An interview with Terryn Naumann BSc(Pharm), PharmD the Director of Academic Detailing and Optimal Use at the British Columbia Ministry of Health by Winnie Ho, NaRCAD Program Coordinator.
Overview: Terryn previously spoke about her experiences on a virtual detailing panel at the NaRCAD2019 conference. You can watch the video recording here.
NaRCAD: Terryn, thank you so much for speaking with us today about your experiences with detailing in the province of British Columbia. The BC Provincial Academic Detailing (PAD) Service certainly has a lot of ground to cover. Tell us about the program goals and geography.
Terryn: For reference, British Columbia is geographically larger than Texas, but the population of British Columbia is only about 5 million people. We provide our detailing services to family practice physicians, nurse practitioners, and a few other healthcare professionals. Our detailers each do more than 175 visits per year, and collectively, they see about 2000 providers per topic, which includes about a third or so, of all the family physicians in BC.
We have 12 detailers in total, half of whom are working in less densely populated areas. For example, the northern end of the province is mostly small communities with only 3-4 providers in each town. One year, one of the detailers drove over 17,000 km (10,563mi) for her visits alone!
NaRCAD: That’s an incredible amount of work that your detailers have been up to! And you yourself have been active in AD for a long time. What was your experience then like?
Terryn: I started in 1993 with the program that would one day expand to become the PAD service, and I detailed for about 7 years. I came back to academic detailing in 2008 as the coordinator of the provincial program. When I started in 1993, I had just graduated with my PharmD. I had read about AD and was excited to try something new.
You have to realize, at the time, technology wasn’t that advanced... I didn’t even have an e-mail address when I first started. You couldn’t just send people a note and say “When would you like to meet?” It wasn’t simple to access people.
NaRCAD: How would you describe how AD has changed since you started?
Terryn: When I started, I was the first academic detailer in Canada. There were about 70 physicians that I would go out to visit for each of the topics I put together after having the content reviewed by a local physician specialist from within our own community. One of the things that has changed is the breadth of resources and the growth of the AD community. There are so many more people involved, content is more thoroughly researched, and the literature is more readily accessible through technology.
NaRCAD: Technology has certainly changed the way the world works, and it’s something that detailing programs are turning to more and more to tackle the challenges you’ve mentioned, such as trying to serve a large and scattered population with a limited team. We’ve seen the increased use of tele-communications to do detailing. What has your experience been with virtual detailing, also commonly called ‘e-detailing’?
Terryn: One of the things we value about AD is that truly interactive, face-to-face encounter and that ability to individualize sessions to the provider’s learning needs. Virtual detailing uses a different methodology altogether. I think there are advantages to virtual detailing, but sometimes I think that it’s not as simple as moving AD to a web platform. I worry about the personal elements you can lose, even when using a web platform where you can see each other. My detailers often end up making slides of the original materials, which sometimes turns the session into more of a presentation.
NaRCAD: Can you elaborate further on the nuances you’ve seen with this new approach?
Terryn: We started with something we called Technology-Enabled AD (TEAD) which was a limited study done to compare the efficacy of TEAD versus a traditional face-to-face visit. They found that there was an effective knowledge exchange during both types of sessions, but the time it took for TEAD was far shorter. However, when we added TEAD as an optional feature for our providers, we ran into multiple challenges, such as detailers and providers not being familiar enough with the technology. The large majority of our providers choose to meet in person when they have that option.
That said, virtual detailing has been useful considering BC’s terrain and rough winters. Some regions have winter 8 months of the year and travel is limited for safety reasons. We have used virtual detailing, but find that we need detailers that are tech-savvy and can guide providers through accessing the platform easily.
The key is maintaining the interactivity component and having the session not become a presentation. If we can embrace virtual detailing as its own, unique skillset, we may be able to take advantage of all of its benefits. I think that we’re also at a changing point in technology – the next generation of providers (and detailers) will have grown up with and be more comfortable using technology.
NaRCAD: There will be a lot of growth in detailing as we are able to incorporate more options into how we reach providers, with the emphasis being on building a strong relationship.
Terryn: The goal of AD has always been to have a clinician who values a discussion about the evidence, and then is able to incorporate the evidence into their own practice and drug therapy decision making. E-detailing is just another modality for doing that.
We found that virtual detailing is most effective after establishing a prior relationship with the provider during a face-to-face visit. We received fantastic feedback from one provider who felt the virtual detailing session that he participated in from the comfort and privacy of his home allowed him to ask questions he might otherwise have avoided asking in a group setting. If we can use technology to build relationships like that, then ultimately isn’t that what we want?
I would say that it is.
Terryn Naumann is the Director of Academic Detailing and Optimal Use at British Columbia’s Ministry of Health’s Pharmaceutical Services Division. She earned her pharmacy degrees from the University of British Columbia and completed a hospital pharmacy residency at St. Paul’s Hospital in Vancouver. Terryn began her career in academic detailing in 1993 when she worked at Lions Gate Hospital in North Vancouver as the clinical pharmacist for the Community Drug Utilization Program – the first academic detailing program in Canada.
Since 2008, Terryn has led BC’s Provincial Academic Detailing (PAD) Service, a team of 12 academic detailing pharmacists who conduct over 2000 academic detailing/small group learning sessions each year. She is a member of the Canadian Academic Detailing Collaboration, having served as chairperson and secretary. She has also been a facilitator at several of the Centre for Effective Practice’s Basic Academic Detailing workshops.
