0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

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

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.
Text Size: A A A
Published online

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.

Figures in this Article

Evolving models for health care delivery and reimbursement will demand that primary care physicians independently care for patients with more complex comorbidities and contexts (hereinafter, complex patients), while specialists provide support for evidence-based, locally delivered care.1,2 Consequently, it is expected that physicians will increasingly ask and answer clinical questions at the point of care (POC learning). Computer-based knowledge resources and clinical information should contribute much-needed support to the collaborative management of complex patients36 and may also play an important role in physician continuous professional development and lifelong learning.79 Although electronic medical records, decision support, and ordering systems have received much study,4,5,10,11 little is known about their optimal design and implementation.5,12 Levinson’s13(p607) statement from 30 years ago still applies: “Part of today’s problems of high costs, quality of care, physician burnout, and patient dissatisfaction reflect the inefficient information management methods on which much of the health care process depends.” The realization of design improvements demands that we better understand the nature of clinical work,14,15 including POC learning.

Physicians frequently ask questions in clinical practice16,17 but elect to answer only a minority of these questions,1820 and inquiries are frequently unsuccessful.17,20 In theory, ready access to information will lead to fewer and more appropriate referrals and tests and more efficient and evidence-based treatments. Yet, many barriers limit searches, including insufficient time, inadequate search skills, lack of reliable resources, excessive information, and belief that an answer is not available.17,2125 Other than determining knowledge resource preferences, few studies21,22 have investigated the decisions physicians make as they work around these barriers. Likewise, existing conceptual models for physician learning in practice26,27 describe the process in general terms but do not elaborate on specific activities and decisions.

Clinicians, educators, administrators, and technologists responsible for POC learning systems would benefit from a deeper understanding of how physicians learn in practice. To better understand this process, we conducted a qualitative study focused on the questions: what barriers and enabling factors influence physician POC learning, and what decisions do physicians face during this process?

We conducted a grounded theory study among practicing internal medicine and family medicine physicians in a large, multisite health system. From October 2011 through February 2012 we conducted 7 focus groups at an academic medical center and 4 at primary care sites up to 70 miles away. Fifty board-certified physicians participated (Table 1).

Table Graphic Jump LocationTable 1.  Session and Participant Demographics
Context: Accessible Resources

In addition to publicly available Internet resources, all health care providers in our health system have free and unlimited access to online knowledge resources, including UpToDate (an evidence-based, physician-authored resource), MD Consult (a compilation of full-text journal articles and medical references), and Micromedex (a collection of databases focused on drugs and toxicology). Participants also have access to a locally developed resource, AskMayoExpert, that contains evidence-based content, including care process models, concise answers to frequently asked questions, and names and contact information for topic experts.

Physicians on the academic campus can call one another directly and be immediately connected to ask a question. Physicians at other sites enjoy this same access (although it remains underutilized) and can also access various local subspecialists.

Focus Groups

Each focus group lasted about 1 hour and comprised 3 to 5 physicians selected through purposive sampling (see the next subsection). At the start of the session the moderator (K.J.S.) presented a brief clinical scenario (reproduced in the eAppendix in the Supplement) featuring a diagnostic uncertainty and asked the question, “What barriers do you face in finding timely answers to clinical questions as you care for patients?” (For the last 5 groups, to encourage discussion of evolving themes, the question was changed to, “How do you go about finding an answer to your clinical question?”) The moderator used an interview guide (see eAppendix in the Supplement) listing potential follow-up questions but did not ask all questions of a given group.

Participants and Sample Size

We used purposive sampling to include physicians representing a wide range of specialties (aiming for similar numbers of internal medicine [both specialists and generalists] and family medicine physicians), ages, and times until next board recertification. Participants were recruited via e-mail. Sample size was determined using thematic saturation: after the first 6 sessions, and after every 1 or 2 thereafter, transcripts and moderator notes were analyzed for newly emergent themes. We stopped scheduling group sessions when no new themes emerged.

All participants enrolled voluntarily after the e-mail invitation and provided verbal consent at the start of each session. The institutional review board deemed this study exempt.

Data Collection and Analysis

Each session was recorded and transcribed verbatim, with name substitution to mask participant identity. Transcripts were reviewed using the constant comparative method28 to identify emergent themes. Three investigators (D.A.C., K.J.S., and R.A.B.) independently derived initial themes (open coding), then iteratively revised these through successive in-depth discussions to explore interrelationships among these themes (axial coding). We used Dedoose (www.dedoose.com) to facilitate this analysis.

