What’s in a name? Tensions between formal and informal communities of practice among regional subspecialty cancer surgeons

Abstract

In 2007 the Cancer Care Ontario Hepatobiliary-Pancreatic (HPB) Community of Practice was formed during the wake of provincial regionalization of HPB services in Ontario, Canada. Despite being conceptualized within the literature as an educational intervention, communities of practice (CoP) are increasingly being adopted in healthcare as quality improvement initiatives. A qualitative case study approach using in-depth interviews and document analysis was employed to gain insight into the perceptions and attitudes of the HPB surgeons in the CoP. This study demonstrates how an engineered formal or idealized structure of a CoP was created in tension with the natural CoPs that HPB surgeons identified with during and after their training. This tension contributed to the inactive and/or marginal participation by some of the surgeons in the CoP. The findings of this study represent a cautionary tale for such future engineering attempts in two distinct ways: (1) a CoP in surgery cannot simply be created by regulatory agencies, rather they need to be supported in a way to evolve naturally, and (2) when the concept of CoPs is co-opted by governing bodies, it does not necessarily capture the power and potential of situated learning. To ensure CoP sustainability and effectiveness, we suggest that both core and peripheral members need to be more directly involved at the inception of the COP in terms of design, organization, implementation and ongoing management.

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References

  1. Begg, C. B., Cramer, L. D., Hoskins, W. J., & Brennan, M. F. (1998). Impact of hospital volume on operative mortality for major cancer surgery. JAMA, 280(20), 1747–1751.

    Article  Google Scholar 

  2. Berger, P., & Luckmann, T. (1991). Social construction of reality: A treatise in the sociology of knowledge. New York: Anchor.

    Google Scholar 

  3. Berman, L., Rosenthal, M. S., Curry, L. A., Evans, L. V., & Gusberg, R. J. (2008). Attracting Surgical Clerks to Surgical Careers: Role Models, Mentoring, and Engagement in the Operating Room. Journal of the American College of Surgeons, 207(6), 793–800, 800–2. doi:10.1016/j.jamcollsurg.2008.08.003.

  4. Birkmeyer, J. D., Finlayson, E. V. A., & Birkmeyer, C. M. (2001). Volume standards for high-risk surgical procedures: Potential benefits of the Leapfrog initiative. Surgery, 130(3), 415–422. doi:10.1067/msy.2001.117139.

    Article  Google Scholar 

  5. Birkmeyer, J. D., Lucas, F. L., & Wennberg, D. E. (1999). Potential benefits of regionalizing major surgery in Medicare patients. Effective clinical practice: ECP, 2(6), 277–283.

    Google Scholar 

  6. Bloch, M., Lave, J., & Wenger, E. (1994). Situated learning: Legitimate peripheral participation. In R. Pea & J. S. Brown (Eds.), Man (Vol. 29). Cambridge: Cambridge University Press. doi:10.2307/2804509.

    Google Scholar 

  7. Borzillo, S., Aznar, S., & Schmitt, A. (2011). A journey through communities of practice: How and why members move from the periphery to the core. European Management Journal, 29(1), 25–42. doi:10.1016/j.emj.2010.08.004.

    Article  Google Scholar 

  8. Cancer Care Ontario. (2007). HPB Community of Practice workshop. Surgical Oncology News, 2(2).

  9. Cancer Care Ontario. (2009a). HPB surgery standards. https://www.cancercare.on.ca/cms/one.aspx?pageId=41179.

  10. Cancer Care Ontario. (2009b). Technical information: HPB surgery standards.

  11. Cancer Care Ontario. (2010a). Hepato-Pancreatic-Biliary (HPB) cancer surgery standards. Toronto: Ontario.

    Google Scholar 

  12. Cancer Care Ontario. (2010b). Technical information: HPB cancer surgery standards.

  13. Cancer Care Ontario. (2011). Frequently asked questions (FAQ): community of practice (COP). https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=88179.

