clarification Choosing and using KT tools	Shared decision making in preventive health care. What it is; what it is not¹⁷ Eliciting patient values and preferences to inform shared decision making in preventive screening¹⁸ Patient perspectives. Exploring patient values and preferences¹⁹ To share or not to share. When is shared decision making the best option?²⁰ Teaching shared decision making. An essential competency²¹ Knowledge translation tools in preventive health care²²
4. Organization and evaluation of preventive care Subthemes: Efficiency of the process Quality of the process	Practice organization to support effective preventive care Assessment of quality of preventive health care in primary care practice setting Evaluation and choice of measures of quality of care in screening Interpretation of quality measures in physician practice settings	Practice organization for preventive screening²³ Quality of the screening process. An overlooked critical factor and an essential component of shared decision making about screening²⁴ Measuring what really matters. Screening in primary care²⁵
5. Screening wisely Subtheme: Overscreening	How patient circumstances influence decision making (eg, start and stop ages) Patient perception of risk versus actual risk Resource use in preventive screening	Age to stop? Appropriate screening in older patients²⁶ Periodic preventive health visits: a more appropriate approach to delivering preventive services²⁷ Rethinking screening during and after COVID-19. Should things ever be the same again?²⁸ Too soon or too late? Choosing the right screening test intervals²⁹
6. Adaptation for special populations Subtheme: Adaptation of screening recommendations to specific patients	The importance of context	Improving preventive screening with Indigenous peoples³⁰ Preventive screening in women who have sex with women³¹

GRADE—Grading of Recommendations Assessment, Development and Evaluation; G-TRUST—Guideline Trustworthiness, Relevance, and Utility Scoring Tool; KT—knowledge translation; SDM—shared decision making.

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Table 2.

Key questions and linked learning objectives for the SDM subtheme of doctor-patient communication

KEY QUESTIONS TO ENGAGE LEARNERS	LEARNING OBJECTIVES	KEY POINTS FROM THE ARTICLE SERIES
Many screening recommendations from the Canadian Task Force on Preventive Health Care can be qualified as conditional Question 1: Conditional on what?	1a. Explain what is meant by the concept of a conditional recommendation for a screening intervention 1b. Distinguish between conditional and strong recommendations in terms of when to engage in SDM	SDM should be considered when there are at least 2 medically valid options yielding a balance between benefits and harms (equipoise) If the recommendation is conditional and in favour of the intervention: offer a discussion about it If the recommendation is conditional and against the intervention: engage in SDM only when a patient asks about it
SDM is a structured process used to improve decision making Question 2: What are the core elements of SDM?	2a. Describe the core elements of SDM 2b. Demonstrate the ability to engage in SDM with a patient	The core elements of SDM are risk communication and values clarification To get at these elements, use infographics and decision aids
Patient preferences for treatment of conditions detectable through screening are highly variable Question 3: How would you explain the following concepts: patient values and patient preferences?	3a. Describe what is meant by patient values and preferences using examples 3b. Demonstrate how to elicit patient values and preferences	Values clarification considers both patient values and patient preferences Values refer to how patients value the clinical outcomes arising from the various options Values help determine preferences Preferences are inclinations toward or away from an option
Some patients do not understand the meaning of values in the context of decision making about screening interventions Question 4: With respect to a screening decision, how would you help a patient clarify their values?	4a. Explain the relationship between values and the health outcomes of screening interventions using examples 4b. Demonstrate the ability to facilitate a patient decision	In the context of SDM, values pertain to the importance patients place on the potential beneficial and harmful outcomes that can result from a screening intervention or test. Patients’ preferences are the health care options they most favour For screening decisions, clarifying values focuses on determining patients’ desires to diagnose disease early as well as their understanding and aversion to the risks and implications of false-positive test results and overdiagnosis Clarifying patients’ values often helps inform their preferred options, but it can also be challenging for patients who prefer not to be involved in decision making
Tools can facilitate the process of SDM Question 5: How can infographics or decision aids be incorporated into the office visit?	5a. Explain the difference between an infographic and a decision aid 5b. Demonstrate an ability to use tools at the point of care to improve decision making	Many screening recommendations highlight the close balance between benefits and harms
SDM is not appropriate for all situations Question 6: When is SDM probably not the right approach?	6a. Using an example, explain when SDM should be introduced and when it should not be introduced 6b. Explain the difference between sharing information and SDM	In strong recommendations, the balance between benefit and harm is not close to even While SDM is often underused, it may be introduced in situations where it probably should not be used When SDM is not warranted, sharing information remains a good practice