We asked 4 focus group participants, reflecting diverse specialties and practices, to critique our main findings (member check); they agreed with the themes and model without modification.

We discuss main themes with supportive quotes. Table 2 contains additional quotes.

Table Graphic Jump LocationTable 2.  Additional Quotes in Support of Identified Themes
Barriers and Enablers

Each focus group identified insufficient time as the main barrier to finding answers to clinical questions, often deferring even straightforward questions for lack of time. Many physicians mentioned time per se, while others reported surrogates, such as having the next patient waiting in the room or increased productivity targets.

Sometimes it’s easier to refer the patient ... than to take the time to look up the information, even if it’s something that I know I could manage, but I just don’t have the time to deal with it. (Session 7)

Physicians frequently noted patient complexity as another barrier. This influences information seeking in at least 2 ways: First, complex patients require more time, leaving less time for learning. Second, the questions generated by complex patients are themselves more complex, making it harder to search for and find answers to clinical questions since most clinical guidelines and research studies do not generalize to patients with multiple comorbidities.

The sheer volume of information was identified as a barrier: rather than facilitating learning, abundant information sometimes makes learning more difficult. Physicians also expressed concern that constantly changing electronic resources may be less effective for durable learning than print resources or colleagues.

It used to be the case where we had difficulty finding the information. Well, now we have difficulty finding the information but it’s for a little bit of a different reason. There’s so much out there it’s like, “Where’s Waldo?”…Where is the information buried? (Session 4)

Additional barriers mentioned by only a few physicians included not knowing which resource to search, belief that the search would not yield an answer, difficulty remembering questions for later study if not answered immediately, and inconvenient access to computers (at community sites only).

Physicians mentioned few features that specifically enabled or facilitated POC learning, although many of the themes discussed herein could be interpreted as enablers. Readily accessible electronic resources and resources that are quick, credible, and current were specifically mentioned.

Several physicians noted that they learn best during a POC encounter, and most physicians seemed to equate learning with finding the desired information.

I prefer learning at the time. I think it just stays with me better for one thing, and I can use it immediately. (Session 7)

Whether to Look

Although not part of our main study focus, several participants spontaneously discussed factors that prompted them to search for information (rather than relying on what they already knew): (1) as a refresher for situations they encounter infrequently, such as the details of diagnostic criteria or the indications for specific therapy; (2) to keep up with practice changes; (3) for use in patient education (eg, to illustrate or explain anatomy, a diagnostic workup, treatment side effects, or procedural steps) and to respond to difficult patient questions; and (4) to guide management in the setting of complexity, uncertainty, and multiple competing priorities.

People say, “Have you heard of this before?” or “Do you know about this condition?” [I respond] “No, I don’t, but let’s go find out.” (Session 11)

It’s not so much, you know, “Here’s a condition, what’s the drug?” or “Here’s a condition, what’s the test?” It’s, “Here’s a specific nuance” or “Here’s a test result.” … It’s interpreting that next level, which again is tough to find in a textbook. (Session 8)

These factors were reflected across a variety of topics, including diagnostic strategies, treatment decisions, drug-specific information (dosing, interactions, pill identification), procedural steps, and online tools (eg, a body mass index calculator).

When to Look

Participants noted that POC learning extends beyond the face-to-face patient encounter to include learning both before and after the visit.

Learning Before: An Extra Coat of Paint

Physicians often seek information before entering the room, particularly if they know that a specific question will come up during the encounter. Several physicians noted that this previsit learning usually focuses on details such as specific thresholds and diagnostic criteria.

I have to remind myself about, “OK, I know lupus has these 11 criteria, but what are the thresholds within each of those?” …Sometimes that extra coat of paint can help as you go into the room. (Session 3)

Learning After: One More Thing to Do

Another option is to learn after the patient leaves. However, physicians were nearly universal in their disfavor of this option:

If you’re not able to find the answer at that time then … that adds one more thing on your to-do list. (Session 1)

They also expressed concern about remembering to answer deferred questions and described at least 4 methods to ensure follow-up: (1) making a note on paper, (2) sending themselves an electronic message, (3) not finalizing the electronic record until the question was answered, and (4) asking the patient to call if they haven't received an answer after several days.