  14. Cox, A. M. (2005). What are communities of practice? A comparative review of four seminal works. Journal of Information Science, 31(6), 527–540. doi:10.1177/0165551505057016.

    Article  Google Scholar 

  15. Dudley, R. A., Johansen, K. L., Brand, R., Rennie, D. J., & Milstein, A. (2000). Selective referral to high-volume hospitals: Estimating potentially avoidable deaths. JAMA, 283(9), 1159–1166. doi:10.1001/jama.283.9.1159.

    Article  Google Scholar 

  16. Fox, S. (2000). Communities of practice, Foucault and ANT. Journal of Management Studies, 37(6), 15. doi:10.1111/1467-6486.00207.

    Article  Google Scholar 

  17. Fung-Kee-Fung, M., Goubanova, E., Sequeira, K., Abdulla, A., Cook, R., Crossley, C., et al. (2008). Development of communities of practice to facilitate quality improvement initiatives in surgical oncology. Quality Management in Health care, 17(2), 174–185. doi:10.1097/01.QMH.0000316995.79167.be.

    Article  Google Scholar 

  18. Gagliardi, A., Wright, F. C., Anderson, M. A., & Davis, D. (2007). The role of collegial interaction in continuing professional development. Journal of Continuing Education in the Health Professions, 27(4), 214–219. doi:10.1002/chp.

    Article  Google Scholar 

  19. Gbrich, C. (2007). Qualitative data analysis: An introduction. London: Sage Publications. doi:10.1017/CBO9781107415324.004.

    Google Scholar 

  20. Glasgow, R. E., Showstack, J. A., Katz, P. P., Corvera, C. U., Warren, R. S., & Mulvihill, S. J. (1999). The relationship between hospital volume and outcomes of hepatic resection for hepatocellular carcinoma. Archives of surgery (Chicago, Ill.: 1960), 134(1), 30–35.

    Article  Google Scholar 

  21. Green, J. L., & Thorogood, N. (2009). Qualitative Methods for Health Research. Thousand Oaks: Sage Publications.

    Google Scholar 

  22. Hall, P. (2005). Interprofessional teamwork: Professional cultures as barriers. Journal of Interprofessional Care, 19(1), 188–196. doi:10.1080/13561820500081745.

    Article  Google Scholar 

  23. Halm, E. A., Lee, C., & Chassin, M. R. (2000). How is volume related to quality in health care? A systematic review of the research literature. Interpreting the volume-outcome relationship in the context of health care quality. Workshop summary. Washington, DC: National Academy of Sciences.

    Google Scholar 

  24. Handley, K., Sturdy, A., Fincham, R., & Clark, T. (2006). Within and beyond communities of practice: Making sense of learning through participation, identity and practice. Journal of Management Studies, 43(3), 641–653.

    Article  Google Scholar 

  25. Hannan, E. L., O’Donnell, J. F., Kilburn, H., Bernard, H. R., & Yazici, A. (1989). Investigation of the relationship between volume and mortality for surgical procedures performed in New York State hospitals. JAMA, 262(4), 503–510. doi:10.1001/jama.1989.03430040075029.

    Article  Google Scholar 

  26. Hsieh, H.-F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. doi:10.1177/1049732305276687.

    Article  Google Scholar 

  27. Kennedy, T. J., & Lingard, L. A. (2006). Making sense of grounded theory in medical education. Medical Education, 40(2), 101–108. doi:10.1111/j.1365-2929.2005.02378.x.

    Article  Google Scholar 

  28. Kitto, S. C., Chesters, J., & Grbich, C. (2008). Quality in qualitative research. Medical Journal of Australia, 188(4), 243–246.

    Google Scholar 

  29. Kitto, S. C., Gruen, R. L., & Smith, J. A. (2009). Imagining a continuing interprofessional education program (CIPE) within surgical training. Journal of Continuing Education in the Health Professions, 29(3), 185–189. doi:10.1002/chp.

