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