We next discuss the third option: learning during the patient visit.

Where to Look: The Health Care Provider's Physical Location

When learning during the encounter, several groups discussed whether to do this in front of the patient or in another location (eg, a nearby office). Participants seemed about evenly split in their preferences.

Reasons to Leave the Examination Room

By far the most common reason to leave the examination room was that physicians feel rushed, awkward, or constrained when seeking answers in front of patients, and this impedes the process of searching and learning. They also worry that searching for information in front of the patient might damage the patient-physician relationship or make some patients uncomfortable. Others feel more efficient using familiar resources not available in the examination room.

I might be seen as stumbling or bumbling around for a few minutes, if I don’t know exactly where I’m going or if I don’t know the best source of the information. … Sometimes it’s just easier to step out and do that. (Session 5)

Several physicians create opportunities to leave the room to answer a question:

I would leave the exam room sometimes, find a reason to leave, and I would contact one of my colleagues or go to UpToDate. … I leave my stethoscope in my [office], so after every time I get a history, I always leave to go get my stethoscope just in case I need a break. (Session 3)

Reasons to Stay in the Examination Room

The most common reason for staying in the examination room was the same as that used by others to justify leaving the room—namely, that this strengthens the physician-patient relationship. Many also viewed this as an opportunity for the physician and patient to learn together and a chance to promote patient engagement. Several physicians noted that they are more likely to stay if the question is not one to which they should already know the answer. Finally, several physicians noted that staying in the room is simply more efficient.

It sends several really important messages: one, you’re transparent, you’re honest, so it really builds trust; and second, “Wow, that person really went out of his way to do something for me.” (Session 1)

Sometimes, if it's something that I should know and I just need to refresh my brain, I might scoot out, because I don’t want them to think I’m completely stupid. But if it’s something that I really don’t see that often, I explain to them that I don’t, and then I go in and I’ll read it in the room with them. (Session 11)

Just as some physicians created excuses or opportunities to leave the room, others had adopted scripts that enable them to search for information in the room without damaging the relationship:

I’ll almost always stay within the room and … I’ll just be very candid and say, “I don’t know how to approach this situation. Would you mind if I just took a moment to read something?” (Session 9)

What Type of Resource: Phone a Friend or Look It Up?

All groups discussed the options of contacting a more knowledgeable colleague or searching for the answer on their own using resources, such as computers and textbooks. Each option has advantages and disadvantages, and the choice is highly dependent on the situation. Participants agreed that human authorities are best for complex patients and obscure topics, whereas for management of a defined, common problem a reference source is sufficient and preferred over inconveniencing a colleague.

Usually it’s not just the one question; it’s in the context of other things that the book doesn’t know. … So, it is more helpful to [contact someone], but weighing that against the fact that sometimes you can’t get them and you know it’s an imposition. (Session 8)

Several physicians mentioned timeliness of response as a key factor, but this seemed primarily determined by local systems features. Physicians working at the academic center or larger multispecialty community sites indicated that contacting a human expert is usually faster, while physicians working at smaller primary care clinics indicated that searching books or online resources typically saves time.

What Specific Resource

A full analysis of all factors influencing how physicians select a specific resource is beyond the scope of this study. However, we will summarize 2 dominant themes that may apply to both human and computer sources.

First, and in keeping with the chief barrier of time, physicians desire efficiency. Many physicians explicitly identified both the likelihood of finding their answer (ie, comprehensive topical coverage and sufficiently detailed content) and the speed with which the answer can be found as the driving forces behind their decisions. The latter condition (speed) involved at least 3 considerations: (1) the organization and search functionality, (2) the length of content, and (3) familiarity with the resource. A poor search function was often cited as a reason not to use a given resource. Excessively long content was likewise cited as a barrier. Familiarity with a resource enhances speed and efficiency. Physicians noted that these features (completeness, brevity, and searchability) were often in conflict, and no single resource was superior on all considerations.

When you have a choice of multiple resources to go to, what you want to know is, very quickly, (1) Is the answer here? (And you want to spend as little energy possible finding out is the answer here or not.) and … (2) How quickly can I get to it through reliable search? (Session 8)

Second, but mentioned far less often than efficiency, physicians sought a credible information source. It seems that physicians decide on a resource’s credibility during their initial encounter and thereafter continue to trust an approved resource on subsequent use. They identified 4 approaches to determining the credibility of an unfamiliar resource: (1) agreement with the physician’s expectations, (2) triangulation (finding the same answer in another resource), (3) reference to the literature or presentation of actual evidence (study data), and (4) credible sponsor (university or government source).

