Situational cues surrounding family physicians seeking external resources while self-monitoring in practice

Abstract

Many models of safe and effective clinical decision making in medical practice emphasize the importance of recognizing moments of uncertainty and seeking help accordingly. This is not always done effectively, but we know little about what cues prompt health professionals to call on resources beyond their own knowledge or skill set. Such information would offer guidance regarding how systems might be designed to offer better individual support. In this study, the authors explored the situational factors that are present during moments of uncertainty that lead primary care physicians to access external resources. To do so, a generic qualitative exploratory analysis was conducted on 72 narratives collected through audio recorder-based, self-observational, journaling completed by 12 purposively selected family physicians. Participants were asked to provide a detailed descriptive account of the circumstances surrounding their consultation of external resources immediately after 6 sequential patient encounters in which they felt compelled to seek such support. Thematic analysis of the transcripts was performed to better understand participants’ experiences of the social, contextual, and personal features surrounding decisions to seek support. When doing so we observed that specific features of patient encounters were routinely present when physicians decided to access external sources for help. These included medical aspects of the case (e.g., complex presentations), social aspects (e.g., the presence of another individual), and personal factors (e.g., feeling a need for reassurance). External resources were seen as an opportunity for verification, a mechanism to increase patient satisfaction, and a means through which to defend decision-making. Accessing such resources appeared to influence the physician–patient relationship for various reasons. Recognition and further study of the cues that prompt use of external information will further our understanding of physicians’ behavioural responses to challenging/uncertain situations, highlight mechanisms through which a culture of self-directed assessment seeking might be encouraged, and offer guidance regarding ways in which physicians can be encouraged to practice mindfully. Our results make it clear that reasons for which primary care physicians seek the support of external resources may be multifactorial and, therefore, one should be cautious when inferring reasons for the pursuit of such support.

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References

  1. Barsky, A. J., Ettner, S. L., Horsky, J., & Bates, D. W. (2001). Resource utilization of patients with hypochondriacal health anxiety and somatization. Medical Care, 39, 705–715.

    Article  Google Scholar 

  2. Bell, D. E. (1982). Regret in decision making under uncertainty. Operations Research, 30, 961–981.

    Article  Google Scholar 

  3. Borell-Carrio, F., & Epstein, R. (2004). Preventing errors in clinical practice: A call for self-awareness. Annals of Family Medicine, 2, 310–316.

    Article  Google Scholar 

  4. Croskerry, P. (2005). The theory and practice of clinical decision-making. Canadian Journal of Anesthesia, 52, R1–R8.

    Article  Google Scholar 

  5. Curley, S. P., Connelly, D. P., & Rich, E. C. (1990). Physicians’ use of medical knowledge resources: Preliminary theoretical framework and findings. Medical Decision Making, 10, 231–241.

    Article  Google Scholar 

  6. Davies, K. (2007). The information-seeking behaviour of doctors: A review of the evidence. Health Information and Libraries Journal, 24, 78–94.

    Article  Google Scholar 

  7. De Bruin, A. B. H., Dunlosky, J., & Cavalcanti, R. B. (2017). Monitoring and regulation of learning in medical education: The need for predictive cues. Medical Education, 51, 575–584.

    Article  Google Scholar 

  8. Donohoe, M. T., Kravitz, R. L., Wheeler, D. B., Chandra, R., Chen, A., & Humphries, N. (1999). Reasons for outpatient referrals from generalists to specialists. Journal of General Internal Medicine, 14, 281–286.

    Article  Google Scholar 

  9. Ely, J. W., Osheroff, J. A., Ebell, M. H., Chambliss, M. L., Vinson, D. C., Stevermer, J. J., et al. (2002). Obstacles to answering doctors’ questions about patient care with evidence: Qualitative study. British Medical Journal, 324, 710–713.

    Article  Google Scholar 

  10. Emanuel, K. J., & Emanuel, L. L. (1992). Four models of the physician–patient relationship. Journal of the American Medical Association, 267, 2221–2226.

    Article  Google Scholar 

  11. Epstein, R. M. (1999). Mindful practice. Journal of the American Medical Association, 282, 833–839.

    Article  Google Scholar 

  12. Eva, K. W., & Regehr, G. (2005). Self-assessment in the health professions: A reformulation and research agenda. Academic Medicine, 80, S46–S54.

    Article  Google Scholar 

  13. Eva, K. W., & Regehr, G. (2007). Knowing when to look it up: A new conception of self-assessment ability. Academic Medicine, 82(10), S81–S84.

    Article  Google Scholar 

  14. Eva, K. W., & Regehr, G. (2008). “I’ll never play professional football” and other fallacies of self-assessment. Journal of Continuing Education in the Health Professions, 28, 14–19.

    Article  Google Scholar 

  15. Eva, K. W., & Regehr, G. (2011). Exploring the divergence between self-assessment and self-monitoring. Advances in Health Sciences Education, 16, 311–329.

    Article  Google Scholar 

  16. Eva, K. W., Regehr, G., & Gruppen, L. D. (2012). Blinded by “insight”: Self-assessment and its role in performance improvement. In B. D. Hodges & L. Lingard (Eds.), The question of competence: Reconsidering medical education in the twenty-first century (pp. 131–154). New York: Cornell University Press.

    Google Scholar 

  17. Feinstein, A. R. (1985). The ‘chagrin factor’ and qualitative decision analysis. Archives of Internal Medicine, 145, 1257–1259.

    Article  Google Scholar 

  18. Forrest, C. B., Nutting, P. A., Starfield, B., & von Schrader, S. (2002). Family physicians’ referral decisions. The Journal of Family Practice, 51, 215–222.

    Google Scholar 

  19. Freeman, T. R. (2016). McWhinney’s textbook of family medicine (4th ed.). New York: Oxford University Press.

    Book  Google Scholar 

  20. Hautz, W. E., Schubert, S., Schauber, S. K., Kunina-Habenicht, O., Hautz, S. C., Kämmer. J. E., & Eva, K. W. (2019). Accuracy of self-monitoring: Does experience, ability, or case difficulty matter? Medical Education, ePublished February 14.

  21. Johnson, C. G., Levenkron, J. C., Suchman, L., & Manchester, R. (1988). Does physician uncertainty affect patient satisfaction? Journal of General Internal Medicine, 3, 144–149.

    Article  Google Scholar 

  22. Kahlke, R. M. (2014). Generic qualitative approaches: Pitfalls and benefits of methodological mixology. International Journal of Qualitative Methods, 13, 37–52.

    Article  Google Scholar 

  23. Koriat, A., Nussinson, R., & Ackerman, R. (2014). Judgments of learning depend on how learners interpret study effort. Journal of Experimental Psychology. Learning, Memory, and Cognition, 40(6), 1624–1637.

    Article  Google Scholar 

  24. Longhurst, M. (1988). Physician self-awareness: The neglected insight. Canadian Medical Association Journal, 139, 121–167.

    Google Scholar 

  25. Lovell, B. (2018). What do we know about coaching in medical education? A literature review. Medical Education, 52, 376–390.

    Article  Google Scholar 

  26. Mamede, S., Schmidt, H. G., Rikers, R. M. J. P., Penaforte, J. C., & Coelho-Filho, J. M. (2007). Breaking down automaticity: Case ambiguity and the shift to reflective approaches in clinical reasoning. Medical Education, 41, 1185–1192.

    Article  Google Scholar 

  27. Mamede, S., Schmidt, H. G., Rikers, R. M. J. P., Penaforte, J. C., & Coelho-Filho, J. M. (2008). Influence of perceived difficulty of cases on physicians’ diagnostic reasoning. Academic Medicine, 83(12), 1210–1216.

    Article  Google Scholar 

  28. McConnell, M. M., Regehr, G., Wood, T. J., & Eva, K. W. (2012). Self-monitoring and its relationship to medical knowledge. Advances in Health Sciences Education, 17, 311–323.

    Article  Google Scholar 

  29. Moulton, C., Regehr, G., Lingard, L., Merritt, C., & MacRae, H. (2010). Slowing down to stay out of trouble in the operating room: Remaining attentive in automaticity. Academic Medicine, 85(10), 1571–1577.

    Article  Google Scholar 

  30. Northup, D. E., Moore-West, M., Skipper, B., & Teaf, S. R. (1983). Characteristics of clinical information-searching: Investigation using critical incident technique. Journal of Medical Education, 58, 873–880.

    Google Scholar 

  31. NVivo Qualitative Data Analysis Program. (2008). Version 8. Melbourne: QSR International Pty. Ltd.

    Google Scholar 

  32. Pope, C., Ziebland, S., & Mays, N. (2000). Analysing qualitative data. British Medical Journal, 320, 114–116.

    Article  Google Scholar 

  33. Pusic, M. V., Chiaramonte, R., Gladding, S., Andrews, J. S., Pecaric, M. R., & Boutis, K. (2015). Accuracy of self-monitoring during learning of radiograph interpretation. Medical Education, 49(8), 838–846.

    Article  Google Scholar 

  34. Salmon, P., Ring, A., Dowric, K. C. F., & Humphris, G. M. (2005). What do general practice patients want when they present medically unexplained symptoms, and why do their doctors feel pressurized? Journal of Psychosomatic Research, 59, 255–262.

    Article  Google Scholar 

  35. Schön, D. (1983). The reflective practitioner: How professionals think in action. London: Temple Smith.

    Google Scholar 

  36. Wears, R. L. (2009). What makes diagnosis hard? Advances in Health Sciences Education, 14(S1), 19–25.

    Article  Google Scholar 

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Acknowledgements

The authors would like to thank the family physicians who participated in this study for their time and support.

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Correspondence to Linda Lee.

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This study was approved by the Office of Research Ethics at Western University.

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Lee, L., King, G., Freeman, T. et al. Situational cues surrounding family physicians seeking external resources while self-monitoring in practice. Adv in Health Sci Educ 24, 783–796 (2019). https://doi.org/10.1007/s10459-019-09898-1

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Keywords

  • Self-monitoring
  • Professional self-regulation
  • Maintenance of competence
  • Patient safety