Effectiveness of half-day interactive continuing medical education workshop in improving oncologists’ knowledge in prescribing opioids [version 1; peer review: awaiting peer review]

Background : Patients with cancer commonly experience persistent pain, and opioids have remained the mainstay of pain treatment because of their rapid effectiveness in treating moderate to severe pain. As medicine progresses, we need to establish continuous medical education sessions to educate, update, and establish competency in opioid prescribing in cancer patients. Aim: The objective of this study was to explore whether continuing medical education interventions improve oncologists’ knowledge about pain management when prescribing opioids. Methods: We conducted a cross-sectional prospective pre-post-test study. Continuing medical education workshops lasting three identical half-days was offered in 2019. Training sessions were held at the Princess Noorah Oncology Education Center. A total of 40 participants


Introduction
Patients with cancer commonly experience persistent pain, on average 30%-50% of patients undergoing active cancer therapy and 75%-90% with advanced disease suffer from chronic pain that necessitates pain management. 1,2 Currently, opioids have remained the mainstay of treatment because of their rapid effectiveness in treating moderate to severe pain. 3 However, a systematic review published in 2008 revealed that 43.4% of cancer patients were undertreated according to the Pain Management Index (PMI). 4 The undertreatment of pain is a worldwide phenomenon. In recent years, however, health professionals have identified pain educational efforts as an important step towards making pain management more effective. 5 The lack of formal education in medical schools is one reason why continuing medical education (CME) is useful for educating doctors on pain management. 5 Medical professionals have a constant need to incorporate new concepts into their practice to remain medically competent. The CMEs program makes it possible for physicians to learn about the ever-evolving body of medical knowledge while maintaining their clinical competencies, but there has never been a study that evaluated whether CME can improve the knowledge of oncology physicians regarding opioid prescribing for patients with cancer. [6][7][8][9][10][11] Conducting such studies is critical to ascertain whether a CME workshop is necessary to improve the knowledge deficiency in pain management and prescribing opioids among physicians. To accomplish this, a team of palliative care pain experts developed a CME activity geared towards oncologists to improve their knowledge and attitudes toward chronic cancer pain management and opioid prescription.
The primary goal of this study was to explore whether CME interventions improve oncologists' knowledge of pain management and prescribing opioids. The secondary objective was to determine the effectiveness of a half-day workshop with traditional training, which consisted of one or two days.

Study design and setting
This was a cross-sectional, prospective pre-and post-study performed at a single site. In this study, a convenience sample design involving 40 healthcare professionals from our oncology department was used. The study population consisted of staff physicians, residents, assistants, associate consultants, and consultants from our oncology department with varying levels of experience and training. The workshops were conducted three times in 2019 in the education room at the Princess Noorah Oncology Center (PNOC) at King Abdulaziz Medical City, Jeddah. Each workshop accommodated 8-17 participants; with a total of 40 participants. The same presenters and the same material were presented in each workshop. All study participants provided written informed consent, and the study design was approved by the ethics review board of King Abdullah International Medical Research Centre, study number RJ20/171/J.

CME intervention overview
A team consisting of three pain specialists from our palliative care unit in collaboration with a pharmacist designed the contents of the CME course. This program includes a half-day workshop on pain management and prescribing opioids for cancer patients, geared primarily toward oncologists. The CME workshop was tailored to a small group of specialists within a single field of medicine and designed to provide participants with knowledge and skills. Oncologists should be knowledgeable about the use of opioid therapy while considering their educational needs. The CME activity consisted of six lectures, case presentations, and discussions. The content of this lecture includes cancer pain principles: pathophysiology and assessment; cancer pain management: non-pharmacological and pharmacological; opioids pharmacologically; opioids prescribing in cancer patients: WHO guidelines and pathways, opioid rotation and conversion, and prevention and treatment of opioids' side effects, and complications also opioids use disorders.