If it corroborates what I already think the answer’s supposed to be, I can stop. (Session 3)

If you find the same thing on a couple different sites, 2 or 3 sites, then you’re pretty sure it’s replicable. So, … you look through 3 or 4 or 5 sources and if 4 of them say the same thing, then you can tell who’s an outlier. (Session 10)

When to Stop (Sufficiency)

To determine sufficiency (when to stop), physicians apply the credibility criteria described in the previous subsection—in particular, corroboration of expectations and triangulation. Indeed, consulting multiple sources to answer 1 question seems not uncommon. Sometimes, however, available resources cannot provide a quick answer, and physicians have no choice but to defer learning.

We sought to understand the barriers, enabling factors, and key decisions that influence physician POC learning. We found that time is the greatest barrier, with patient complexity and information overload also interfering. We also inductively identified 6 key decisions (Figure): whether, when, and where to search; what resource type and what specific resource to use; and when to stop. Each decision represents an opportunity for educators and systems engineers to optimize the clinical environment to support learning and patient care. Features that seem to be particularly important include quick and accurate search, brevity, comprehensiveness, familiarity, assistance in identifying and contacting colleagues, and reference to evidence.

Place holder to copy figure label and caption
Figure.
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.

Graphic Jump Location
Integration With Prior Work

Several of these themes, such as time being a key barrier,17,20,29 efficiency being of critical importance,19,22,30 and health care practitioners commonly seeking advice from colleagues rather than books or computers,24 have been reported separately. However, we are not aware of prior work integrating these disparate themes into a comprehensive model for POC learning. Models of physician learning-in-practice have described these processes only in general terms26,27 or addressed specific aspects, such as reflective practice,3133 self-assessment,34 and deliberate practice.35 Most models of information seeking focus on the context, why people initiate a search, and how they determine successful completion,3638 yet neglect the details of the search itself. Our study thus complements these models by proposing a detailed model of decisions physicians face when seeking information and learning during a clinical encounter.

In contrast to research suggesting that inadequate search skills are an important barrier,20,21 this theme did not emerge in our analysis. Rather, participants focused on shortcomings of the knowledge resource, such as nonintuitive search features. This could reflect evolving expectations for knowledge resources, failure to recognize personal skill deficiencies, or preference for secondary sources (eg, UpToDate) rather than primary sources (eg, PubMed).

Study Limitations and Strengths

As with many qualitative studies, generalizability may be limited. However, within our geographic region we included physicians representing primary care, academia, and multiple medical specialties. Although our participants’ experiences with a locally developed knowledge resource (AskMayoExpert) are unique, these experiences permitted insightful contrasts with other widely used resources. Our model does not provide quantitative evidence to support specific solutions, but it does advance our understanding of clinical work14 and indicates areas for attention in designing new resources.

Implications

Our findings have important implications for practice and research in POC learning and knowledge resource development. First, time is the greatest barrier to POC learning, and efficiency is the strongest determinant in the selection of a knowledge resource. This suggests that shorter answers may be appropriate, but these must be accompanied by intuitive search capability that yields a correct answer quickly and on the first query. Moreover, failure to identify an answer discourages future use of that resource, suggesting that comprehensiveness is a critical element. Addressing the competing demands of brevity and comprehensiveness may require a user-adaptive (eg, short answer and long answer) format. Finally, reducing practice demands (eg, patient volumes) might paradoxically improve overall efficiency if this provides time to answer important questions.

Much POC learning actually occurs outside the room—ideally before the patient visit; often during the visit but not necessarily with the patient; and least preferably after the patient leaves. Information seeking and physician learning will be enhanced to the degree that information systems anticipate physician needs, or make it easier (and more comfortable) for physicians to find information while in the room.

Many clinical questions, particularly those involving complex patients or situations, are difficult to answer using existing knowledge resources. Answering such questions will require better evidence and better search functions. In the meantime, such questions may be best answered through discussion with a colleague. Efforts to improve “curbside consultations” could reduce costs and enhance patient care.39,40

Information seeking, information application, and learning are related yet not synonymous.15Learning suggests that newly acquired knowledge can be recalled and applied to novel, related future problems (“transfer”).41 A busy clinician might successfully find and apply information to solve a specific problem but not learn the knowledge required to improve clinical efficiency and enhance subsequent question recognition and formulation.42 We suggest further research to understand and optimize the conditions and processes that transform POC information to learned knowledge. Research to understand how physicians recognize knowledge gaps and select questions to answer is also needed.

