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Original Investigation |

Barriers and Decisions When Answering Clinical Questions at the Point of Care:  A Grounded Theory Study

David A. Cook, MD, MHPE1,2,3; Kristi J. Sorensen, MSEd3; John M. Wilkinson, MD4; Richard A. Berger, MD, PhD5,6
[+] Author Affiliations
1Office of Education Research, Mayo Medical School, Rochester, Minnesota
2Division of General Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
3Knowledge Delivery Center, Mayo Clinic, Rochester, Minnesota
4Department of Family Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
5School of Continuous Professional Development, Mayo Clinic College of Medicine, Rochester, Minnesota
6Department of Orthopedic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
JAMA Intern Med. 2013;173(21):1962-1969. doi:10.1001/jamainternmed.2013.10103.
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Importance  Answering clinical questions affects patient-care decisions and is important to continuous professional development. The process of point-of-care learning is incompletely understood.

Objective  To understand what barriers and enabling factors influence physician point-of-care learning and what decisions physicians face during this process.

Design  Focus groups with grounded theory analysis. Focus group discussions were transcribed and then analyzed using a constant comparative approach to identify barriers, enabling factors, and key decisions related to physician information-seeking activities.

Setting  Academic medical center and outlying community sites.

Participants  Purposive sample of 50 primary care and subspecialist internal medicine and family medicine physicians, interviewed in 11 focus groups.

Results  Insufficient time was the main barrier to point-of-care learning. Other barriers included the patient comorbidities and contexts, the volume of available information, not knowing which resource to search, doubt that the search would yield an answer, difficulty remembering questions for later study, and inconvenient access to computers. Key decisions were whether to search (reasons to search included infrequently seen conditions, practice updates, complex questions, and patient education), when to search (before, during, or after the clinical encounter), where to search (with the patient present or in a separate room), what type of resource to use (colleague or computer), what specific resource to use (influenced first by efficiency and second by credibility), and when to stop. Participants noted that key features of efficiency (completeness, brevity, and searchability) are often in conflict.

Conclusions and Relevance  Physicians perceive that insufficient time is the greatest barrier to point-of-care learning, and efficiency is the most important determinant in selecting an information source. Designing knowledge resources and systems to target key decisions may improve learning and patient care.

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Key Decisions in Physicians’ Point-of-Care Learning

This model was derived from focus group discussions. Decisions in practice might often be unconscious and follow a different order than what is outlined herein.

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