Assessment instrument
Based on our need our assessment instrument was targeting opioid prescribing in cancer patients and based on a questionnaire from previous studies, a comprehensive questionnaire that fulfills our workshop objectives was drafted. [12][13][14][15] The content validity of the pre-and post-test was accomplished by the tool that was devised and reviewed by three specialized palliative physicians who were experienced in prescribing opioids to cancer patients and if there's any issue in understanding the question. At the beginning of the workshop, participant physicians were asked to complete the pre-test assessment which consisted of 16 multiple choice questions (case scenario format) with four options. Each question had one mark. For the correct answer, one mark was awarded. For any wrong answer or any question answered with more than two choices no mark was given. A scoring system based on the correct answers was employed. Since cancer pain assessment, management, and safe opioids prescribing are connected, a total of 16-item multiple-choice questions in the case scenario (Table 1) format were prepared in three parts including pain assessment, opioids prescribing, and opioids side effect assessment and management. The pain assessment domain had three questions, the opioids prescribing domain had eight questions, and the opioids side effects assessment and management domain had five questions. The opioids equianalgesic table (British Columbia opioids equianalgesic table) was included in the question sheet. 16

Data collection
As part of the pre-test questionnaire, data were also collected concerning age, gender, occupation, level of physician (staff physician, resident, clinical fellow, assistant consultant, associate consultant, and consultant), and years of oncology practice. Details of previous pain education (yes/no) were also obtained.

Statistical data analysis
The mean and standard deviation was used to describe continuous variables and the frequencies and percentages for the categorical variables. The Kolmogorov-Smirnov test and the histograms were used to assess the statistical normality assumption for the physician's continuous measured variables. The multivariate Generalized Linear Mixed Modelling was used to assess the predictors for the change in the physician's knowledge score on opiate prescription from before to after the workshop, but the data was restructured from long-to-wide data via the data restructuring feature before the generalized linear mixed analysis was used yielding a data matrix equal to (40 subjects Â 2 repeated knowledge score measures = 80 records), the associations between the predictors with the physician's knowledge on opiates were expressed as a beta coefficient with 95% confidence interval. The Cohen's D effect size statistic was used to quantify the size of the change in physician's knowledge from before to after the educational session. Chi-square was used to compare the effectiveness of the workshops. p < 0.05 was used to indicate a statistically significant result.

Results
A total of 40 physicians attended the workshop and completed the pre-test and post-test assessments. Half of them were male, and the remaining half were female. The average age of the participants was 38.60 years, and the SD was 6.40 years. However, 65% of the participating physicians were under forty, and 35% were over 41. The mean number of years experience in oncology for the physicians was equal to four years, SD = 2.24 years, and the distribution of their medical level was as follows: 25% of the participating physicians were clinical fellows, most of them 45% were staff physicians and another 17.5% of the physicians were assistant consultants, 7.5% were associate consultants and 5% were indeed oncology consultants. A majority of the doctors, 70%, were juniors and 30% were senior oncology doctors. A descriptive analysis of physicians' socio-demographic characteristics and professional characteristics appears in Table 2.
Knowledge scores at pre-and post-test On the pre-and post-test, the mean physicians' knowledge scores on prescribing opiates were 9.48 and 11.93, respectively. Subsequently, the mean physicians' knowledge score was raised by 2.54 following the post-test which was statistically significant with a p < 0.001 and a 95% confidence interval of (1.157%-3.743%), t = 0.831, df = 39. Based on the Cohen's D effect size statistic (0.61), the learning session resulted in a substantial (moderate) increase in physicians' knowledge of opiate prescribing (Table 3).
Based on the marks they received, physicians were categorized into four grades: Grade A, 90% and above, Grade B, 75%-89%, Grade C, 50%-74%, and Grade D, below 50%, as shown in Table 4. The pre-test score distribution was 7.5% grade A, 5% grade B, 67.5% grade C, and 20% grade C, whereas the protest score distribution was 20.0% grade A, 35%

Objectives
• To assess cancer pain and its severity.
• To manage cancer pain according to WHO ladder WHO Analgesic Ladder.
• To demonstrate prescribing skills by starting the Appropriate Opioid drug and with appropriate starting dose as per our Saudi national palliative care guidelines.