Finally, limited evidence suggests that computer-based knowledge resources may improve patient care and practice efficiencies.5,43,44 Further research evaluating the clinical impact of interventions to support POC learning would be useful.

Accepted for Publication: May 21, 2013.

Corresponding Author: David A. Cook, MD, MHPE, Division of General Internal Medicine, Mayo Clinic College of Medicine, Mayo 17, 200 First St SW, Rochester, MN 55905 (cook.david33@mayo.edu).

Published Online: August 26, 2013. doi:10.1001/jamainternmed.2013.10103.

Author Contributions: Dr Cook had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Cook, Wilkerson.

Acquisition of data: Cook, Sorenson.

Analysis and interpretation of data: All authors.

Drafting of the manuscript: Cook.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Cook.

Administrative, technical, or material support: Cook, Sorenson, Wilkerson.

Study supervision: Cook.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by internal funding through the Knowledge Delivery Center, Mayo Clinic.

American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Defining the medical home. http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. Accessed February 15, 2013.
Rittenhouse  DR, Shortell  SM, Fisher  ES.  Primary care and accountable care. N Engl J Med. 2009;361(24):2301-2303.
PubMed   |  Link to Article
Garg  AX, Adhikari  NKJ, McDonald  H,  et al.  Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005;293(10):1223-1238.
PubMed   |  Link to Article
Chaudhry  B, Wang  J, Wu  S,  et al.  Systematic review. Ann Intern Med. 2006;144(10):742-752.
PubMed   |  Link to Article
Lobach  D, Sanders  GD, Bright  TJ,  et al.  Enabling health care decisionmaking through clinical decision support and knowledge management. Evid Rep Technol Assess (Full Rep). 2012;(203):1-784.
PubMed
Tang  H, Ng  JHK.  Googling for a diagnosis. BMJ. 2006;333(7579):1143-1145.
PubMed   |  Link to Article
Ebell  MH, Shaughnessy  A.  Information mastery. J Contin Educ Health Prof. 2003;23(suppl 1):S53-S62.
PubMed   |  Link to Article
Green  ML, Reddy  SG, Holmboe  E.  Teaching and evaluating point of care learning with an Internet-based clinical-question portfolio. J Contin Educ Health Prof. 2009;29(4):209-219.
PubMed   |  Link to Article
Reed  DA, West  CP, Holmboe  ES,  et al.  Relationship of electronic medical knowledge resource use and practice characteristics with Internal Medicine Maintenance of Certification Examination scores. J Gen Intern Med. 2012;27(8):917-923.
PubMed   |  Link to Article
Bright  TJ, Wong  A, Dhurjati  R,  et al.  Effect of clinical decision-support systems: a systematic review. Ann Intern Med. 2012;157(1):29-43.
PubMed   |  Link to Article
McGowan  JL, Grad  R, Pluye  P,  et al.  Electronic retrieval of health information by healthcare providers to improve practice and patient care. Cochrane Database Syst Rev. 2009;(3):CD004749.
PubMed
Wang  CJ, Huang  AT.  Integrating technology into health care. JAMA. 2012;307(6):569-570.
PubMed
Levinson  D.  Information, computers, and clinical practice. JAMA. 1983;249(5):607-609.
PubMed   |  Link to Article
Wears  RL, Berg  M.  Computer technology and clinical work: still waiting for Godot. JAMA. 2005;293(10):1261-1263.
PubMed   |  Link to Article
Regehr  G, Mylopoulos  M.  Maintaining competence in the field. J Contin Educ Health Prof. 2008;28(suppl 1):S19-S23.
PubMed   |  Link to Article
Smith  R.  What clinical information do doctors need? BMJ. 1996;313(7064):1062-1068.
PubMed   |  Link to Article
Davies  K, Harrison  J.  The information-seeking behaviour of doctors: a review of the evidence. Health Info Libr J. 2007;24(2):78-94.
PubMed   |  Link to Article
Ely  JW, Osheroff  JA, Ebell  MH,  et al.  Analysis of questions asked by family doctors regarding patient care. BMJ. 1999;319(7206):358-361.
PubMed   |  Link to Article
González-González  AI, Dawes  M, Sánchez-Mateos  J,  et al.  Information needs and information-seeking behavior of primary care physicians. Ann Fam Med. 2007;5(4):345-352.
PubMed   |  Link to Article