    Article  Google Scholar 

  30. Kitto, S. C., Peller, J. C., Villanueva, E. V., Gruen, R. L., & Smith, J. A. (2011a). Rural surgeons’ attitudes towards and usage of evidence-based medicine in rural surgical practice. Journal of Evaluation in Clinical Practice, 17(4), 678–683. doi:10.1111/j.1365-2753.2011.01695.x.

    Article  Google Scholar 

  31. Kitto, S. C., Petrovic, A., Gruen, R. L., & Smith, J. A. (2011b). Evidence-based medicine training and implementation in surgery: The role of surgical cultures. Journal of Evaluation in Clinical Practice, 17(4), 819–826. doi:10.1111/j.1365-2753.2010.01526.x.

    Article  Google Scholar 

  32. Kitto, S. C., Sargeant, J., Reeves, S., & Silver, I. (2012). Towards a sociology of knowledge translation: The importance of being dis-interested in knowledge translation. Advances in Health Sciences Education, 17(2), 289–299. doi:10.1007/s10459-011-9303-6.

    Article  Google Scholar 

  33. Ko, C. Y., Whang, E. E., Karamanoukian, R., Longmire, W. P., & McFadden, D. W. (1998). What is the best method of surgical training?: A report of America’s leading senior surgeons. Archives of surgery (Chicago, Ill.: 1960), 133(8), 900–905. doi:10.1001/archsurg.133.8.900.

    Article  Google Scholar 

  34. Langer, B. (2007). Role of volume outcome data in assuring quality in HPB surgery. HPB: The Official Journal of the International Hepato Pancreato Biliary Association, 9(5), 330–334. doi:10.1080/13651820701611234.

    Article  Google Scholar 

  35. Langer, B., & Stern, H. (2007). An integrated system-wide strategy for quality improvement in cancer surgery. British Journal of Surgery, 94(1), 3–5. doi:10.1002/bjs.5680.

    Article  Google Scholar 

  36. Lave, J., & Wenger, E. (1991). Situated learning: Legitimate peripheral participation. Cambridge University Press, 138 p.

  37. Lee, J., Morrison, S., & Morris, H. (1957). Fatality from three common surgical conditions in teaching and non-teaching hospitals. Lancet, 273, 785–791.

    Article  Google Scholar 

  38. Li, L. C., Grimshaw, J. M., Nielsen, C., Judd, M., Coyte, P. C., & Graham, I. D. (2009). Evolution of Wenger’s concept of community of practice. Implementation Science: IS, 4, 11. doi:10.1186/1748-5908-4-11.

    Article  Google Scholar 

  39. Luft, H. S., Bunker, J. P., & Enthoven, A. C. (1979). Should operations be regionalized? New England Journal of Medicine, 301(25), 1364–1369. doi:10.1056/NEJM197912203012503.

    Article  Google Scholar 

  40. Marcaccio, M., Langer, B., Rumble, B., & Hunter, A. (2006). Hepatic, pancreatic, and biliary tract (hpb) surgical oncology standards hepatic, pancreatic, and biliary tract (hpb) surgical oncology standards. Toronto: Ontario.

    Google Scholar 

  41. McCord, J. H., McDonald, R., Sippel, R. S., Leverson, G., Mahvi, D. M., & Weber, S. M. (2009). Surgical career choices: The vital impact of mentoring. Journal of Surgical Research, 155(1), 136–141. doi:10.1016/j.jss.2008.06.048.

    Article  Google Scholar 

  42. Miles, M., & Huberman, A. (1994). Qualitative data analysis: An expanded sourcebook (2nd ed., Vol. 20). Thousand Oaks: Sage Publications. doi:10.1016/S1098-2140(99)80125-8.

    Google Scholar 

  43. Mørk, B. E., Aanestad, M., Hanseth, O., & Grisot, M. (2008). Conflicting epistemic cultures and obstacles for learning across communities of practice. Knowledge and Process Management, 15(1), 12–23. doi:10.1002/kpm.