An interview with Zack Dumont, BSP, ACPR, MS, a clinical pharmacist with the RxFiles Academic Detailing Service in Regina, Saskatchewan, Canada and a NaRCAD Training Facilitator
by Winnie Ho, NaRCAD Program Coordinator
Overview: The Cannabis Act went into effect in Canada in October of 2018. The legalization of a drug with strong potential for a myriad of clinical uses was followed by many questions from patients and providers alike about its effectiveness, its safety, and lack of previous research. The RxFiles have carried out a cannabinoid academic detailing campaign to address the demand for truth in a time where research has just begun to shed light on previous myths, misconceptions, and clinical promises.
NaRCAD: Zack, thank you for taking the time to speaking with us today! RxFiles has been around for more than 20 years. What do you do you believe is driving the demand for the resources that academic detailing is providing?
Zack: There’s an element of doubt in the information out there, because people have experienced misinformation before. People are often interested in the truth and that’s one of the most amazing things about academic detailing. There is also a desire for practical information that can be used to actually treat patients, and there’s a ton of overlap there. These things are important to these very, very busy providers who want the best for their patients.
NaRCAD: We know that your team is working on a cannabinoid campaign, which can be a nebulous topic. Can you discuss a little more about cannabinoid policy and conceptions in Canada?
Zack: We’re coming up on the one-year anniversary of recreational marijuana legalization, but medicinal cannabis has been legal for about two decades. With the legalization of recreational cannabis though, we’re seeing fairly rapid change in perceptions of what the truth is. It’s tough to keep up with.
With academic detailing, it was challenging to decide how to tackle it – can we just talk about the medicinal cannabis side? Or do we have to dive deeper? When we dug into it, it became clear that we also had to talk about the recreational side. For example, the people we provided our services to also wanted to know, “if I decline my patient cannabis prescriptions, what will they be able to get on their own?”
NaRCAD: Did RxFiles choose to launch its cannabinoid campaign with the passage of the Act, or has this been planned for a longer period of time?
Zack: It’s coinciding with our work on pain, following our work on pain and opioids. In addition, because legalization was approaching, the providers had more questions because their patients were asking about cannabis as an alternative to opioids.
NaRCAD: How have provider responses been to the cannabinoid campaign so far?
Zack: It’s welcomed. Our information is usually welcomed. There’s some frustration over how little information there is out there. While frustrating, I think it’s kind of comforting to know that we’re not that far behind. It’s kind of mixed, but at the same time, they’re still happy to get information from a trusted resource. There's a lot of gray area information right now because it's a newer field.
NaRCAD: Right now is a shifting and transformational time, especially with something like cannabinoids with a distinct history of stigma and legalization, even with all this new interest. As an academic detailer, how do you source your information knowing that there isn’t enough research out yet and a lot of gray area information? How do you begin to build a campaign around a topic like this?
Zack: The evidence pyramid gives us the best approach for practical information, for people who are the interface of care. You want to find high quality, synthesized information. Whether its osteoporosis or COPD or pain or cannabis, you start with the guidelines and figure out what kind of information they are providing. We started with some recently published guidelines and it was a synthesis of systematic reviews, and made an attempt to summarize all the evidence of where cannabis was found to be of benefit. We also reviewed the bibliography with all the primary literature and metanalyses.
This process is pretty similar for any academic detailing topic. The other process is going to the people we provide services for, and asking what their patients are asking to treat with cannabis. They tend to ask about cannabis for pain, insomnia, or for things like tremors and that gives us some guidance in terms of what kind of literature we want to find. Of course, we are also looking into what the key messages are in the information we find and distribute. With cannabis, the interesting thing was the lack of information on the different conditions it could be used for. In some ways, it was easier, as weird as it sounds. We didn’t have as much reading to do on that topic.
NaRCAD: Is there any advice you would give any other academic detailing organizations considering this topic for a campaign?
Zack: One, you’re going to have your conversations about stigma. There isn’t a perfect picture of who uses cannabis and it could be absolutely anyone. You’ve got to have the conversation about stigma and get to know your own biases.
In the same vein, we thought about how important word choice and language is. We thought about whether or not we call it cannabis, marijuana, pot, or cannabinoids. Do we call it a medication or a product? All of those words and the considerations that we’ve given opioids - do we call them "addicts", or is it "dependence", and what are the differences between addiction and dependence? The third piece would be that you’ve got to talk to your providers in your local area and find out what their main questions are.
Your job is to provide a service, and if you can find out what their wants and needs are, you’ll provide a far more satisfying service for them and could establish strong relationships that you can build on. There will be a lot of information out there and you will need a lot of leads to help you sort through it all. This won’t be the last time we're addressing this.
NaRCAD: Thank you for taking the time to speak with us, and for leading the charge in bringing cannabinoids to the conversation about treatment for pain.
Zack Dumont is an clinical pharmacist with the RxFiles Academic Detailing Service in Regina, Saskatchewan, Canada and a new expert facilitator for NaRCAD's training courses. He has been involved with the RxFiles since 2008, with experience in both academic detailing and content development of RxFiles’ evidence-based drug therapy comparison tools. Zack maintains clinical practices for inpatient internal medicine, with more specialized experience in anticoagulation and heart failure. His professional interests include teaching evidence-based medicine, knowledge translation, development of clinical decision supports, collaboration, and leadership.
Zack graduated as a Pharmacist from the University of Saskatchewan in 2008. Following graduation, he completed a hospital pharmacy residency with the Regina Qu’Appelle Health Region, where he currently serves as a Clinical Support Pharmacist, with involvement in training new staff, precepting pharmacy residents and undergraduate students, and providing clinical support to various health region committees and working groups.
Highlighting Best Practices
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