Coumou  HC, Meijman  FJ.  How do primary care physicians seek answers to clinical questions? J Med Libr Assoc. 2006;94(1):55-60.
PubMed
Ely  JW, Osheroff  JA, Ebell  MH,  et al.  Obstacles to answering doctors’ questions about patient care with evidence: qualitative study. BMJ. 2002;324(7339):710.
PubMed   |  Link to Article
Ely  JW, Osheroff  JA, Chambliss  ML, Ebell  MH, Rosenbaum  ME.  Answering physicians’ clinical questions: obstacles and potential solutions. J Am Med Inform Assoc. 2005;12(2):217-224.
PubMed   |  Link to Article
Green  ML, Ruff  TR.  Why do residents fail to answer their clinical questions?  Acad Med. 2005;80(2):176-182.
PubMed   |  Link to Article
Bennett  NL, Casebeer  LL, Zheng  S, Kristofco  R.  Information-seeking behaviors and reflective practice. J Contin Educ Health Prof. 2006;26(2):120-127.
PubMed   |  Link to Article
Revere  D, Turner  AM, Madhavan  A,  et al.  Understanding the information needs of public health practitioners. J Biomed Inform. 2007;40(4):410-421.
PubMed   |  Link to Article
Slotnick  HB.  How doctors learn: physicians’ self-directed learning episodes. Acad Med. 1999;74(10):1106-1117.
PubMed   |  Link to Article
Sargeant  J, Mann  K, Sinclair  D,  et al.  Learning in practice: experiences and perceptions of high-scoring physicians. Acad Med. 2006;81(7):655-660.
PubMed   |  Link to Article
Glaser  BG.  The constant comparative method of qualitative analysis. Soc Probl. 1965;12(4):436-445.
Link to Article
Bates  DW, Kuperman  GJ, Wang  S,  et al.  Ten commandments for effective clinical decision support. J Am Med Inform Assoc. 2003;10(6):523-530.
PubMed   |  Link to Article
McKibbon  KA, Fridsma  DB.  Effectiveness of clinician-selected electronic information resources for answering primary care physicians’ information needs. J Am Med Inform Assoc. 2006;13(6):653-659.
PubMed   |  Link to Article
Schön  D. The Reflective Practitioner. New York, NY: Basic Books Inc; 1983.
de Groot  E, Endedijk  M, Jaarsma  D, van Beukelen  P, Simons  RJ.  Development of critically reflective dialogues in communities of health professionals [published online September 14, 2012]. Adv Health Sci Educ Theory Pract. doi:10.1007/s10459-012-9403-y.
PubMed
Mamede  S, Schmidt  HG.  The structure of reflective practice in medicine. Med Educ. 2004;38(12):1302-1308.
PubMed   |  Link to Article
Sargeant  J, Armson  H, Chesluk  B,  et al.  The processes and dimensions of informed self-assessment: a conceptual model. Acad Med. 2010;85(7):1212-1220.
PubMed   |  Link to Article
van de Wiel  MW, Van den Bossche  P, Janssen  S, Jossberger  H.  Exploring deliberate practice in medicine. Adv Health Sci Educ Theory Pract. 2011;16(1):81-95.
PubMed   |  Link to Article
Case  DO. Looking for Information.3rd ed. Bingley, England: Emerald Group; 2012.
Wilson  TD.  Models in information behavior research. J Doc. 1999;55(3):249-270.
Link to Article
Leckie  GJ, Pettigrew  KE, Sylvain  C.  Modeling the information seeking of professionals. Libr Q. 1996;66(2):161-193.
Link to Article
Wegner  SE, Humble  CG, Feaganes  J, Stiles  AD.  Estimated savings from paid telephone consultations between subspecialists and primary care physicians. Pediatrics. 2008;122(6):e1136-e1140.
PubMed   |  Link to Article
Golub  RM.  Curbside consultations and the viaduct effect. JAMA. 1998;280(10):929-930.
PubMed   |  Link to Article
Norman  G.  Research in clinical reasoning. Med Educ. 2005;39(4):418-427.
PubMed   |  Link to Article
Epstein  RM.  Mindful practice. JAMA. 1999;282(9):833-839.
PubMed   |  Link to Article
Bonis  PA, Pickens  GT, Rind  DM, Foster  DA.  Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States. Int J Med Inform. 2008;77(11):745-753.
PubMed   |  Link to Article
Isaac  T, Zheng  J, Jha  A.  Use of UpToDate and outcomes in US hospitals. J Hosp Med. 2012;7(2):85-90.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
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.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1.  Session and Participant Demographics
Table Graphic Jump LocationTable 2.  Additional Quotes in Support of Identified Themes

