Meeting the information needs of family physicians in the complex world of cancer control

For most people in British Columbia, the family physician provides an entry point into the health care system and a link to secondary care.[1] As the medical professional who initiates inves­tigations, counsels the patient, and directs the course of care, the family physician is in a unique and strategic position to deliver effective health care messages and influence the patient’s care experience. 

Cancer is one of the most common and complex chronic conditions that family physicians must manage. Many Canadian women (39%) and men (44%) will develop cancer over their lifetimes.[2] 

Cancer control includes a spectrum of health-related activities such as prevention, screening, early diagnosis, ongoing care and support for patients, palliation, cancer re­search, and education. 

Family physicians play an important role in every aspect of cancer control.[3] Many re­sources for cancer control exist for patients and cancer specialists, but few are available for family physicians. 

The Family Practice Oncology Net­work (FPON)[4] of the BC Cancer Agency (BCCA) sought to understand the current cancer management practices and cancer information needs of family physicians through a needs assessment conducted by the University of British Columbia’s Division of Continuing Professional Devel­opment and Knowledge Translation. 

This survey[5] had three main objectives:
• To assess the context in which family physicians require cancer information (e.g., practice setting, type of cancer care information). 
• To assess family physicians’ comfort level in searching for and ac­cessing cancer care information. 
• To determine the types of resources family physicians use to find cancer information and how they prefer to access this information.

Methods
The survey was developed by a group of specialist and family physicians, and other experts in research, education, and technology. 

The survey consisted of three sections. The first section included questions about cancer management practices and how much time family physicians spend managing cancer. 

The second section included questions about supporting patients’ information needs and how physicians prefer to access cancer control re­sources. Both these sections used Likert scales for responses. 

The third section included standard demographic questions about physician gender, graduation year, and practice location. 

Every section of the survey also in­cluded open-ended questions that gave respondents an opportunity to expand on their responses and share their experiences in more detail. 

The survey was mailed to a random sample of family physicians in Bri­tish Columbia—approximately one-third of the province’s population of family physicians. 

Three hundred and sixty completed surveys were returned for a response rate of 25% and an accurate representation of the population of BC family practitioners (confidence interval 95% +/- 4.97%). 

Data from the survey were analyzed using integrated quantitative and qualitative techniques. The means of the quantitative survey items were compared using t tests, and content analysis was performed on the open-ended qualitative data.

Results
Of the 360 respondents, 37% were fe­male and 63% were male, while 73% practised in an urban setting and 27% practised in a rural setting, as defined by BC’s Subsidiary Agreement for Physicians in Rural Practice. 

Data pertaining to the year of graduation from medical school revealed a normal distribution of survey participants. The majority of participants (88%) graduated in the 1970s, 1980s, or 1990s, while 7% graduated in the 1950s or 1960s, and 4% in the year 2000 or later. This respondent group closely matched the provincial population of family physicians in terms of age and gender.[6]

Practice setting
The majority of physicians who res­ponded to the survey (93%) worked in general practice offices. At the time of the survey, more than 39% of respondents were working regularly in two or more practice settings (e.g., a general practice office and a long-term care facility). 

In a typical week, 60% of physicians estimated that the number of cancer patients they saw ranged between one and nine, with a cancer patient defined as anyone newly diagnosed, undergoing treatment, or in remission.

Information needs
Overwhelmingly, the physician respondents indicated that family physicians should provide cancer prevention information to their pa­tients. 

Moreover, rural respondents were significantly more likely than urban respondents to indicate that family physicians should be more involved in patient follow-up care after cancer treatment (P<.05). 

Family physicians noted the need for additional cancer control information at the point of care and the lack of supports available to physicians de­livering this care. 

More than 55% of respondents indicated that in a typical month they “sometimes” encounter situations challenging their cancer knowledge and feel they cannot adequately answer patients’ questions. Likewise, 48% of respondents indicated that in a typical month they feel the need to look up specific cancer information during a patient visit.

Table 1 describes the typical cancer-related support family practitioners report providing to patients.  Table 2 summarizes practitioners’ responses to questions about how comfortable they feel when providing this support, and  Table 3 indicates which cancer information resources practitioners use most often.