Narrative
The scenario started with Mrs Omar is a 56-year-old woman, known case of carcinoma of the sigmoid colon came to the clinic complaining of severe abdominal pain 8/10 that is not responding to over-the-counter medications.

Expected actions
• To identify that the patient is having severe pain and have to be started on strong opioids (Morphine). • To manage her pain first and to complete the assessment after she settles down.
• To discuss side effects with the patients and start preventive measures for those side effects.
grade B, 37.5% grade C, and 7.5% grade C. The workshop results showed that five of the eight participants who scored a D in the pre-test (5/8 = 62.5%) were able to achieve a C or higher.
Pre-test results show that only 12.5% of the participating physicians scored 12 or more out of 16 while on post-test 55% scored more than 12 points (Table 4). A significant increase of 42.5% in the number of physicians who scored posttest p < 0.0001 (Figure 1).  Table 3. Descriptive analysis of the physician knowledge score on opioid prescription before and after the workshop.

Mean (SD) Minimum Maximum
Knowledge score before the workshop 9.48 (2.67) 5 16 Knowledge score after the workshop 11.93 (2.86) 6 16 To ascertain our findings from the bivariate analysis the data was transposed from long-to-wide data format yielding a data matrix equal to (40 subjects Â 2 repeated knowledge measured scores = 80) and generalized linear mixed methods analysis was used to regress physicians repeated measured knowledge scores against the time (post-versus preeducation) with the physician's other factors like their experience, level, and gender. The yielded findings from the multivariate analysis (Table 5) showed that the physician's sex, experience, and seniority did not converge significantly on their knowledge score before and after the educational session was attended, but the analysis model showed that the physician's knowledge after the educational session was significantly greater than before attending the session on average, beta coefficient = 2.450, p < 0.001, by considering the other predictor variables as accounted for, however, therefore it can be implied that regardless of the oncology physicians sex, age, experience and rank the educational session is effective at enhancing their opiate prescription in the palliative oncology settings (Table 5).

