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Table 1 The operationalisation of the specific CME elements based on the identified barriers

From: A geographical cluster randomised stepped wedge study of continuing medical education and cancer diagnosis in general practice

Barriers Capability Psychological/physical Opportunity Social/physical Motivation Automatic/reflective
Insufficient GP knowledge of PPV of symptoms of cancer Positive predictive values for cancer symptoms. PPV cards followed by explanation were delivered as hand-outs to bring home to practice.  
Lack of recognition of the "low risk but not no risk" symptoms Only 50% of cancer patients presented organ alarm symptoms.   Evoking emotions by watching the educational film. Case-based experience. Exchanging experience from daily practice.
Lack of knowledge of benefits of early diagnosis Explaining the waiting paradox. Delay may influence prognosis.   Understanding the value of early diagnosis.
False reassurance from a normal test and other pitfalls 20% of lung chest X-rays are false negative. Only 33% of ovarian tumours can be found with a gynaecological examination. Blood test cannot exclude a risk of cancer.   
High risk-taking Cancer is a low-prevalence condition in general practice. Even alarm symptoms have low PPVs for cancer. This explains the need for having a low PPV for cancer among referred patients. Debate on pros and cons of early cancer diagnosis. Opinion leaders and hospital consultants backing up earlier referral. Understanding the need for having a low PPV for cancer among referred patients. Debate on cost and overdiagnosis. Debate on the GP’s role
Low use of fast-track cancer pathway referral Fast-track referrals reduce diagnostic intervals. If not, it is a challenge for the hospital to redirect patients referred via the usual route to a cancer fast-track pathway or the patient risks investigatory delay. Fast-track pathways for cancer investigation already available. Increasing experience in using regional GP website raised awareness on referral guidelines. Sharing experience. Accepting that 95% of referred patient will not have cancer.
Inadequate experience with online cancer guidelines Reintroducing the regional GP homepage. Guiding in search strategy and contents, including referral guidelines.   Improving the GP’s self-confidence in decision-taking
Difficulties in communicating cancer risk Most patients presenting alarm symptoms had been worried about cancer before consulting a general practitioner. Patient leaflets were delivered to support communication about cancer risk. Sharing experience on cancer risk communication.
  1. The CME-elements were approached by capability, opportunity or motivation (COM).