References

American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Defining the medical home. http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. Accessed February 15, 2013.
Rittenhouse  DR, Shortell  SM, Fisher  ES.  Primary care and accountable care. N Engl J Med. 2009;361(24):2301-2303.
PubMed   |  Link to Article
Garg  AX, Adhikari  NKJ, McDonald  H,  et al.  Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005;293(10):1223-1238.
PubMed   |  Link to Article
Chaudhry  B, Wang  J, Wu  S,  et al.  Systematic review. Ann Intern Med. 2006;144(10):742-752.
PubMed   |  Link to Article
Lobach  D, Sanders  GD, Bright  TJ,  et al.  Enabling health care decisionmaking through clinical decision support and knowledge management. Evid Rep Technol Assess (Full Rep). 2012;(203):1-784.
PubMed
Tang  H, Ng  JHK.  Googling for a diagnosis. BMJ. 2006;333(7579):1143-1145.
PubMed   |  Link to Article
Ebell  MH, Shaughnessy  A.  Information mastery. J Contin Educ Health Prof. 2003;23(suppl 1):S53-S62.
PubMed   |  Link to Article
Green  ML, Reddy  SG, Holmboe  E.  Teaching and evaluating point of care learning with an Internet-based clinical-question portfolio. J Contin Educ Health Prof. 2009;29(4):209-219.
PubMed   |  Link to Article
Reed  DA, West  CP, Holmboe  ES,  et al.  Relationship of electronic medical knowledge resource use and practice characteristics with Internal Medicine Maintenance of Certification Examination scores. J Gen Intern Med. 2012;27(8):917-923.
PubMed   |  Link to Article
Bright  TJ, Wong  A, Dhurjati  R,  et al.  Effect of clinical decision-support systems: a systematic review. Ann Intern Med. 2012;157(1):29-43.
PubMed   |  Link to Article
McGowan  JL, Grad  R, Pluye  P,  et al.  Electronic retrieval of health information by healthcare providers to improve practice and patient care. Cochrane Database Syst Rev. 2009;(3):CD004749.
PubMed
Wang  CJ, Huang  AT.  Integrating technology into health care. JAMA. 2012;307(6):569-570.
PubMed
Levinson  D.  Information, computers, and clinical practice. JAMA. 1983;249(5):607-609.
PubMed   |  Link to Article
Wears  RL, Berg  M.  Computer technology and clinical work: still waiting for Godot. JAMA. 2005;293(10):1261-1263.
PubMed   |  Link to Article
Regehr  G, Mylopoulos  M.  Maintaining competence in the field. J Contin Educ Health Prof. 2008;28(suppl 1):S19-S23.
PubMed   |  Link to Article
Smith  R.  What clinical information do doctors need? BMJ. 1996;313(7064):1062-1068.
PubMed   |  Link to Article
Davies  K, Harrison  J.  The information-seeking behaviour of doctors: a review of the evidence. Health Info Libr J. 2007;24(2):78-94.
PubMed   |  Link to Article
Ely  JW, Osheroff  JA, Ebell  MH,  et al.  Analysis of questions asked by family doctors regarding patient care. BMJ. 1999;319(7206):358-361.
PubMed   |  Link to Article
González-González  AI, Dawes  M, Sánchez-Mateos  J,  et al.  Information needs and information-seeking behavior of primary care physicians. Ann Fam Med. 2007;5(4):345-352.
PubMed   |  Link to Article
Coumou  HC, Meijman  FJ.  How do primary care physicians seek answers to clinical questions? J Med Libr Assoc. 2006;94(1):55-60.
PubMed
Ely  JW, Osheroff  JA, Ebell  MH,  et al.  Obstacles to answering doctors’ questions about patient care with evidence: qualitative study. BMJ. 2002;324(7339):710.
PubMed   |  Link to Article
Ely  JW, Osheroff  JA, Chambliss  ML, Ebell  MH, Rosenbaum  ME.  Answering physicians’ clinical questions: obstacles and potential solutions. J Am Med Inform Assoc. 2005;12(2):217-224.
PubMed   |  Link to Article