Discussion
We present some key findings of this study. First, the CME sessions at the three half-day workshops were effective in improving physicians' knowledge. The average pre-test score was 9.48 and that of the post-test was 11.93. An increase of 20.5% in mean scores from pre-test to post-test. The difference in mean scores between pre-test and post-test was significant, p < 0.001. Literature has shown that the pre-and post-test score technique used in our study is a reliable and valid indicator of knowledge gain among participants. 9 Furthermore, several studies have demonstrated an improvement in physician knowledge as an indicator of the effectiveness of CME programs. [17][18][19] Many studies in the literature show that CME and other forms of educational training can improve participants' knowledge. [20][21][22] Our findings corroborate these findings.  Second, socio-demographic factors do not predict higher levels of knowledge post-workshop. Our study found that the improvement in mean pre-and post-test scores (gain in knowledge) was achieved regardless of the difference in age, gender, experience, or ranking of oncology physicians. Even though these predictors contributed to higher knowledge post-workshop, the effect was not statistically significant (Table 5). A difference between pre-and post-test scores because of age, gender, type of practice, or the number of years since training commenced was not statistically significant. The findings are similar and confirm the findings of an earlier study conducted by Nazim et al, which indicated no significant differences between pre-and post-scores regardless of demographic factors such as gender, age, or type of practice of the participant. 10 Third, in the resent study, post-test scores improved markedly for physicians who obtained lower grades in the pre-test, while those who received higher grades in the pre-test continued to receive higher grades with a significant improvement in their post-test scores. Out of the eight physicians who completed the pre-test with a Grade D, five (62.5%) advanced to Grade C or higher. Among the 27 participants who achieved a Grade C, 12 (80%) advanced to Grade B or higher. Furthermore, 35 (87.5%) physicians scored Grade C or less on the pre-test compared to 18 (45.0%) on the post-test, a 42.5% decrease in the number of physicians scoring <75% in pre-test, p < 0.0001. These findings indicate a significant increase in the number of physicians securing higher grades of marks. Shivaswamy et al. used pre-test and post-test questionnaires to explore improvement in knowledge of acne among medical students and found a similar pattern to ours. 21 The study by Chan et al. sought to evaluate the attitude and changes in the clinical knowledge of emergency physicians and nurses through a training course and found significant improvements on the part of the participants. 22 Interestingly, they reported similar distributions of scores between pre-test and post-test to those observed in the present study.
Furthermore, several studies have demonstrated an improvement in physician knowledge as an indicator of the effectiveness of CME programs. [17][18][19] However, the effectiveness of various workshops has not yet been examined in a study. To gain some insight into the effectiveness of different CME workshops, we compared workshops lasting three hours, a full day, and two full days. Within the ambulatory setting, Vettese et al. conducted a three-hour interactive workshop that focused on teaching internal medicine residents responsible opioid usage and effective chronic pain management. 19 They found that, at the postintervention knowledge test, residents scored 73% correct, higher than 51% at the preintervention test, an increase of 22.0%. There was no significant difference between their and our findings, p = 0.202.
Gupta et al. presented a one-day CME workshop on thyroid cancers and their management aimed mainly at the surgical oncologists, otolaryngologists, head-neck surgeons, and other healthcare professionals relevant to the management of thyroid diseases. 20 Pre-test scores averaged 24.8 and post-test scores averaged 31.90, an increase of 22.2% compared to the 20.5% difference in the current study, p < 0.699. It follows that a half-day CME is as effective as a full-day CME. Unlike Gupta, Nazim et al. 10 evaluated whether a two-day CME program could improve urologists' clinical and operative knowledge of urology. There was a significant difference between the pre-test mean score of 37.8% and the post-test mean score of 50.3%, suggesting that the workshop improved knowledge. However, their finding differs significantly from that in the present study, p < 0.033. This finding reveals that a two-day workshop is less effective than a half-day CME workshop. Based on the above findings, we conclude that CME lasting a half-day is as effective as a one-day workshop and even superior to traditional CME lasting two days.
Third, our study also found that a half-day CME workshop tailored to a small group of specialists within a single field of medicine is as effective as a one-or two-day program.
To our understanding, this study is the first to compare half-day workshops with traditional training, which consists of one day or two days. It provides empirical evidence that suggests a CME lasting a half-day may be more effective than the traditional CME lasting two. If this novel finding is substantiated by other studies, it may change the current CME practice and also have potential economic benefits and time savings implications.

Limitations
There were a few limitations to our study. First, the present study is a cross-sectional study from a single oncology department, and a small sample size of oncologists, the findings cannot be generalized to all medical professionals or other healthcare professionals or other oncology centers. Second, the present study focused exclusively on short-term knowledge gain and improvement and was unable to follow up on long-term knowledge retention or knowledge improvement. Third, no evaluation of the CME program was undertaken to determine whether it improved clinical practice or patient outcomes. Consequently, the intervention must be evaluated over several months to determine its longterm effectiveness and sustainability.

Conclusion
Our study demonstrates that a well-designed half-day CME workshop course can improve oncologists' knowledge on pain management and opioids physicians. In addition, the present study confirmed previous studies that sociodemographic factors contributed to higher knowledge levels post-workshop but not significantly. Age, gender, and years of experience of physicians, or their ranking did not predict higher levels of knowledge after the workshop.
Institutional Review Board statement: The study was conducted according to the guidelines of the Declaration of Helsinki and approved by King Abdullah International Medical Research Centre ethics review board, study number RJ20/171/J.
Informed consent statement: Informed verbal and written consent was obtained from all subjects involved in the study.