    Article  Google Scholar 

  44. Pope, C., Ziebland, S., & Mays, N. (2000). Analysing qualitative data, 320(January), 5–7.

    Google Scholar 

  45. Ranmuthugala, G., Georgiou, A., Braithwaite, J., Cunningham, F. C., Westbrook, J. I., & Plumb, J. J. (2011). How and why are communities of practice established in the healthcare sector? A systematic review of the literature. BMC Health Services Research, 11(1), 273. doi:10.1186/1472-6963-11-273.

    Article  Google Scholar 

  46. Roberts, J. (2006). Limits to communities of practice. Journal of Management Studies, 43(3), 623–639. doi:10.1111/j.1467-6486.2006.00618.x.

    Article  Google Scholar 

  47. Sandelowski, M. (2004). Using qualitative research. Qualitative Health Research, 14(10), 1366–1386. doi:10.1177/1049732304269672.

    Article  Google Scholar 

  48. Simunovic, M., Urbach, D., Major, D., Sutradhar, R., Baxter, N., To, T., et al. (2010). Assessing the volume-outcome hypothesis and region-level quality improvement interventions: Pancreas cancer surgery in two Canadian Provinces. Annals of Surgical Oncology, 17(10), 2537–2544. doi:10.1245/s10434-010-1114-0.

    Article  Google Scholar 

  49. Sonnenday, C. J., & Birkmeyer, J. D. (2010). A tale of two provinces: Regionalization of pancreatic surgery in Ontario and Quebec. Annals of Surgical Oncology, 17(10), 2535–2536. doi:10.1245/s10434-010-1117-x.

    Article  Google Scholar 

  50. Stokes, D., & Bergin, R. (2006). Methodology or “methodolatry”? An evaluation of focus groups and depth interviews. Qualitative Market Research, 9(1), 26–37. doi:10.1108/13522750610640530.

    Article  Google Scholar 

  51. Thakur, A., Fedorka, P., Ko, C., Buchmiller-Crair, T. L., Atkinson, J. B., & Fonkalsrud, E. W. (2001). Impact of mentor guidance in surgical career selection. Journal of Pediatric Surgery, 36(12), 1802–1804. doi:10.1053/jpsu.2001.28842.

    Article  Google Scholar 

  52. Thurmond, V. A. (2001). The point of triangulation. Journal of Nursing Scholarship, 33(3), 253–258. doi:10.1111/j.1547-5069.2001.00253.x.

    Article  Google Scholar 

  53. Wenger, E. (2013). Communities of practice: Learning as a social system. Systems Thinker, 10((June 1998)), 1–10.

    Google Scholar 

  54. Wenger, E., McDermott, R., & Snyder, W. (2001). Cultivating communities of practice. Boston: Harvard Business School Press.

    Google Scholar 

  55. Wright, F. C., Fitch, M., Coates, A. J., & Simunovic, M. (2011). A qualitative assessment of a provincial quality improvement strategy for pancreatic cancer surgery. Annals of Surgical Oncology, 18(3), 629–635. doi:10.1245/s10434-010-1337-0.

    Article  Google Scholar 

  56. Yin, R. (2009). Case study research: Design and methods (4th ed.). Thousand Oaks: Sage Publications.

    Google Scholar 

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Acknowledgements

This study was funded by the Academic Health Science Centres (AHSC) Alternative Funding Plans (AFP) Innovation Fund.

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Correspondence to Simon C. Kitto.

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Kitto, S.C., Grant, R.E., Peller, J. et al. What’s in a name? Tensions between formal and informal communities of practice among regional subspecialty cancer surgeons. Adv in Health Sci Educ 23, 95–113 (2018). https://doi.org/10.1007/s10459-017-9776-z

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Keywords

  • Quality improvement
  • Surgery
  • Community of practice
  • Medical education