Green  ML, Ruff  TR.  Why do residents fail to answer their clinical questions?  Acad Med. 2005;80(2):176-182.
PubMed   |  Link to Article
Bennett  NL, Casebeer  LL, Zheng  S, Kristofco  R.  Information-seeking behaviors and reflective practice. J Contin Educ Health Prof. 2006;26(2):120-127.
PubMed   |  Link to Article
Revere  D, Turner  AM, Madhavan  A,  et al.  Understanding the information needs of public health practitioners. J Biomed Inform. 2007;40(4):410-421.
PubMed   |  Link to Article
Slotnick  HB.  How doctors learn: physicians’ self-directed learning episodes. Acad Med. 1999;74(10):1106-1117.
PubMed   |  Link to Article
Sargeant  J, Mann  K, Sinclair  D,  et al.  Learning in practice: experiences and perceptions of high-scoring physicians. Acad Med. 2006;81(7):655-660.
PubMed   |  Link to Article
Glaser  BG.  The constant comparative method of qualitative analysis. Soc Probl. 1965;12(4):436-445.
Link to Article
Bates  DW, Kuperman  GJ, Wang  S,  et al.  Ten commandments for effective clinical decision support. J Am Med Inform Assoc. 2003;10(6):523-530.
PubMed   |  Link to Article
McKibbon  KA, Fridsma  DB.  Effectiveness of clinician-selected electronic information resources for answering primary care physicians’ information needs. J Am Med Inform Assoc. 2006;13(6):653-659.
PubMed   |  Link to Article
Schön  D. The Reflective Practitioner. New York, NY: Basic Books Inc; 1983.
de Groot  E, Endedijk  M, Jaarsma  D, van Beukelen  P, Simons  RJ.  Development of critically reflective dialogues in communities of health professionals [published online September 14, 2012]. Adv Health Sci Educ Theory Pract. doi:10.1007/s10459-012-9403-y.
PubMed
Mamede  S, Schmidt  HG.  The structure of reflective practice in medicine. Med Educ. 2004;38(12):1302-1308.
PubMed   |  Link to Article
Sargeant  J, Armson  H, Chesluk  B,  et al.  The processes and dimensions of informed self-assessment: a conceptual model. Acad Med. 2010;85(7):1212-1220.
PubMed   |  Link to Article
van de Wiel  MW, Van den Bossche  P, Janssen  S, Jossberger  H.  Exploring deliberate practice in medicine. Adv Health Sci Educ Theory Pract. 2011;16(1):81-95.
PubMed   |  Link to Article
Case  DO. Looking for Information.3rd ed. Bingley, England: Emerald Group; 2012.
Wilson  TD.  Models in information behavior research. J Doc. 1999;55(3):249-270.
Link to Article
Leckie  GJ, Pettigrew  KE, Sylvain  C.  Modeling the information seeking of professionals. Libr Q. 1996;66(2):161-193.
Link to Article
Wegner  SE, Humble  CG, Feaganes  J, Stiles  AD.  Estimated savings from paid telephone consultations between subspecialists and primary care physicians. Pediatrics. 2008;122(6):e1136-e1140.
PubMed   |  Link to Article
Golub  RM.  Curbside consultations and the viaduct effect. JAMA. 1998;280(10):929-930.
PubMed   |  Link to Article
Norman  G.  Research in clinical reasoning. Med Educ. 2005;39(4):418-427.
PubMed   |  Link to Article
Epstein  RM.  Mindful practice. JAMA. 1999;282(9):833-839.
PubMed   |  Link to Article
Bonis  PA, Pickens  GT, Rind  DM, Foster  DA.  Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States. Int J Med Inform. 2008;77(11):745-753.
PubMed   |  Link to Article
Isaac  T, Zheng  J, Jha  A.  Use of UpToDate and outcomes in US hospitals. J Hosp Med. 2012;7(2):85-90.
PubMed   |  Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Supplement.

eAppendix. Interview Guide Used During Focus Groups

Supplemental Content

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 5

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections