It’s an exciting time to be a haematologist/oncologist, with new clinical data emerging and new drugs being approved at a stunning pace. But this comes at a price – physicians sometimes struggle to keep pace with the mountains of data, and the resulting implications for clinical practice and the patient sitting in front of them.
Decision making is becoming particularly difficult for haematologists/oncologists in the community setting – who treat more than 50% of all cancer patients in Europe. Community haematologists/oncologists can also see patients who present with every type of solid tumour, as well as haematological malignancies.
A Medscape confidence-based assessment of European Union haematologists/oncologists found that, when selecting from eight different treatment choices for a patient with relapsed/refractory multiple myeloma, only 43% of them were confident in their choice, at best (see figure 1).
Figure 1: Decision-making for a relapsed/refractory case of multiple myeloma
She adds that time is another challenge.
“Pressures are mounting on physicians in several different ways and finding the time to not only keep up to date with all the available data, evolving guidelines and clinical protocols, but to also consider how these impact their patients is challenging. Collectively this adds to the complexity of making continuous treatment decisions for each patient they see, as well as the confidence that they have in making those decisions.”
Dr Katie Lucero, director of outcomes and insights at Medscape Education Global, says that patient pressures may also contribute to this lack of confidence.
“With the availability of information about treatments and patient experience 24/7 via the internet, patients come armed with their own idea of what treatment should be along with their personal goals for treatment.
“Triangulated with the need to stay up to date because of the fast pace of the latest evidence and institutional protocols for treatment, this situation creates a complex system for making treatment decisions and having confidence in those decisions.”
As noted by Medscape’s whitepaper, Behavioral Insights: Practicing Hematologists’/Oncologists’ Search for Evidence to Empower Clinical Decision-Making, the gap between physicians knowing what they’re doing and feeling comfortable with what they’re doing is growing wider.
The whitepaper also showed that very few haematologists/oncologists demonstrated mastery – defined as showing both competence and confidence – in making treatment decisions with the presence of an adverse effect.
In fact, only 15% demonstrated mastery when answering a case-based question regarding a patient with multiple myeloma who presented with severe peripheral neuropathy (figure 2).
Meanwhile, 44% of those surveyed demonstrated neither competence nor confidence – 21% were misinformed and were confident about continuing to use an agent that was not recommended for use in patients with this condition.
Figure 2: Confidence-based assessment of a multiple myeloma patient presenting with severe peripheral neuropathy
Lucero says these results likely come down to “a lack of education and experience”.
“In this case the treatment was linked with a particular adverse event. The majority of survey respondents were community haematologists/oncologists, so it is plausible that they had not encountered such an adverse event before, and it didn’t jump out at them when they read the case.
“Obviously surveys do have limitations in that they are not as high stakes as the real world, so although research shows case vignettes are correlated with and good indicators of real world practice, they may not motivate information-seeking in the same way. For example, if one was unsure in the real world, they might seek additional information.
“It’s unlikely that during the survey, they sought additional information to answer the questions. So that 15% is a conservative estimate but still reflective of the small percentage who could recall the correct answer with confidence.”
Harvey-Jones adds: “Community haematologists/oncologists never know what they will be presented with next in the clinic and the more nuanced the patient presentation the more challenging it is for the clinician to make treatment decisions.”
Lucero says the results suggest that, because of the multitude of treatments available that may be effective in multiple myeloma, haematologists/oncologists need continuing medical education (CME) to truly understand how to apply evidence to practice.
“Behavioural theories and research generally point to the importance of confidence in behaviour change. Confidence is typically obtained from vicarious learning – watching others successfully enact the behaviour, through skills practice, and knowledge acquisition. Adding formative feedback (immediate feedback after practicing) adds an additional bump to learning and confidence.
“We see that when competence improves or is reinforced (i.e. confirmation of current decision-making) from education, there is also an increase in confidence. Confidence gains are largest when there is improvement in competence, but there are still significant gains from experiencing reinforcement. If one does not demonstrate any competence from the activity via assessment, that is linked with lower starting confidence and non-significant increases in confidence from pre to post.”
The whitepaper shows that education has a consistent impact on knowledge, competence, and confidence – average relative increases in knowledge/competence in clinical trial data, treatment decisions, and patient management resulting from CME activities in acute myeloid leukaemia, multiple myeloma, and chronic lymphocytic leukaemia were 20%, 25% and 28%, respectively.
Importantly, although baseline knowledge and competence consistently decrease in the wake of market events from the previous quarter, subsequent evidence-based education increases the knowledge and evidence-based decision making of the learners.
Harvey-Jones says that case-based education is important for community haematologists/oncologists.
“While a review of available data is useful, expert opinion and translating these data into practical application using case-based learning is critical. Community-based haematologists/oncologists want to know how to apply the multitude of available clinical data, so they can transfer their knowledge of that data into confident and optimal decision-making that ultimately has a positive impact on patient outcomes.”
