Good question!  We faced the same problem recently in our fracture clinic in Derby where diabetic patients were getting put into lower limb casts without anyone routinely documenting their foot sensation.  I got a little cluster of Charcot / neuropathic fracture patients referred to me over the course of a couple of weeks, which is what made me take action.  Things we have done to improve the service include:

1.  We bought some monofilaments which are available in the fracture clinic plaster room (I always carry one in my shirt pocket)

2.  We made some posters reminding staff (medical and non-medical) of the importance of monofilament testing in all diabetics, and about the 10 points to test (

 Deanna, you ask a question which is a common conundrum for all "lifelong learners."

Teaching and learning can be a complex process. We, as learners must understand what it is we don't know or do, and be willing to accept what it is we need to do to simply be better at what we do, if that makes sense.

Often, it is more than a simple matter of implementation of a reminder system to change our behaviour, rather, in adult learners, most particularly in the post graduate group, it is important to enact some form of educational interventions which have a direct effect on changing physician performance and behavior.

Dr. Milner's recommendations above have a great deal of merit, and I do particularly like the fact that teaching sessions were an important component of directly influencing the knowledge gaps which are related to non- compliance (or inconsistent compliance) as you describe. 

I might suggest that if you have a good relationship with the head of the department, that you ask him or her that at the next teaching session, (no matter the topic) that an assessment be written and provided by you  with the endorsement of the department head, to all attendees at the training meeting. The focus should be on routine protocols and practice adherence to diabetic patients entering hospital. Include questions (and you might want to use a Likerd Scale) which are related to the work-up of diabetic patients and the importance of foot checks. The survey need not be long, 5-8 questions at most, but should be carefully written with the goal of determining the knowledge LEVEL around diabetic patient workup, and where knowledge gaps EXIST.

For example, Deanna, questions which would be relevant to assessing compliance issues for foot checks might include something of this nature:

"Among the workup of diabetic patients entering the clinic, your comfort level in administering foot checks and the relevant information it provides is:

You can then use a 1-5 Likerd Scale to measure the knowledge gap with 1 being Not at all comfortable to 5 being "Fully Comfortable".

Adding other questions related to HOW OFTEN or WHEN foot checks are done in their practice as well,  would begin to paint a very accurate picture of the actual compliance and provide you with an overview to discuss with the department head, as a future medical education topic. You may suggest that the department head prepare a relevant presentation on diabetes and mandatory workup procedures as a "refresher" for all participants, and lead the exercise.

Your survey, which should (if answered with candor) indicate that there is a lower than normal practice of including foot checks in routine workups,  and would give you worthy ammunition for selection of material to present, as well as in itself, remind respondents about the importance of the foot check in any diabetic assessment. Opening the presentation with an aggregate overview of the survey results is a good way to justify the topic, and focus on the issue of compliance. Adult learners rely on peer influence a great deal as they mature in their professions.

Generally, creating some discomfort and illuminating knowledge or practice gaps will motivate most learners to willingly seek information to address those gaps. Administering some sort of intelligence gathering can certainly help you in getting the process started!

Good luck and let us know how it goes!

Dear Rory,

Many thanks for your insight and knowledge. I have found the information you provided very helpful.  Kind regards