Only 10% of respondents rated access to information on cancer prevention and treatment as “good.” A clear majority of respondents (more than 75%) agreed or strongly agreed that improved access to cancer information at the point of care is needed.

Respondents were also asked to rate their preferred method for obtaining cancer information and engaging in learning related to cancer management. The Internet and computer-based resources in a handheld form were rated as the “most preferred” delivery method. 

Approximately 39% of respondents rated the Internet highest when stating their preference for obtaining cancer information and engaging in learning related to cancer management. 

Computer-based resources such as Five-Minute Consult and other cancer guidelines available for personal digital assistants (PDAs) platforms were rated as the “most preferred” by 28% of respondents.

Physician preferences
The survey results suggest that family physicians are not comfortable ad­dressing patients’ information needs and, more worrisome, find it difficult to access information in a world where cancer control is evolving rapidly. 

The survey results also reveal that while family physicians are comfortable communicating with and caring for their cancer patients, they find it difficult to guide them through the cancer care system. 

And rather than accessing comprehensive local resources developed specifically for their use, such as the BCCA Cancer Management Guidelines, family physicians are accessing a diverse range of resources, including the BC College of Physicians and Surgeons online library, the Centre for Integrated Healing, and guidelines distributed by other provinces (e.g., Ontario) and American organizations. 

This need to access a variety of in­formation sources indicates family physicians require both diverse and specific cancer control information. Overall, results from the survey draw attention to the importance of the family physician in cancer management and the shortage of accessible information suited to the family physician.

New point-of-care tool
Findings from this needs assessment are now being used to guide the de­velopment of Cancer Information at Point of Care (CI-POC), software that allows family physicians to access various cancer supports such as condensed clinical practice guidelines and web sites from a PDA or Internet-connected computer. 

This cancer information tool addresses both the family physicians’ preference for computer-based resources and their need to access up-to-date information. This tool also serves to draw attention to and promote Internet resources al­ready available for family physicians. 

CI-POC uses the same technical platform (CliniPEARLS) used by the Guidelines and Protocols Advisory Committee (GPAC),[7] jointly sponsored by the BC Medical Association and the Ministry of Health. This allows CI-POC to provide unified and direct access to both cancer information and information about other chronic diseases such as diabetes. 

The content continues to be developed with the assistance of family physician focus groups and under the supervision of the BCCA Tumour Groups. In future, information will cover the full spectrum of care, including prevention, screening, early diagnosis, investigations, staging, treatment, follow-up, and management of complications.

Conclusions
Family physicians who responded to a BC Cancer Agency survey indicated that they want better access to current cancer-related information in order to support their patients. 

CI-POC is a new tool being developed with these survey results in mind. By adapting computer-based resources such as CI-POC to better suit the preferences and meet the needs of family physicians, we can potentially improve the quality of patient care in the complex world of cancer control.

Competing interests
At the time this article was written, Drs Chritchley and Murray were employed by the BC Cancer Agency, on whose behalf the survey was conducted.

Acknowledgments
This research was supported by funding from the BC Provincial Health Services Authority. We would like to thank, in alphabetical order, Gail Compton, Jennifer Cor­deiro, Laurel Jebamani, Olive Kung, and Elizabeth Stacy for their contributions to the research and organization of this project.

Dr Novak Lauscher is the director of re­search in the Division of Continuing Professional Development and Knowledge Translation at the University of British Columbia (UBC). Ms Poole is the provincial network facilitator and secretariat for the Strategic Leadership Council at the BC Cancer Agency. Dr Chritchley has practised internal medicine and medical oncology for 25 years in the Interior of BC, and is vice president of the BCCA Communities Oncology Network. Dr Murray is a family physician from Nelson, BC, and is member of the Family Physician Oncology Network of the BC Cancer Agency. Dr Jarvis-Selinger is an assistant professor in the Department of Surgery and associate research director in the Division of Continuing Professional Development at UBC. Ms Cressman is a research coordinator in the Division of Continuing Professional Development and Knowledge Translation at UBC. Dr Kendall Ho is an emergency physician and associate professor in the Department of Surgery at UBC.