CME – When Old Beliefs Won’t Budge: Evaluating Entrenched Attitudes and Resistance to Change Among Healthcare Professionals

Each year, the Alliance for Continuing Education in the Health Professions (ACEHP) holds its annual meeting, bringing together hundreds of thousands of continuing education professionals and stakeholders.  During this past year’s meeting, there was an interesting poster entitled: “When Old Beliefs Won’t Budge: Evaluating Entrenched Attitudes and Resistance to Change Among Health Care Professionals.”   

The poster was presented by Carole Drexel, PhD, CCEMP, Anne Jacobson, MPH, CCEMP, and Jay M. Katz, MA, CCEMP, on behalf of the Potomac Center for Medical Education.  The presentation was part of a CME-certified dinner symposium, held in conjunction with the American Diabetes Association (ADA) 71st Scientific Sessions in June 2011 entitled, “Emerging Options for Type 2 DM Management: Glucose Control and The Kidney,” and was supported by an educational grant from Bristol-Myers Squibb and AstraZeneca, LP.  

Background 

Live activities remain popular educational formats in CME.  However, are stand-alone CME activities effective in addressing persistent gaps in knowledge and competency?  Accordingly, the authors sought to compare the performance of various qualitative and quantitative assessment methods, including pre-activity, post-activity, and follow-up tools, in measuring entrenched beliefs among health care professionals. 

Then the authors described the advantages and limitations of specific educational activity formats in addressing entrenched beliefs and facilitating change toward evidence-based clinical practice.  Finally, they identified opportunities to close knowledge and competence gaps with optimal program planning, design, and outcomes measurement, against a backdrop of entrenched beliefs.  Upon successful completion the symposium, participants were meant to be able to:  

• Cite the results of key clinical trials that have shown the long-term benefits of glycemic control in patients with T2DM
• Make therapeutic decisions driven by patient presentation, as well as the safety and efficacy of therapeutic agents
• Understand the role of the kidney in glucose regulation and outline how the mechanism of action of SGLT2 inhibitors differs from that of currently available hypoglycemic agents
• Highlight the data from key clinical trials of investigational SGLT2 inhibitors and discuss the potential role of these agents in the treatment of patients with T2DM     

The program was designed as a 2-hour satellite symposium with 4 live interactive lectures (20 to 40 min each), including polling questions using ARS, and interactive discussions with questions/answer sessions after each presentation.  Two lectures covered basic T2DM care, including ADA guideline recommendations, HbA1c targets, and first- and second-line drug management.  In addition, two lectures covered topics that were new to the target audience, including renal physiology, glucose metabolism, and clinical experience with SGLT2 inhibitors  

An outcome assessment was performed to evaluate the knowledge of a number of topics in the management of T2DM.  The results showed  that the audience had many years in practice and a high volume of patients with T2DM.  

• 29% endocrinologist;
• 13% PCP;
• 12% diabetes educator;
• 7% pharmacist;
• 7% RN/NP/PA;
• 33% others (including research)  

The activity also showed improvement in knowledge regarding the role of the kidney and the SGLT2 co-transporter in glucose regulation.  Participation in the activity resulted in increased knowledge of newer concepts that were taught (e.g. renal physiology and effects of SGLT2 inhibition):  

• Icrease from 44% (pre-activity) to 100% (post-activity) of participants who correctly identified the effects of SLGT2 inhibition on glucosuria, systolic blood pressure, and weight  
• Increase from 60% to 80% of participants who correctly identified the proportion of glucose filtered by the kidney  

The authors noted, however, that confusion remained about basic clinical concepts in T2DM management, including: The results from the tight glucose control trials (e.g. ACCORD, ADVANCE, VADT) (28% prior vs 35% post)     

Participation in the activity was not associated with an increase in self-ratings of competence; however, it was noteworthy that the participants self-assessment was already high in the following areas:  

• managing patients with type 2 diabetes to recommended HbA1c target goals, while minimizing weight gain and CV and hypoglycemia risks [mean rating 3.7]
• selecting an initial T2DM therapy [4.0]
• selecting add-on therapy [3.9]     

Gaps in Competency  

Despite these positive results, the recognized that noticeable discrepancies emerged between participants’ high perception of their own competence levels and their response patterns to key clinical challenges.  Even in this high-level audience, responses to clinical questions clearly indicated:  

• Confusion between the AACE and ADA guideline recommendations
• Lack of awareness of management strategies for a patient with renal impairment (guidelines)
• Lack of awareness about the armamentarium available to manage hyperglycemia and the role and place of the newest agents (e.g. incretins)
• Remaining confusion about individualization of HbA1c targets, specifically in patients with CV risk factors  

After participating in this educational activity:  

• Only one-quarter of clinicians selected the appropriate HbA1c target for a patient with T2DM and high cardiovascular risk
• Only 35% were able to apply evidence from trials of tight glucose control to current T2DM management
• Only 32% were able to identify appropriate treatment options for a patient with renal impairment
• Uncertainties about guideline recommendations also remained, with only 28% able to identify the correct steps for a patient with inadequate response to glyburide and metformin  

The authors noted that clinicians can make major gains in knowledge and competence related to new material by participating in a single, 2-hour, live CME activity.  However, many basic concepts in T2DM management remain unclear, even in high-level diabetes professionals.  

These data emphasize the need to proactively identify opportunities to incorporate “old material” in CME activities, even as new concepts are being taught.  This includes: 

• Making time in the program agenda to review basic concepts related to diagnosis, treatment goals, and guideline recommendations
• Reiterating “old material” in case studies; and
• Testing for knowledge and competence in the basics in all outcomes assessments 

Until incorrect “entrenched beliefs” are unlearned, clinicians will not be able to apply basic concepts in clinical practice.  Correction of “entrenched beliefs” is likely a major barrier to clinical change, the authors concluded.