“Case-based learning is more exciting and can enliven topics that might otherwise not be engaging,” notes Dr Sagar Lonial, chief medical officer, Winship Cancer Institute of Emory University, quoted by the report.
Flexibility in format is a key point – with Medscape’s study finding that over 75% of learners identified convenience and content quality as important factors in choosing a learning activity.
“There is definitely a trend for preference of more bite-size lengths of content – such as two 15-minute segments versus one 30-minute segment,” Lucero says.
Harvey-Jones notes that this is partly driven by changing demographics among HCPs.
“Some years ago, we reached a digital tipping point where most practicing physicians are now ‘digital natives’ and are often going online for their education rather than seeking face to face opportunities.”
Lucero predicts that medical education in this area will continue to trend towards digital, expedited, of course, by the effects of the COVID-19 pandemic.
“The COVID-19 pandemic really has highlighted the presence of conflicting information available. This means clinicians need to have trusted, up-to-date, scientific sources of information to feel confident in what they are consuming and utilise the best evidence in practice.”
Further data from a 2020 McKinsey report suggests that 93% of physicians expect to use digital tools for clinical-decision support the same amount, greater or significantly greater after the COVID-19 crisis. Furthermore, 90% of physicians say they will engage with remote learning tools the same amount, greater or significantly greater after COVID-19.
“We know that haematologists/oncologists get information that impacts their practice from a multitude of sources beyond online education – including scientific journals, live meetings, clinical/medical news, colleagues, and pharma,” says Lucero. “If the information is important to the extent that not using it may cause harm, then it must be available at the point of care. That’s what makes online very powerful. Making the same information available in many different formats is one way to reach clinicians with the right information at the right time.”
Dr Lonial agrees: “CME is most valuable when presenters provide clinical context regarding real-world situations rather than just regurgitating study data. This type of CME can be done at live meetings and recorded for online presentation. CME is used over and over again by people who can’t be at live meetings.”
He says that it is important to recognise that “most digital sources of medical information are not peer reviewed”. Conversely, he says, non-biased, evidence-based, peer-reviewed CME, “provides a lot of credibility”.
While the whitepaper showed that 47% of practice changes were driven by medical journals, online CME also has the advantage of being able to cover late-breaking developments reported at conferences – recorded and interpreted for rapid online delivery.
“The types of digital education will also evolve,” says Harvey-Jones, “becoming more innovative and interactive to maintain that important scientific exchange between teacher (the expert) and learner (the community physician) that provides value during those face to face educational opportunities that may become less frequent.”
Harvey-Jones adds that a blended approach to learning will continue to be important and this is key for engaging all kinds of physicians.
“It’s important to provide education in a variety of formats, such as text-based, video-based or simulation, and at the time that suits physicians the most. Haematologists/oncologists get their information from a multitude of different sources such as online news articles, guideline updates, medical journals, expert opinions – it’s important to have these available to them.
“We also need to ensure that the content is convenient and of high quality – short, bite-sized pieces of education are becoming increasingly popular and it’s important to make sure that the data is contextualised for what it means for daily clinical practice and the patients sitting in front of them.”
A recent study by the FDA and Medscape, published in Pharmacy Practice, has also shown that digital CME combined with Targeted Short Form Messages can often offer the biggest benefit for HCPs.
The problem identified was inappropriate clinical behaviour in the face of a black box warning concerning fluoroquinolones. The study design exposed only high-volume prescription writers of fluoroquinolones to one of three behaviour modification strategies: CME, Targeted Short Form Messages, or a combination of both.
The study looked at 320,478 prescribers of fluoroquinolones, 28,000 of whom were “high decile” prescribers.
The results found that all arms showed a statistically significant impact on clinical behaviour with CME alone, and with CME plus messaging yielding the greatest impact.
The authors noted that they were able to “target clinicians who may have been compromising public health, reach them, and have a positive impact on their behaviour”.
Since then, the role of digital CME has become even more important in light of COVID-19 and the resulting lack of face to face learning opportunities, thanks to its ability to increase the confidence of haematologists/oncologists in making informed treatment decisions for their patients.
To read the full whitepaper download it here.
Katie Lucero is director of outcomes and insights at Medscape Education Global. She has nearly 20 years of experience in research and evaluation in developmental psychology, public health, health outcomes, and education (K-12 and CME). Prior to Medscape, she was director of research and evaluation for McREL International where she was responsible for designing, pursuing, and managing education evaluation and research studies, including government projects.
Victoria Harvey-Jones is an associate director of clinical strategy at Medscape Oncology Global where she designs impactful physician education to improve patient outcomes. She has spent the last 10 years in the medical education and communications industry. She previously helped found touchIME, the Independent Medical Education division at Touch Medical Media, where she was the head of medical and editorial.
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